I know that there are a lot of questions, and many of them are related to coding issues, isn't that right, Eden? It sure is. So, I think we're going to need to get Jill to step right back up to the plate to answer some of these. So let's go for it. Okay, here we go. So the first question was, in coding for highest complexity, is it correct to code IBS diarrhea predominant will be a higher than simply IBS unspecified? Coding to the highest specificity for IBS was only an example that was made. It's not an HCC code, which is a hierarchical category code. So if you look under your Medicare Advantage plans, you will not see IBS as a code that if you risk adjust or code to that higher level that you would get a greater reimbursement if a patient had Medicare Advantage. Common codes are going to be congestive heart failure, diabetes, the different granularity diabetes, if there's a cancer involved, if there's cirrhosis of the liver. It's amazing how patients can carry a diagnosis of liver cirrhosis, but if they're not coded for it on an annual basis, that risk adjustment score falls off of it. So that was only an example, but not a specific for HCC code. So the next one is regarding a billing question regarding a multi-specialty building that was told that if they saw a patient within that specialty building within the past three years that they were not able to code if it was out of their specialty. So all specialties have a taxonomy code. The problem with NPs and PAs is that we don't have our own taxonomy code. So if wherever I work, when my claims are built under my name, no one knows that I'm working in a gastroenterology practice. So I would actually question that because different specialties can get the credit for billing for a new patient code. Now the challenge is if there's not a taxonomy code, say for someone like Dr. Kyle, who is a subspecialist, or Dr. Martin, who's a subspecialist within that gastroenterology practice, then that's when, if there's not a taxonomy code to carve him out to show that he is a super specialist, so to speak, then it's difficult to code for that new patient visit. But you're comparing apples to oranges when you're saying, if my patient saw a cardiologist last week, but now they're seeing us in GI for the first time. There are different taxonomy codes. So I would question that, to be honest with you. Can I code for lengthy phone calls, not part of the telehealth visit? Absolutely, you can. There are specific codes for that. But the question is, will you get reimbursed for it? So there's two different conversations. There's a CPT code that may translate that information, but will a health plan acknowledge that? So if you wanted to look up telephone codes, it's 99442, and it's time dependent. So that's 11 to 20 minutes. And then 99443 is 21 to 30 minutes. But again, is the insurance company going to pay for it? I know many years ago, before the pandemic, I wanted to start tracking that, to be able to then build that medical, to build that necessity of administrative time, because I was spending a lot of time on phone calls with patients, preparing them for their procedures. And especially now with open access, there's a lot of work that's done that's not captured in our normal work, our view plate. And when I brought the discussion about is starting to bill for these codes, you know, the conversation was, well, if the insurance company doesn't pay for it, then that bill is going to be adjudicated to the patient. And then that's a patient dissatisfier, because now they're going to get a bill for potentially $59. So here's the problem with all of a sudden submitting codes without having that conversation with your coding and billing department. Another conversation was, is it true that telephone visits won't be reimbursed in the future? Again, this is payer specific, but I will tell you that when the public health emergency ends 150 days after that, then they're revisiting reimbursing for our telehealth visits, and the telephone visits, because right now we're using those telephone visits, we're getting reimbursed, as if it was a virtual visit. So our organizations and individual practices, we're going to have to pivot and be able to bring those patients back in again in the office to be able to recoup that potential cost where we've got at least 20% of my patient population loves the virtual visits, and they don't want to go back. So organizations really have to start paying attention to this and develop some type of outreach program for their patients to bring them back in again. The last question, the coding question I saw, I feel like I frequently under code. If you feel like you under code, then most likely you are. Now the question was, will the coding auditor bring to my attention if I'm under coding or only over coding? They should be doing both because it's still considered coding fraud if you are under coding or over coding. Now there are a lot of physicians and gastroenterologists that I've worked with over the years that have said, oh, I heard 99215s are audited more often than other codes, so I'm never going to use a 99215. And what's happened over the years is that as our patients have gotten sicker, that code is being used more often, but really we should have been using it all along because it describes the severity of the illness of the complex patients that we see. None of our follow up patients that we see in the office completely improve their symptoms and or they bring in another symptom to us to help care for them or symptoms come back that they had before. So talk to your coding department just to make sure that they're giving you an audit of over and under coding. Then the last one that I saw was, can you clarify how to choose a new patient and a consultation billing code? So Joe showed a slide that gave the key components of a consultation code. So you need a referral, you need to render your referral, and there needs to be a request for it. So you need those and you need to render a report. So you need those three key components to consider using for a consultation code. Now, new patients, we do our documentation as if it were a consultation. So it's a matter of semantics, I think, but as far as if you're using the actual codes for the billing set, you need those three components to actually code a consultation. I'll just add a one line comment. Years ago when I was looking at these departmentally, 60% of our faculty were under coding compared to national benchmarks, if it makes you feel any better at the APP level, but it's a common problem. And one of the things that Jill mentioned is almost never discussed, which is under coding in the eyes of the law is an equal level fraud. It never comes up. And thank you, Jill, for bringing that up. Oh, you're welcome. Well, load up those coding questions. We're going to jump over to a couple legal questions really quickly. And we know Dr. Shields had to leave us, unfortunately, he had another commitment. But if I could address this to Dr. Call and Sarah, in New York State, there is no longer a requirement for a supervising position for PAs. How do you recommend PAs manage legal situations where they are considered the sole provider? Would you be able to provide your perspectives on that? Yeah, so Dr. Call, if it's okay, I'll just clarify, and then I'll turn it over to you. So in New York State, during the COVID pandemic, PAs have been granted full practice authority. We don't actually have full practice authority yet, it is actually expiring. There's a bill right now with the governor that will grant PAs full practice authority if they have over 8,000 hours, and they work in a primary care specialty, or only certain non-surgical subspecialties and GI is not one of them. And so it remains to be seen whether this bill passes or not. When you're in a institution that has a practice agreement, though, you still have that collaborative practice. That's my understanding. And so if you are in a practice where you don't have that agreement in place, I believe it's handled the same as the physicians. Is that right, Dr. Call? Yes. So what you basically alluded to is that there are caveats to this new mandate or new dictum, so to speak. I always say, you know, whenever there's a new randomized trial that comes out and says, you know, we don't need antibiotics for pancreatic cyst FNA anymore. It's one paper. I don't change my entire practice based on one 45 patient study. It's good to make note of it. It's obviously important to digest that as new information and accommodate that as best as you can. But I think these type of paradigms are now coming into play in the post-pandemic era. Going back to what all of us said, and Joe alluded to up front in the morning, is that there is a severe access issue. And I think for many other reasons, but also for that reason especially, I think it is now being promoted and propagated that the APP practice paradigm needs to be elevated to a level where they really truly should be considered as independent providers. And I think a lot of these policy and regulatory changes are coming in line with what the ground realities are. So I think the bottom line is there's more to come on this. In the meantime, I think it would behoove us to use common sense, work within our skill sets, work with guideline-based recommendations, and absolutely still maintain, even if it's informal, but those collaborative relationships between the physicians and MDs that will serve our patients well so that each of us have each other's back when there's a contentious issue. I think, you know, I do a lot of legal work and one of the easiest days for the prosecution is when two parties in a practice are talking against each other. There is no case for defense in that situation. Sounds like that theme, you know, really is the same one where, you know, we're always stronger as a group than we are individually, right? Absolutely. You always want strength to come from collaboration, and whether it's making clinical decisions in complex matters, or with legal liability, there is strength, not only in numbers, but in agreement and collaboration. Yeah, and I distinctly remember an ERCP lawsuit where a patient, you know, back in the days of moderate sedation, a patient was desaturating and the deposition read like this, you know, the nurses, pages and pages of documentation saying I'm telling the doctor that patient is desaturating and the doctor says the nurse never said that. So, I think, you know, I think this is a collaborative practice regardless of what mandate comes down the pike. I think we are better positioned to focus on the interest of the patient, which comes best from collaborating. No question about it. Really appreciate that erudite discussion. Eden, it looks like there's a couple of additional questions that remain that are related to billing. Right up Jill's alley. Yeah. I'll jump right in there. So if a patient has GERD and also obesity and obstructive sleep apnea, I can bill for those for clinical decision making. So you want to, you want to code and submit on your encounter every appropriate code that's pertinent to that visit. So if it's not pertinent to the visit or your discussion, then you wouldn't want to submit an ICD-10 code. But all those codes absolutely would go towards your clinical decision making. Because from looking at this information, you're giving me data, you're giving me diagnoses. From this I'm already making a decision that if I'm going to order an endoscopy, I'm going to recommend monitored anesthesia because of our requirement for obstructive sleep apnea. So would that make a difference though? This is a new patient between 9-9-2-0-4 and 9-9-2-0-5. Probably not. If that patient all of a sudden had, you know, her hemoglobin, his or her hemoglobin had dropped, and I had to make some type of emergency decision and coordinate an endoscopy within 24 hours to do those procedures, then yes, that patient is sicker. And I could build that case for it to being that higher level of a highest medical decision making. A question regarding the teaching hospital. You know, I don't work in a teaching hospital, but this was under the same vein that I just spoke about. General GI and a subspecialty, if there's not a separate taxonomy within that specialty, then it would still be considered a follow-up visit. Am I right, Dr. Kahl? Absolutely correct. The three-year time clock still exists, and if it's one business entity, it's a follow-up visit. Absolutely. How many taxonomies are there in gastroenterology? Is it just one? That's another course altogether. That's another course. We have to charge. We have to charge separately for that, right? No, there's a lot. There's a lot. But I think the basic rules are still there. And I'll also say this in the interest of simplicity. Whenever there's a question in the moment, err on the side of what you think might be the safer answer. In other words, that is not the day and moment to try and make an extra buck. I think if you have a question, your billers and coders and administrators will always be able to revise that and upgrade that. But err on the side of what you think is the right thing to do. I also want to put a plug in for when you talk about medical decision-making and complexity, what I have found very useful because I didn't go to typing school, and my hands are probably better used in cannulating bile ducts, which I already still struggle with compared to Dr. Martin. I found voice recognition software very, very useful. And not just because it's finally come of age. It's finally come of age. It's 99.99% accurate, even with my accent. So try to look into that. I'm not going to put a plug for one company or another, but voice recognition software, even in the clinic, can actually translate your sentiment, your concern, your level of complexity, your difficulty with the case, so eloquently that no amount of typing can do that. It'll take away a lot of your after hours, what we call pajama time, and it's really, really good. So this one tip that I wanted to offer at the end of today's session is look into voice recognition software. It works across platforms. It's mobile. You can take it to the airport lounge, you know, whatever. And it's really, you can write paragraphs and paragraphs of very meaningful information about that patient and the concern you have about that level of consult and really, really upgrade your level of billing, as long as, obviously, it's medically appropriate. Another billing question for you, Jill. We can sneak in these two final questions. In regards to billing modifiers, is the code AF specialty physician, would that apply when you are collaborating physician assistance and sees the patient with you during the visit? So I'm not familiar with AF code, but as I looked it up, it is a HCPCS code, which makes me, I want to say that this is a Medicare specific code. So I don't have a position on that. Now, is that a code, do you use that at the teaching facility and in a teaching center? I must admit that there's very rare times that I'm stumped, but I do not know the code. It's one thing we should get back to the team on that. Okay. And this person did indicate it was a teaching facility. So to close this out today, Dr. Vacari, in regards to high quality colonoscopy measures, is the ADR published or required or is that voluntary publishing only? So I think once you have your ADRs, how public do you make them is the question. Okay. I want to make sure I had that right. So you do not have to publish them on your website. You don't have to share them with your patient, but all high quality practices should be part of a benchmarking project. So definitely can participate in a benchmarking project or your group should. Then you have access to that information. Most of that comes up in questions from patients. And I guess my point was discuss them as a group rate, not individual rate. But if you within your practice would like to know, in my practice, as all the physicians knew, everyone else's adenoma detection rates and there is nothing sacred. So that means all the nurse practitioners and we only have nurse practitioners, all the nurse practitioners know. So they may know about the rates. The published part is the recommendation for 25% overall. They're in our guidelines, men and women, 20% women, 30% men, those are published. But you don't have to publish the group or individual rates. That's just there for discussion if it comes up.

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