So I'm going to try to synthesize a complex aspect of what we do on a daily basis coding and billing and try to give you some best practices and takeaway. I'm also going to be giving you some 2025 updates for this year. So, here are my disclosures. So two polling questions. What is the most common follow up visit that's usually coded in the gastroenterology department. Very good. So that is correct. So hopefully today for my hard working nurse practitioners and PAs in gastroenterology, I'll be able to teach you some additional pearls. So to give you more confidence to code at a higher level to show you that you're working hard you're taking care of sick patients. Okay, our next polling question. What component of the note determines the level of service. Is it how good you write your history, is it the physical examination, is it the chief complaint, or is it medical decision making. Very good. So we're translating the last one for chief complaint to medical decision making. So, excellent. That is the correct answer. So the objectives I like to go through is to discuss revenue cycle, how to differentiate ICD 10 which are your diagnosis codes from CPT and HCPCS codes. We're going to look at the E&M coding guidelines, review that definition of medical necessity, and you're going to take away the importance of capturing accurate data to communicate your patient story. So the rationale for coding specificity is that it's designed to better represent how to communicate that clinical scenario. As you all know, when the transition from ICD 9 to ICD 10, the code set became much more granular and much more complexity packed into that one single code. So it's important to be able to know the difference between those different codes and make sure you're coding at the higher specificity. Next, we're going to allow precision data mining. If you're looking at your practice and you're wondering, how can I set up a specialty clinic? How can I set myself aside for something different from what I'm seeing on a day to day basis? If you look at those diagnosis codes and you can see, geez, I'm seeing a lot of patients that have decompensated liver cirrhosis. So you can mine your own personal data to start building that business case of how you want to set up your own afternoon clinics just to see those specific patients. And it's going to give an accurate picture of that individual and aggregated attributions to your patients. These ICD-10 diagnosis codes are going to enhance that population health management, which can translate into the specialty clinics that we're describing. And then also physician APP-specific public transparency underscores the needs of that accurate representation of the types of patients that we're caring for. If you're having a higher acuity of patient, then you may be able to build that business case of, I need longer than 15 minutes with this type of acuity of patients, or I need longer than 20 minutes, or can we shift my patient load so I'm seeing them in the afternoon, where all those specific patients are bundled together. And then reimbursement strategies for risk-adjusted insurance codes. So depending on which part of the country that you're in, you're going to have a different penetration of Medicare Advantage plans. And Medicare Advantage plans base their per member per month reimbursement on the risk-adjusted codes, which is going to be making sure that you're coding at that highest level for your patient's acuity. So the coding system, you have alphanumeric language, and the AMA CPT codes, CPT codes are actually owned by AMA. And every year, a new CPT code set gets set up. And it goes through a process where there are an editorial panel where the different specialty societies will actually present their different codes. And then the panel will vote on it, whether they need to be changed or updated or new ones need to be added in. So these are your common codes that you use in your office, your 99214s, 04s, and then procedure codes. So these are also codes that are current procedural terminology codes. And then the HCPC codes, these are codes that you're going to see used by our government payers or Medicare. These are the G code sets. And a code that came into use last year that I want to reintroduce everyone to, I thought it was worthwhile, because even some of my colleagues aren't utilizing it, it's G2211. This is an add-on code that you can put on with your A&M code, which will show that there's moderate complexity. So you're describing to the payer that I'm seeing this patient, and they're pretty sick, and I want to see them back again. So because of this longevity and complexity of care, I'm going to add this code on there, and I'm going to get more reimbursement for that visit that I'm seeing that patient for today. And then there's another G code, G0136. This was approved in 2024 as well, and it describes about you assessing a patient in your office that has some certain challenges with their environment or their lifestyles or their finances, and you're determining that there's a social determinant barrier that may interfere with their care and the care that you're providing. You need to provide additional resources for them. So ICD-10 diagnosis codes, I've given you several examples here, and a CPT code, including your anoscopy, and a modifier. Modifier communicates to the payer that you're adding on another code to communicate to the payer that they need to reimburse you completely for that. So in my office, if I did a 99214 and then added an anoscopy that day, I need to add a modifier 25 because I'm going to communicate to the payer, pay me 100% for that additional procedure code. Because you'll find in procedural coding, with the physician coding when they're doing procedures, depending on how many procedures they're doing that day, sometimes there's a reduction in that reimbursement. So this is an example of coding to the highest principle. So we know that irritable bowel syndrome unspecified, it's a K58.9. The nine is your cue that it's an unspecified code. But if you look at the granularity, we can choose irritable bowel syndrome that's diarrhea predominant or constipation predominant or mixed. And then here's the important part. You want to add on the additional codes that impact your clinical decision-making. Specifically, it's going to drive that medical necessity. So in the case study, which was perfect, dovetails in what we're discussing with Dr. Tiwani, when he described that elderly gentleman that had a new problem, undiagnosed, and he had comorbid conditions that are going to impact his medical decision-making. He's sitting there with that patient, looking at patient that, you know, you're not the healthiest. And I need to put some more thought into this to make sure I'm taking care of you and that you're going to stay well. So during his visit, he's going to make sure that he's adding the atrial fibrillation code. And also that this patient is on a long-term anticoagulant. And again, that's building that medical necessity that this is an ill person. And he's going to be able to code at a higher level. Illustrating that he's caring for that patient. And it's sicker than an other patient would be. So that's your difference in a nutshell between that 99213 and that 99214. So this patient is requiring more moderate necessity and higher medical decision-making. Here's a list of the ICD-10 tabular codes. And excuse me, I listed these because these are specific for GI specifically that you may find some codes that you would use in your coding and your billing. Now, ICD-10, these codes are free. You can actually go onto the CDC website or another website, AHA, and you can get a list of these codes just by Google searching it. So new codes for 2025, specifically more medical granularity with anal fissures. And you can see it's broken down from simple initial complex, and then also the rectal fistulas have been broken down between simple recurrent complex persistent, and then anal rectal fistulas, unspecified, simple or complex. Additional codes that came into effect this year are classifying or reclassifying obesity into class one, class two, class three. And then you can see what the BMI ranges to less to 30 to less than 35, 35 to less than 40, and then 40 or greater. And these are the Z codes. You want to make sure that when you're coding your obesity codes that you're going to match up the Z code to be able to be on that medical claim that's submitting to the payer. I know in our group practice, if our BMI is over a certain range, then we need to order an anesthesiologist to assist with that sedation. So you can see how you're building that medical necessity of this patient is more ill, and it's going to require more services for you. So social determinants of health, this is an important key concept to understand and to actually include in your note if appropriate, because you're going to see in a few slides that social determinants health was actually added to the medical complexity aspect of determining medical decision making. So these are some examples of problems that were related. So just some examples, education or literacy. A patient is going to be at risk if they don't understand what you're describing to them or their risk and benefits of the actual procedure. And these are some other examples. So problems related to housing and economic circumstances. In my practice, I've had patients that are homeless. I've had to find additional resources to support their bowel prep and give them ideas or suggestions on where they can go to be able to do that bowel prep. And so this is going to take time and intensity in your office and also trying to identify additional resources that you can provide for your patient. So you can see these type of visits are going to be longer than your other standard appointments. So key document concepts when you're using one of the social determinants of health codes. On the left hand side, you're going to see some keywords and how you can describe that. That's going to communicate to what that Z code is for your social determinant of health. So difficulty or unstable housing or housing support services. You can see how that translates to lack of housing, inadequate housing, environmental compromised housing, food insecurity, transportation difficulty. I think that I'm not the only one that some of our patients will delay services because they have no transportation. So again, it's going to take more time and intensity in your clinic visit to be able to navigate that patient's care and to system with that care. Excuse me. So evaluation management CPT codes are broken down into new patient visits established and consultation codes, and I haven't, I haven't broken down the consultation codes because there's a very few payers that are paying for the consultation codes, but again, this is dependent on your region of the country, there may be payers that that will follow these codes so even though I'm emphasizing education on new and established visits, it doesn't mean that these aren't still appropriate for your, your region. So medical decision making everyone, everyone was able to get 100 on that polling question, because medical decision making, it's not the physical anymore. It's not your HPI even though that's extremely important to build that business case in the story of your patient. Now it's looking at understanding the number and complexity of the problems, the amount complexity of the data that you're reviewing, and then the risk and complications and morbidity and mortality of that patient. Dr. Tawani's patient, elderly patient, atrial fibrillation, he's on anticoagulant therapy, you know, did he just recently, in additional history if we elaborate on it, did he just recently have a stent placed, you know, is he on a drug eluding stent, does he need to be on anticoagulant. You know, the full year was it just put in just two months ago so these are other things that we have to work through. Also, you're making the effort to reaching out and contacting the cardiologist, this takes time and intensity of work. So this actually was a great keywords that actually one of my coders recently discussed with me when I went through one of my coding audits. She said this is how I teach my providers, teach, educate my clinicians. She said how to define the extent of work. What am I addressing? What information am I considering? And what steps am I taking? And if you think of it, and I thought that was just so simplistic, if you think of it in those three buckets, then that's how you can start to craft your note, that quality note, and start to care for your patient and write that story on how much work I need to put into that patient. So three sections of your medical necessity. You need to have two out of these three meet to then to be able to drive that decision making which will then drive your code. I want to highlight. So your moderate complexity, this is your level four. And this is specifically for my colleagues who chose the 992 and three as the most common code to be coded in the office. Now, I want to let you know the number of diagnosis codes and management options in this in this column is not exhaustive. So if you look at moderate, so one of the codes. If you look back at Dr. Tawani's case study, he was actually describing an undiagnosed new problem with uncertain prognosis. So in him documenting his differential diagnosis, he's laying out that case of, well, it could be this, it could be this, it could be this I'm not sure it might be this. So this is an undiagnosed problem. If you look at also for the under the moderate medical necessity. If you're looking at the example that I gave one or more chronic illnesses with an exacerbation of progression of side effects of medication, our follow up patients, they don't usually come back in because they're better. So follow up patients usually come back in because they're not quite better, or something's gotten worse, or the original problem they saw you for is progressing. And, and one tip I can give you is, if you look at these guidelines start to use these words, and they're not bad words to use in your note they're good words to use. So, you're, you're writing that that patient is exacerbated, you know, the reflex that I saw them for. I recommended, you know, PPI therapy I counseled on the 30 minutes before breakfast. And, you know, I documented how many days a week they're having the symptoms. Well, and then they come back and now that it's worsened you know they're failing the therapy they're having breakthrough symptoms, and it's worsening or progressing. So if you start to think about it in these terms use these words, then it's going to help drive the medical necessity of your note. So there are new codes this year they're telemedicine codes, our previous phone codes have been deleted and now we have new synchronous audio video in em codes, and then synchronous audio only codes. So if you're, if you're not using them, these are appropriate to use. And then I'm going to give you this as a reference you're going to see how these different codes that so their audio and video for new evaluation. Think, remember the time based coding and I have a few slides I'll go over with you for that. So there is time based coding for all of the visits. So if you don't have the medical necessity to base that on for your driving for your visit, then you can use time based coding but you have to document that. And then these are the visits for your, for your audio visit codes. One of the coding guidelines it does say to make sure that you're documenting for your, for your audio only new visits so we're going into here. You want to document that there's 10 minutes of medical discussion and then you write down your total time. So you want to make sure that you're documenting 10 minutes of medical discussion of what you spoke with the patient about and what the anticipation of that next plan of action is. And you can see how these are time additionally time based codes that you can document if you don't have that high medical necessity to drive the code. This is the G2211. And again, it describes that their medical complexities inherent in the evaluation of this patient. What's new now is that this G2211 can be used with visits, if there is a modifier so if there's something else that's added on to that visit that day that you need to code for now they're allowing for that this year so that was the big change. And this is the G0136 this is the administration of a standardized based assessment tool. Now what's interesting is that this, this is screening tool, it describes it not as a screening tool. But when you during that visit face to face if you identify that there's a social determinant potential risk. It's during that visit then you administer that tool. And there's an example down at the bottom of a tool that you can you can download. In other words, you can't pre screen these patients. Here's a slide coding based on time it's going to be, it's going to be walked out between new visit code and established visits. So you have to document that that amount of time in your note, so you have to write down the time in your note, and then you have to document what was discussed from a generality perspective. So you can see document in a single statement I spent 30 minutes reviewing the patient's diagnostic test, seeing the patient talking visiting them and then documenting in the record. Remember, in 2021 with a new guideline EM guidelines came out. We can now use that entire day. When the clock starts when you start prior to seeing your patients, you can start keeping track of the minutes that you that you used to do a chart review or review the patient that you're going to be seen. And this is an example of what you can do non face to face, you can start counting that time counting the clock for preparing to see the visit so reviewing the test, looking at reviewing their history, you can pre order medications or tests maybe the patient had called and said that this is what they needed for the visit ahead of time, referring and communicating with patients and coordinating care. So key coding elements you want to make sure you have your chief complaint, your three components you're documenting, and you're looking at that treatment plan, make sure you have your differential diagnosis, ancillary tests performed, and make sure that that medical decision making drives that medical necessity. So there are different pairs that we encounter and different pairs are going to have different guidelines, and you're going to follow those guidelines based on your on your documentation. Revenue cycle we're all in a situation where we have to work with different companies to require prior authorization. So this is an example of prior authorization requirements for UnitedHealth. It seems that it's become even more burdensome with different organizations asking for prior authorization, but if we don't drive or if we don't document our medical necessity, then insurance organizations have advanced practice providers that are very familiar with our guidelines and if we don't include that in the guideline, if we don't include that in our documentation, then they're going to notice, then they're going to identify that and say, Okay, excuse me, why are you ordering an upper endoscopy, you haven't even started this patient on a, on a PPI. Sorry everyone I'm losing my voice. So practice pearls. You want to develop visual cues or reminders for the different coding levels, develop templates to optimize capturing data, assess workflows to see if your assistants can also support also support your workflow, and then request coding team reviews and perform peer to peer clinical review. So in summary, make sure you're diagnosing to that highest specificity provide adequate documentation, make sure you're doing the two out of three components, identify those social determinants and use keywords for the that high risk and severity in the clinical documentation and specify, specify the measurable treatment plan and outcomes tied to that individual care plan I think we, if we remember that one line, this is going to be a best practice that we can we can carry on through the rest of our career. And we have some resources for you. So thank you very much for this presentation.

gastroenterology coding

ICD-10 transition

E&M guidelines

revenue cycle management

social determinants of health

modifiers G2211