This is such an important topic that is near and dear to our heart that we need to provide our worth in our organization. I have no disclosures, no financial relationship. Let's see here. Okay, first polling question. What is the most common follow up visit that is coded in the gastroenterology setting? Very good. 99214. Oh, this is a smart group. Now, for my colleagues who are who are coding 99213, I want you to pay attention to what the coding guidelines are, because you may be under coding. Some organizations and some medical practices don't have the luxury to have a coding department and or certified coder to go over their coder frequencies and or opportunities for them to improve their coding. So, make note of these coding guidelines and see what your practices when you go back on Mondays actually reflect on what you've been doing and what your coding practices. Very good. So what component of the note determines the level of service? Is it your history, which Joe was saying is one of the most important things that we need to get for our patients, physical examination, chief complaint or medical decision making? Absolutely, absolutely. So medical decision making is the cognitive thought that you're going to put into the work of caring for your patients. How much thought have you put into it? How much diagnostic testing are you putting in to find out what the diagnosis is and how much work is involved? Okay, so the objectives of my presentation today, I want to describe the overview of the revenue cycle. I want to talk to you about differentiating the difference between an ICD-10 CM code, a CPT code and HCPCS code. We're going to look at the E&M coding guidelines, look at some past and look at some present guidelines. Look at that definition of medical necessity and describe the importance of capturing accurate data. So the rationale for coding specificity, it's designed to better represent and communicate the clinical scenario. We have to communicate how we're caring for our patients with numbers. These numbers then transmit to an insurance carrier and they're the ones that will determine if the service that you've billed is appropriate. It allows for precision data mining. Because we're communicating with numbers now, you can ask for a coding frequency of your ICD-10 or diagnosis codes and it's going to look at how sick your patients are. What type of patients do you see? Is your coding frequency for that first coded of ICD-10 code, are you seeing more IBD patients or are you seeing more liver patients or are you straight across the board? A lot of times by looking at the granularity of the data, you can take that information, go back to your administration and say, I would like to have additional education. I've had an uptake now, I'm seeing more patients with inflammatory bowel disease. This is a changing trend in my coding frequency eight months ago, so I'd like to have additional training and have that administrative support to go to other CMEs. It's going to look at your coding potentially will enhance that population health management as well. If you're looking at clusters of data, then you're going to see that in that group, you're going to identify ways to provide greater service for those patients. If you're all of a sudden have an uptick in your coding frequency of more fatty liver disease, more patients whose BMIs are greater than 40, then you know that you need some additional services, which may be referrals to a dietitian. Or you can use this information to say, hey, I want to develop a community outreach program on fatty liver disease and healthy eating and diet and exercise. Again, this data can translate into many opportunities to enhance your practice. Also, you're thinking out of the box and providing more opportunities that your practice can then potentially find some revenue streams from. Reimbursement strategies, when you talk about risk-adjusted insurance plans, these are your Medicare Advantage plans. Medicare Advantage, which has a greater penetration on the West Coast and the East Coast, these are health plans that are reimbursed on a month-per-month basis based on how ill the patient is. How do they assess how ill the patient is? It's based on ICD-10 coding. A patient who has atrial fibrillation and is on anticoagulant therapy and has type 2 diabetes with chronic kidney disease stage 4, that per member per month is going to be at a greater rate than if your patient has atrial fibrillation and unspecified diabetes. It's the greater degree on how your coding's specificity that will then translate in that per member per month with that specific insurance plan. When you look at the revenue cycle, and I've touched on this already, our coding systems are alpha and numeric languages that translate into performed and expected payment. AMA owns the CPT, current procedural codes. These are our visit codes. This is what we think automatically when we think about that reimbursement rate. We have established visits, new patient visits, and then the procedural codes. HCPC codes is a language that's used for our Medicare patients. These are the fee-for-service. If you have a patient that is straight Medicare, then you're using the code, or our physician colleagues are putting in a code G0105, where you're looking at a colorectal cancer screening for colonoscopy with the individual at a high risk. Throughout the years, providers, when I've taught billing and coding to my colleagues, they say, Jill, I don't know who the insurance plan is, though. It used to be more so that there were rules put in place in the coding and billing system, so it would hit an edit. Say if I had a straight Medicare patient, and as a provider, I put in 45378, it would hit an edit, and it would say, no, this isn't allowed for this payer class. As we become more and more sophisticated in caring for our patients, I think we need to be more attentive on the different types of payers that our patients do have. Even though we certainly profess to them that we don't know their specific guidelines, when automatically the first question patients will ask me when I'm discussing recommending diagnostic procedures, they'll say, will my insurance company cover this? And I'll say, well, these are all dependent based on your payer-specific guidelines, but you've come to me, and what our discussion is, is that I am documenting that there's medical necessity that you do need a colonoscopy because you're 62. You haven't had a procedure done before, but you're coming to me with bright red rectal bleeding and change in bowel habits. So this is how I've started becoming more clear when I talk to my patients about medical necessity and importance of documentation. So revenue cycle, you have your ICD-10 codes, so examples are rectal bleeding, proctitis, atrial fibrillation, and long-term anticoagulant therapy, your CPT codes, and then modifier. So anyone who does a procedure in the office, modifier 25 means that it's separate and distinct procedure. So if I do anoscopies in the outpatient setting, so if I'm billing established outpatient visit and anoscope, I need to make sure that I'm attaching modifier 95 to that claim because I'm explaining to the insurance company that that's a separate and distinct procedure, and you need to pay me for both procedures equally. So this is a modifier that communicates the insurance company to provide straight reimbursement for both CPT codes. Modifier 25, you will see a lot of insurance companies will provide reports to providers saying you are a higher utilizer of using modifier 25. And when I used to do revenue cycle audits with our medical group, I work in a multi-specialty medical group, it was always our colorectal surgeons that would have the highest rate for, quote, overutilization of modifier 25. But a colorectal surgeon, look at what they're doing. They're doing these shorter procedures in the office to reassess a surgical anastomosis. So it was absolutely appropriate for them, and that's how we would communicate back to our payers. So I gave you two examples of diagnosis coding. So ICD-10, ICD is the International Classification of Diagnostic Coding. Version 10 is version 10 that we're currently working in, and CM is coded modifier. Now, ICD-11 is currently on the horizon, and this is getting pushed back because of, mostly because of the billing systems that need to be updated and changed to allow those additional characters. You know, anyone on the call who remembers when we transitioned from ICD-9 to ICD-10, that certainly was, that can was kicked down the road for many years because of the billing systems that weren't prepared for these different placeholders, for the different characters, for now these longer codes. These longer codes now pack a punch in all the information that they're communicating to the payers, and as I mentioned before, how we can have more population health data to pull from. So ICD-10 tabulist chapters 1 through 21, and these are chapters that I highlighted that are that are GI specific, and every year, either individuals or organizations can put together a petition to the Centers for Disease Control, CDC houses the ICD-10 codes, and you can actually request for a new code to be developed. And I can tell you this year for 2022, one of the codes that I'm excited to see is long term current use for immunomodulators and immunosuppressants. Before the code was Z79, and I can put this actual code in our in our chat box for Q&A box, but before it was long term management of drug therapy, which meant anything, so it could be drug management therapy, could have been anticoagulant therapy, could have been antiplatelets, but now we have that granularity of detail that Z79.620, long term current use of immunosuppressants and biologics. So now you have the capability, starting this year, of asking your coding department or your billing department to pull all your patients that you've used that code in, and see if, when the last time you saw these patients. So these are patients that are on high risk medication, we should be seeing them or monitoring them, you know, for any type of blood disgraces every three months, if not every six months at the most. So this is a great way for you to now to track your patients and do your own individual population management within your own practice. And this is an example of the diagnosis coding principles, coding to that highest specificity. IBS has an unspecified diagnosis, but it now has the granularity of diarrhea predominant or constipation predominant. And then also you want to code all conditions that impact your clinical decision making. So if you're building the case of a patient who has atrial fibrillation and long term use of anticoagulant therapy and they have morbid obesity, just as Joe spoke this morning on creating that optimal clinical note, you're building a case that this is a sick person, and that it's going to take more cognitive thought and work to care for this patient, which is going to then be able to build that medical necessity to build at a higher level. So you have a list of evaluation and management codes. I wanted to make one update, though, that 99241 has been deleted, that lower level consultation code. And just a reminder, Medicare discontinued covering consultation codes in 2010. There are still some handful of payers that will cover consultation codes, which is why they're still in use. So you're determining that extent of work on when you're developing on when you're deciding on which code to use by you're looking at the amount of work that you put in your history and physical and then you're determining the complexity of decision making. Over the last several years, the guidelines have changed now so medical decision making is that overarching reason for choosing that code. And the coding guidelines, where do you start? This is a transition now from 2021 that we don't need these component codes anymore, but I included them in just to highlight the importance of getting a good history, getting a good physical examination, and then that's going to drive that medical decision making and giving you your diagnosis management and that data risk code. So how do you code your visits? The decision making starts with understanding whether your patient is a new or established patient in your specialty. So an established patient is one that's received professional services by anyone in your office within a three year time period. So whenever I see a patient, either it's with one of our previous gastroenterologist or one of my colleagues, I'm sitting there in front of my patients and almost kind of whispering to my breath. Okay, this is 2021, 22, 23, trying to count, let's see, is this a new patient or established patient? And I think this is where, if we can take the time and do some pre-charting the day prior to seeing our patients, which is a best practice to get through our day and to be able to be on top of our patient that's scheduled, what I'll do is I'll be able to already assess right then and there, okay, this is a new patient, this is an established patient. So I'm going to give myself a head start on how I'm going to start building my documentation. Previous guidelines were 1995 and 1997. This was a big switch when all of a sudden the coding guidelines changed to 2021. So now we didn't, you didn't need to have specific components in your history and your physical examination and medical decision making. In fact, I was thinking there'll be someday when I won't talk about 1995 and 1997 guidelines, but I think historically it's still important to remember what we used to do. Now, 2021 guidelines were, their intent is to reduce the administrative burden on our evaluating and seeing the patients and then documenting. And I don't know how much administrative burden it has reduced. It certainly has changed our lives around because it's a new skill set for us to learn and how to document. But the intent is that it's, it's putting more cognitive thought into caring for that patient by now just focusing on the diagnoses, the management options, the amount of data that you've collected, how much you reviewed, how much you've analyzed, but there's still bullet points that you still have to check off. So this is a grid that I'm not going to go into a lot of detail, but it certainly is going to be a reference for you. But I want to highlight in red, if you look in that center section, the amount or complexity of data reviewed, these two categories, when you look at your moderate or extensive categories, this is, this is what is highlighting how much work you're doing as far as either you're ordering a test or you're reviewing information or independently looking at tests too. I don't know if any of my colleagues on the call actually look at CT scans, but there are many that do. So if you're actually looking at a CT scan and reviewing it on your own, you can use that as looking at independent interpretation. Now you're not billing for that review because the radiologist is already billed for that review of the CT imaging, but you are taking it upon yourself to look at it and looking at the information and getting any additional thoughts that you have from that. The other point I want to bring out to you, under moderate complexity 99204 and 99214, if you are monitoring patients prescription drug management, even if you're not renewing the medication or writing the prescription yourself, if you're renewing the medication, I meant to say, and not just the original prescription, this is considered prescription drug management. And also look at social determinants of health. This was a new category and a new set of ICD-10 codes that came up that builds that risk for significant complications, morbidity, mortality. So if you have social determinants of health that you need to navigate, there are now Z codes that you can capture for patients that have food insecurity, patients that have difficulty with travel, patients that have lack of support at home. I had in my career one patient that I had to help navigate scheduling for diagnostic colonoscopy and they were homeless. And it makes you pause because you have to be creative. And how are we going to care for these patients? They don't have the opportunities that most of us do. So it makes you have to think, be creative and think out of the box and look at additional resources for caring for that patient. So for high complexity, 99205 to 99215, looking at intensive drug monitoring, you're monitoring for toxicities, decisions regarding procedures or major surgeries identified. So for definitely more complicated procedures. And you need two of the three of these medical decision-making elements to meet. So again, the focus is on either the number of diagnoses, the amount of complexity or the risk of significant complications. So two out of those columns need to meet. So key changes as I reviewed, you're eliminating new problems to the examiner. So, and also looking at the amount and complexity of the data, they've added analyze. So analyze is a new term. So what I've started to do is I start using some of that verbiage, even into my notes for my documentation to support that documentation. There are still some criticisms for some of these categories because they're not consistent. And I can tell you, I'm a representative for the American Nurses Association with the AMA-CBT code. So I represent ANA for different codes that are submitted or changes that are made. And this is a constant dialogue and they're constantly reviewing this to make sure it is understandable. Risk of complications tables. The new one that I highlighted was a social determinants of health is in a major risk category and more examples are provided in CPT to provide that drug therapy requiring intensive monitoring for toxicity. Two different timetables for coding. If you want documents for straight coding on your visit. What's interesting about the definition of coding now, since 2021, is that it is your total time of coding. So if you start your day at 630 in the morning and you start pre-populating your notes, you can use that time to generate your visit time for that visit for that patient. It has to be within that calendar day. You can't start pre-charting the day before and then use that time to code your visit for the next day. And I went over that. So again, the non-face-to-face time, if you get up early in the morning, it's going to be preparing to see your patients, obtaining or reviewing separately obtained history, ordering medications, test procedures, referring and communicating to other health professionals, documenting in the EMR. And the face-to-face time is performing that medically appropriate examination and evaluation. I have included a PDF file of the updated 2023 CPT codes for this year. So AMA has been very forthright in providing more resources, much more transparency, much more data and resources to us than I've ever seen before. So key coding elements. We still need that chief complaint or that reason for a visit to drive that visit. So if my medical assistant puts in a chief complaint that's completely off from what my patient actually describes, I will change that because that's how my visit is going to be driving. So that is something that I do pay attention to. I'll document time if that is what I am going to base my time on. And of course, we know that with our telehealth visits, the telephone visits are requiring time for it to be billable. And you're looking at your ancillary tests and medical decision making drives your medical necessity. Here's several exam examples of social determinants of health that I had mentioned. And key documentation concepts that you can use for documentation that will then translate into an ICD-10 code. If you think about it, if we're using a code, if I'm going to bill for the ICD-10 code and I'm going to submit that as a charge for atrial fibrillation, I need to mention that in my documentation. So that's going to be key. If I'm going to order a colonoscopy with monitored anesthesia due to obstructive sleep apnea, I not only need to communicate that to my medical assistant, but I also need to mention that in my documentation as well or else that potentially could be a denial. So we covered some government payers. There's Medicare, Medicare Advantage, Medicaid, which is your state programs that are funded through our federal government. And in this private sector, Blue Cross, Blue Shield, PPO, we have UnitedHealth, we have Anthem. I don't know if you've seen recently in the news, but UnitedHealth is now looking for greater documentation for prior authorization for some gastroenterology services. Fortunately, our GI societies are already looking at ways to try to prevent that as a barrier for our patients to have procedures. Sarah had mentioned that one of our roles is that we may find ourselves in a situation where we're asked to speak to either a physician or someone in an insurance company for another one of our patient's procedures that was denied and say if the physician is out of the office. And I've actually, at first I didn't like to do this, but now I think it's kind of fun. It's a game because we're trying to find out, okay, this patient needs the service. Is the documentation sufficient enough to provide for this service? And sometimes we just need to know those right keywords or the keywords of what they're looking for. And I can tell you, they have, they're very articulate in our society guidelines. So as new nurse practitioners and PAs, we need to be very familiar with our guidelines. And in fact, I'll actually document our guidelines within my medical documentation to show that support of why I'm recommending a procedure or why have I ordered a CT scan with IV contrast? Because of weight loss, a patient has had 10% of weight loss over the last two months, which is a definition for potential malnutrition. So we have to be just as articulate as they are when they're looking at documentation review. And I went over this. We talked about the importance of understanding our guidelines. Practice PEARL. Develop visual cues and reminders on these different coding levels. It is not easy. It does not come overnight. It's repetition, repetition, and it's having those templates in front of you. Look at your workflows and see if there's anything that our ancillary staff can help with our documentation. Request a coding team if you have access to perform a sample audit. There are actually tools out there that you can keep track of all your different CPT codes that you submit for 30 days, and you can actually input them into software. I want to say you could even purchase it for $25 a month, or you can have it for two months, and it'll give you a coding frequency on what is your benchmark. How do you compare to other nurse practitioners and PAs in your specialty? And what's important is that make sure that you're being benchmarked against a GI practice, because it's not uncommon when I see my coding frequency, I'm being told that I overcode, but I'm also being compared to my primary care specialists, I mean, my primary care colleagues. So be sophisticated in the information that you're receiving and how to translate that. And also perform peer-to-peer clinical documentation reviews with your colleagues, and we can give each other tips on how to improve, or is there something that's missing? Sometimes we're in a habit, and we're very routine around how we document, but if there's something that's missing, sometimes it takes a colleague to pick up and give us that advice. Wow. Thank you, everyone.

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