Hi everyone, welcome back to our afternoon session. Hopefully you'll get a little break here in between our talks this afternoon. So I'd like to go ahead and we'll start the presentation. I have no financial disclosures. So what is the most common code follow up visit code build in gastroenterology. One choice. Okay, very good. So, 46% so 98214 is the most common outpatient established code code that is coded. Now for 9% for seven out of the 82 people, the 9903 is a new patient code visits. So just to review your guidelines just to let you know. Okay, now we have another question. Very good. So what component of the note determines the level of service and I had mentioned that earlier in my first presentation. So hopefully everyone will get this one right. Excellent. Very good. So medical decision making. So I think half the battle is just understanding the terminology and then what fits into those definitions so this is great. So the objectives for this session is to describe an overview of revenue cycle differentiate between ICD 10 CPT codes and what a hiccup code is review em coding guidelines which we touched on this morning, review definition of medical necessity and describe the importance of capturing accurate data. So for coding specificity now that we have value based coding, we want to make sure that we're gathering as much information within that story to describe the patient so value based care now tells us that we have to be accountable for the care that we give patients and what we're reimbursed as. So it's designed to better represent and communicate the clinical scenario, we want to have more precision data mining. So a scenario would be if I was looking at seeing which patients of mine had Barrett's esophagus but I only wanted to look at patients that had high grade dysplasia, there are ICD 10 codes diagnosis codes that will give me that information. We want to have an accurate picture of individuals and aggregated aggregated as is distributed over patients. In other words, patient population we're looking at now how do we enhance groups of people versus just one person at a time. specific public transparency efforts underscore the need for accurately representing the care that we provide. So now over the last 10 years 15 years we can separate now, who is caring for the patient, is it the nurse practitioner physician assistant, or is it the gastroenterologist that's caring for the patient so we need to be accountable for the care that we give the patients and for our documentation reimbursement strategies are now much more prominent, which is for risk based risk adjusted insurance plans. Now these are based on diagnosis codes versus your procedural codes and when I say procedural codes, I'm referring to our office base codes which is your 99214 or your 99204. Now we're reimbursed by insurance plans that are Medicare Advantage plans, and that's going to be based on our diagnosis codes. So, our Medicare Advantage plans will have educational sessions that our coding department will come to us and they'll want us to code patients who are type two diabetic, who have chronic kidney disease, stage four, or atrial fibrillation they want to make sure that we're capturing those codes because we may be the only visit that that patient has that calendar year. And if those specific codes are not coded within a calendar year, then our reimbursement will drop the following year. And sometimes, if you're caring for the patient you may be the only specialist that happens to be seeing that patient that year, or the patient may see their primary care physician. At the end of the year prior, and you're the only one who's going to have that opportunity to capture those chronic conditions for the patient. So revenue cycle it's a matter of alpha and numerical language that's translated through a payment processing system and CPT codes, an example is a 99214 that's an established patient code. 90204 is a new patient visit code 45378, that's a procedural code, and that's translated as a colonoscopy flexible to splenic flexion diagnostic. And then we have a pick pick code. These are codes that specifically Medicare will use these specific codes. And you can see it's a G code, and that's a colorectal cancer screening colonoscopy on individual with high risk or individual that's not on high risk. So revenue cycle so it's a billing system so we communicate to our payers via numbers and this is electronically submitted to the insurance company. So we're putting in our ICD 10 codes that we put in CPT codes. And in this specific example, I did a established patient visit in the office and then I did an endoscope in the office. Now I need to communicate to the insurance company that I add a modifier 25 because I need to communicate that this is a separately and distinct procedure that I did with my office visit. If I don't communicate and add the modifier 25, then I may be reimbursed at half the rate, or no reimbursement at all, but I'm telling the insurance company I'm communicating it with a modifier that this is a separate and distinct procedure and I made the medical decision making that I was going to perform that procedure that day with my E&M service. So examples of diagnosis coding, you have a screening colonoscopy code and then you're a polyp. K code for colon polyp. So ICD 10 chapters for A to Z, and each chapter has specific ICD 10 codes or diagnosis codes that are specific to your book of business or your care that you're providing. And these are some chapters that I highlighted for you to look at. Now, ICD 10 codes are owned by the CDC and AHIMA and the hospital organizations. So you can actually Google ICD 10 codes and you can have a list of this on your own. Now why I wanted to bring this out is that chapter 21, factors influencing health status, contact and health services, this is where you're going to see your social determinants. Excuse me, social determinants of health. And when the new 2021 guidelines were put into effect, this was a section that was actually built into medical necessity and as a risk factor for your patients. So these codes you're going to find entail examples of homelessness, job insecurity, food insecurity, if there's any type of financial impairment, then this is where that set of codes come out. So it's a code set that we're not familiar to using. So it's important that we are familiar that we can review it and then use it and submit that electronically if it's appropriate to our patient visit for that day. So diagnosis coding principles are that we should code to the highest level. So irritable bowel syndrome comes unspecified, but you can also code it to a higher degree. It can be diarrhea predominant, constipation predominant, or just irritable bowel syndrome. Usually our EMR system will determine which codes that we choose. So when I taught transitioning from ICD-9 to ICD-10, the majority of the feedback was, well, I don't actually see the codes, I'm going to choose the language that the code is going to drive me to. So if you put in the keywords that are of the most specific, then it should come up electronically, the code that you're going to code to the highest specificity. And as what I was mentioning before, you want to code all conditions that impact your clinical decision making. So if you have a patient who's on anticoagulant therapy and you're going to need to hold that or else if it's a high risk situation and you need to contact the cardiologist and you need to document that. If you have a patient that's morbidly obese and your BMI is over 40 and your medical decision making is that you need to request anesthesia or monitored anesthesia, it's important to document that. Because I think we've all been in situations, I know I have, where I've had to talk to a peer-to-peer reviewer and they're asking, they're denying the monitored anesthesia and we have to request a peer-to-peer so then we can build our case of why that we're recommending that monitored anesthesia. So evaluation management codes. The new patient code set series goes with 99202-05, established 99212-15, and the consultation codes, which I touched on this morning, 99241-45. Again, Medicare does not cover consultation codes. Some payers do. It's a matter of your organizational policy, whether you're going to actually build those codes, which they can put edits in place and they will then revert those to your new patient codes if a payer does not cover it. Some organizations say just don't build these codes. Again, the 2021 guidelines do not affect the consultation codes. But what's interesting, even when the 2021 guidelines went into effect and it said that our HPI was medically pertinent, history and physical were medically pertinent to the visit, we weren't checking bullet points anymore, clinically I still was doing the same work. You still need to care for the patient. You still need to gather the data that you need to determine it. And I really wasn't finding I was documenting much less, maybe a little less, but not as much, probably the physical examination if I was doing a comprehensive exam. So to determine that extent of work, you have the history and physical. It's broken down into four different categories, your problem focus, expanded and detailed and comprehensive. And then to determine that complexity of your medical decision making, four categories, straightforward, low complexity, moderate complexity, and high complexity. So coding guidelines, where to start. There are some basics, you need to know that if you haven't seen a patient within your practice within three years, then you can use a new patient, then that's your new patient visit code series. Even if it's new to you, but one of your colleagues saw the patient two years ago, you still have to code that as a follow up visit. For an established patient visit, it's going to be less than three years. Levels of service, three components, you have your history, your physical exam and your medical decision making and your time-based coding. Now the time-based coding, the 50% time counseling spent discussing, that's an older guideline, that's with your 95, 97 guidelines. Now it's going to be cumulative time. And this we just discussed, this is the definition from AMA as far as the definition of a new patient code. So the 1995 to 97 guidelines, it's interesting, I have to, we'll collectively need to make a decision nationally, how long do we keep teaching 1995 and 1997 guidelines. But as long as there's consultation codes or other CPT codes that are still being, that are still in process in place, they still follow the 1995 and 1997 guidelines. So moving forward to the 2021 guidelines, you still need your chief complaint. That's one of the major components, as Dr. Vacari had mentioned earlier this morning, that drives your medical decision making. You always want to make sure your chief complaint matches the story of the patient and why you're seeing them. So your history and physical is now medically appropriate, physical examination is medically appropriate. And your medical decision making is going to be made up of the number of diagnosis codes, management options, the amount of work and the amount of information that you're going to be analyzing, then the risk or mortality for that patient. Your total time is defined as face-to-face and any additional activities with a patient of the date of services. Examples are reviewing records, laboratory data, ordering tests, and completing documentation in your clinical note. In fact, you could even create a template that's off of this verbiage and put that into, have that available as a smart set. So you can use that if you've decided to use time-based coding for that day for that service of patient. This is a schematic drawing of putting side-by-side together the 1995, 97, and the 21 guidelines just to give you a sense of where that change has taken place. The review of the data is much more detailed now. They get into the nuances of the different types of category of data that you review. And whether it's an independent historian or someone else comes with the patient, that counts for data review because you're not getting the actual information from the patient, you're getting it from a reviewer. And then also discussion of the management test performance. Under high complexity, you need to have then two out of those three categories to be able to categorize it as extensive. Now, one of the significant changes I want to draw your attention to under the category of risk and significant complications, morbidity, mortality. If you look under moderate risk, you can see that prescription drug management is still there. There was actually a discussion of whether that was still going to stay in place because the discussion was, well, it should only be if there's a new medication that's been prescribed. That's considered prescription drug management. But the discussion was that even though it's not a new prescription, but you're still monitoring for potential side effects, it's still considered moderate risk. And here, as I pointed out, social determinants of health has a bearing now on this moderate risk category. And then under high risk, you would consider intensive prescription monitoring. So your patients with IBD that you're prescribing, they're on methotrexate, they're on a biologic. These are patients that we worry more about, that we see more about, that we're calling more about. So that's under high risk. So key changes, it's the number and complexity of problems. They eliminated new problem to the examiner. So it doesn't have to be a brand new problem anymore to have it be a complex problem. The amount or complexity of data, they added analyze. They didn't have that terminology analyzed in the past. Included two to three different categories to articulate data ordered, obtained, or analyzed. The definitions of the categories, they are not consistent. So having attended webinars that are predominantly for coders, you can hear their frustration because even though there was this amazing initiative to change this administrative burden now on our providers to theoretically provide less documentation, there's still some inconsistencies that I think that AMA is still going to be working out. Definition of the category two, changes from low to moderate medical decision making. And as I mentioned, the risk and complications table, social determinants factor were now added into moderate risk. And then more examples were provided in CPT to provide, to define drug therapy requiring intensive monitoring for toxicity. And these resources are online. Just if you put in your search bar, AMA CPT 2021 guidelines, you'll get the whole, the entire first section of the CPT code book for E&M coding. So coding based on total time, I wanted to put this table in. I want to bring to your attention though, AMA and CMS, there are some coding, there are some time differences between the two face-to-face coding. One of my key points to you will be to make sure that you have these tools at your desk, because I don't always remember them. I always have tools sitting next to me so I can remember, or you can create, again, the smart sets within your system. So the new time definition, we went over this. Document time in a single statement. I spent 30 minutes reviewing the patient's diagnostic tests, seeing the patient, talking with, visiting nurse, and documenting in the record. It's not necessary to note how much time was spent for each activity. And there's not a requirement to do a stop time, which previously was one of the requirements for some of the face-to-face times. So that non-face-to-face time, this is a nice diagram to show you exactly what's included, because sometimes you don't realize how much you do for your patient. Preparing to see the patient, so reviewing the test. Obtaining or reviewing those separately obtained histories. Ordering medications. Referring communication to other providers. Documenting clinical information in the electronic record. Independently interpreting results and care management. Time face-to-face, performing a medically appropriate exam and or evaluation. So it's not telling you exactly how much time you need to spend or how much work you need to do on that history or physical. Counseling and educating. And then here's the link that I was just mentioning before. So key coding elements. That chief complaint or reason for encounter, it's going to drive your visit. You need to make sure that your visit is going to be based on that chief complaint. If I notice that my chief complaint, my medical assistant has, her intake has brought in a chief complaint that's not why the patient's there, then I'll have to clarify with the patient. This is what was said. Oh, no, well, that's not really why I'm here. This is what I want to talk to you about. Then I make sure that I change the chief complaint. There are three key components for evaluation management service. This is a good polling question. I've only repeated this about six times. Documentation of time for time-based services, treatment and plan of care for documentation, ancillary, ordered and performed diagnostic testing. Here's an example of social determinants of health codes. So homelessness, inadequate housing, discord with neighbors and lodgers and landlord, problems related to living in residential institution, lack of adequate food and safe drinking water, extreme poverty, low income, insufficient social insurance, and other problems related to housing. Key documentation concepts. I want to give you some nice examples of if you use one of these codes, what would be the key concepts that you're documenting? In fact, this is what you would be documenting. And if you didn't choose this code and your coding department had a robust department that they actually would review your codes, your documentation and add the codes, then they would add these in. But where we see it as a clinician, difficulty or unstable housing or housing support services, environmentally compromised housing, food insecurity, transportation difficulty, interpersonal violence, economic difficulties, or lack of social support. Payer options. We touched on this earlier when I discussed the consultation codes and how only one Medicare does not cover this consultation code. I also talked about Medicare Advantage. This is a health plan that's becoming more popular. You saw it mostly on the West Coast, and now you see it, these plans used much more often in the Midwest and on the East Coast. But I've been working in a Medicare Advantage environment for over 10 years. So the additional education that we've been provided, as well as me being a provider liaison in revenue cycle, I've taught risk-adjusted coding. And basically, it's teaching to that highest level. So you're teaching not only you're going to code someone who's diabetic. If you're going to look at the GFR and see if that GFR is a risk-adjusted coding. You're going to code someone who's diabetic. If you're going to look at the GFR and see if that GFR is less than 60 over three months, that's chronic kidney disease. So that's CKD. 3A, I want to believe, because that was just recently split between 3A and 3B. So instead of coding for diabetes, one code, and then renal insufficiency, which the majority of us were used to in the past, because we never wanted to make a commitment on what stage it was. Then there is a bundled code. We use a code for that code with type 2 diabetes with CKD 3A. So that's the basis of coding to that optimal level. And then Medicare, and then there are private sectors, Blue Cross, Blue Shield, and PBOs. So revenue cycle, there's payer-specific guidelines. There's pre-authorization process, internal and external review. There's denial of services or services covered under healthcare benefits and tiered services. Unfortunately, sometimes we get into the situation where we may order a test for a patient, and it's not covered by their health plan, but patients are upset with us because we chose a service that their insurance does not cover, which we're not aware of. Or if we choose a medication that's too high for the patient to pay, or it's not covered by their plan, we have to take that extra time to explain to the patient that this is not a covered service by your plan, or else it is a tiered service. So this medication that we prescribed for you requires a higher copay versus another medication. And unfortunately, we don't always know that. So this learning curve here is through trial and error, and understanding that when we get asked to do those peer-to-peer reviews, it's a learning experience. And I always try to get as much information from the physician that I'm speaking with. Usually, peer-to-peers from the insurance companies, I would find all sorts of different backgrounds, from a pediatrician to an orthopedic surgeon. And I always thought it was interesting that it was a gastroenterology service that they were reviewing, that they were going to be the ones to determine whether they were going to cover my CT scan that I ordered, or even an upper endoscopy. But more and more, you're seeing gastroenterologists that are fitting in this role because there's been a transition of workforce because of the pandemic. And as Dr. Call said, you see APPs filling this role because of burnout and because of what our workforce went through during the pandemic. Medical necessity, this falls into the play of when we order a service, and it gets denied. Why was it denied? Well, it comes down to is document why we're ordering it and what's driving that medical recommendation. You need to build the why of the business case of the medical necessity. So take-home would be learn the standard guidelines. I'm always impressed that the peer-to-peers from the insurance companies, they really do follow the standard guidelines. And a lot of times, if one of my cases is denied, maybe because something just that I've missed, or else that information wasn't included when it was originally sent to the insurance company. So review your American College of Gastroenterology guidelines for GERD, and then the ASA guidelines for anesthesia. All those guidelines are going to be important to make sure that you're documented and perform that documentation improvements in your office as well. So practice pros, develop those visual cues and reminders for different coding levels. Develop templates to optimize capturing your data. Ensure workflows to ensure that your ancillary staff is supporting to their highest level. Request your coding team to review and perform a sample audit. Usually, most organizations will onboard you and give you coding education, and then they'll come back again, say, in three months to revisit that. Don't feel shy if you need additional support to follow up with that. And even if you're in a private practice, inquire what support service do you have or education to go over your documentation and your E&M coding frequencies to make sure that you're capturing those codes at the highest level. But mostly that your documentation meets that. Thank you very much.

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