One of the things I learned the hard way is green top tubes. The same color green can either be a sodium or a lithium heparin tube, and you really need to make sure that when you ask your, your lab, it's, you don't just go by color tubes but you actually ask what the preservatives or chemicals should be in the tubes. And so what I'm going to do now as I said in the video this is really nice because it actually has a box here that sounds when you are in the correct position. This, your, your landmarks are again are here's the top of my patella it's one centimeter above. Here's the bottom and it's one centimeter below, and it's and then I'll mark it with, with a pen but not with the ink, you know there's the little circle where the, where the pen comes out and I'll actually imprint by turning it and it makes a little circle that is easy to see. And so here's one centimeter one centimeter and so it's right about here if you do hit bone. Okay, so went right in. Okay, and then you can hear, and that's what's nice about this and I look forward to when post pandemic, we can meet together because it's just so wonderful to be able to do this over and over and over again. When you do it live. As I said, if we were going to aspirate. If it was this guy's knee I'd actually probably use this 60 cc syringe a very large syringe, that would be partly for comfort stuff, but, but what you would do is you would clamp the tube and then just take aspirated effusion, and then I would grab my steroid and put that in. So it's only one stick. I would inject my steroid. I've got my gauze here that I would put on here. And then just put a little bit of pressure all needles now have safety caps but not our demonstration here. I do have alcohol wipes here. I don't use these in the beginning I use these at the end because what I would do actually is I was holding is I would clean off the beta dine, just because it stains clothing. I would then I already have my bandaid you know partly. Again, everything ready, and then I would just take this off. I'd put the I'm not going to put the bandaid on but I put the bandaid on. And then the last thing I would do is go back and do the post exam. So the pre exam usually you know doing range of motion would cause significant pain if that didn't I wouldn't be doing the, the injection, and then you go back and you do you know range of motion, again, with the patient, and, and it really is miraculous because again this is such an easy joint to hit that you, I mean I don't think I've ever not not hit the joint and had 100% relief and it is kind of magical because they really go. The patients that I do this in our insignificant discomfort. Let me put this back again so I can. You can see me I can see all of you, but, um, but but the main reason why we are again using the anesthetic that was said in the video is that if the pain completely goes away from the injection then you know you got the lidocaine in the right spot and if you got the lidocaine in the right spot. You got the steroid in the right spot. The, the, you know, I would tell them not to do, you know, more activity than usual take it a little easy just for the next six hours or so, because you don't want them causing harm that they don't feel because of the lidocaine. And then the last thing that was again in the video but it's so important is if they are particularly insulin dependent diabetic I have had people that were very well controlled that shot up into the 400s. After a steroid injection it can it can be delayed up to a week. So you really have to have them follow their blood sugars, more closely for at least a week. But again, giving them all this anticipatory guidance really helps them. And sometimes I'll even tell them, you know, just if you know here's the sliding scale if they have a fast acting insulin, and just make sure that they follow the, the, the sliding scale but to call if anything. I have never you know steroid flare in, in the, in the literature happens two to 10% I've never once been called with it but I think it's because of the instructions that we give. I've actually never been called once after a steroid shot in terms of a problem. I do these at most about once a month. And so it's not, it's not an unusually not even, I wouldn't even say 12 times a year. And so it's not too common it's not something that I generally recommend the majority of steroid shots that I do is in people who've had them before, and, and request them again. Usually they have to have relief for at least a month if not more for me to consider giving another one I would never give it before three months, and not more than three in a year there was an excellent JAMA article I think it was in 2015 that showed if you have more than three injections they follow these patients over a few years that they found more rapid progression of the arthritic changes in their, in their knee and generation, and so it is something that is definitely a two edge sword. And so I think I'll stop there. Any questions and I would just love to hear, you know, your thoughts about, do you do injections in the home. Was this helpful. If you don't do injections would this be enough, again it's, it gives a lot greater confidence if you're actually here being able to use the, the model in terms of doing it on your own, but just any thoughts about knee injections or any questions. Do you do, does anyone on here. So far every the two previous groups there were people that were already doing knee injections one guy was actually doing like send us that, that I have not done just because I just don't feel the data supports it very well and, and our patients are generally so advanced osteoarthritis that the literature just doesn't really support it. But anyone doing injections. I would say about 50% of our group does 50% do 50% don't, but yes just steroid injections no symptoms. Okay. And, and do you if the ones that don't. If someone really requests it on a don't don't provider I shouldn't say, I don't provider will sometimes because I've actually done this more for shoulder injections that even for like Dr Chang's patients I would, you know, ask me, you know, Tom, you know this patient is a shoulder injection because I just kind of did them more and longer, and I would sometimes see one of his patients but do you guys do that at all. You do in our practice, the ones that will do the injections will travel to help do them for others. We have an amazing nurse practitioner who is nationally wound certified. And so even. Again, this is what I love about team based care is she is much better at wounds than Dr Chang or I, and so she will travel a little more. to her, or she'll actually see the patient and give us some advice I mean just that great care team where you're using the strengths of everyone. Any questions about any of the other procedures at all. Are you guys changing G tubes at home are you doing trick changes G tubes are the easiest one I mean that's one that I really would encourage if you haven't felt comfortable. They're just so easy to do the risk is absolutely minimal as long as there's been six weeks. In terms of allowing that the track to form I actually this is something I brought up. I actually every time I do a G tube change I show the family how to do it. doing it. I will actually in subsequent visits have them under my supervision, change the G to because G tubes tend not to fall out during business hours. And so, and it's just an easy easy way to prevent an unnecessary hospitalization, and and this was also concurred by someone on the previous breakout. It's amazing when you go to the emergency room to have it replaced, they have to call GI or interventional radiology like even the ED doctors, you know, don't in any and I shouldn't because you know if they're not used to doing it you know concern I mean it's amazing the complexity that you know something I teach, you know, families to do at home. They're calling an interventional radiology and even sometimes in terms of the delay. The whole closes up because if they have a lot of granulation tissue these can close easily within eight hours that's what we say is really need to get out there within or that whole it's amazing how quickly it can close or make it more difficult if it's 18 French to get an 18 French back in any experiences with this or any other questions. I think Brianna who's on is also going to tell us that it pays $227. And so that's just another the knee injection I think only pays about 60 Brianna you're going to give a little talk about billing. Sorry I was working on myself but yes, we are going to go back to the main room very briefly because it actually doesn't take me long to go over procedures and talk about how to bill for some of these things and some of the gray area challenges that we'll get into with the trick on my way I don't recommend billing for certain procedures in the home. Yeah, we stopped billing for trade changes, because of what Brianna is going to going to tell you, and it's so I mean because you know what a blessing to these event dependent I mean I even stress a little bit about, you know, doing trade changes on And because of how it's defined in terms of billing for a trade change as part of Northwestern we just decided it wasn't worth billing for in terms of, of it not being clear is this really something you can build for. But that's something that Brianna will I'm stealing some of her thunder. Last one more time so you guys doing G to change that I haven't heard anything because that really is something that or do you have, I mean I assume you have patients with G tubes is that, is that true with what yeah so I'm seeing shaking heads. Yeah, we definitely have them. And again, it's probably some providers feel comfortable some do not. But I think just a little easy training like this and they would be very comfortable doing it. It's interesting because it sounds I don't know how many are in your group that you know what can we even do to like bring them if there's enough like in a certain area, because this is so practical and have these models to actually because it's just so easy and it's such an easy way to prevent. You know one of my patients Dr Chang on the way home from church. Actually he got a call on call and he just on the way home from church, you know, went to this patient's house was in the area and. And it was a very sad younger patient, and just what a blessing to not have to do an ambulance, the hospital and then just go through all this stuff it's just that simple. But so, you know, that sounds great. How much more time do we have Brianna. Or is Janine still on. She might be in the background sorry I have the agenda. Let me double check really quick. Our last 315. Oh, so we should be done that we might just be given the other breakouts just a moment. I'm so excited to have you all here with us today thank you for a long two days with us and spending so much time and just getting to hear from you all it's been so much fun so just thank you everyone. Absolutely. Thank you. Okay I like we have four more minutes in this round it says. So if anyone needs to take a like a bathroom break or get up and stretch really quick I think four minutes is probably a good plan. Hey, can I just ask a real quick question? This is Tulisa. Sorry, my video keeps going on and off. For the G-tubes, to know if someone's had it changed by interventional radiology previously, is it possible for us to change it at home as long as it's not the short, discrete one? Right. You know, there's actually, and Dr. Chang had a problem once with a PEG tube. And it's actually at HCCI. Paul could actually grab it. So there's a PEG tube, which is sometimes called a permanent tube, but it usually lasts about a year or two. I've had one as long as six years, but it was really not the prettiest. But inside is this silastic. It's about the size of a quarter. It's kind of like shaped like this, but it's just like one whole thing. But what it's made for is that you can put traction on it, like pull up on it. And it literally will compress and go through the tube. And then you put a balloon tube back in. So you can actually remove a PEG tube at home. The problem with Paul is one time he removed a really old one. And as he was pulling it out, the tube actually broke so that the inner bumper, and then there's the whole issue, you know, like you have to watch the stool and, you know, watch for signs of obstruction and stuff like that, which are very unlikely, the pylorus. But anyways, and so he's a little gun-shy, understandably. But I've removed maybe like in 27 years, six of them. So it's not very often, but there's, you know, there's low profile G-tubes, which the only difference is it doesn't have like this movable outer button. You have to order the right, the right length based on their abdominal girth. And so, but what, and those are just have, again, this little button that you put a tube in whenever you go to feed. But what's nice about it is, you know, when you're not feeding, there's not this tube sticking out of you. It's just this little button on the outside. But there is not a G-tube. Again, I said this earlier, and back around 2000, there was actually these G-tubes that the inner bumper was, had to be removed endoscopically. You actually had to go in there and then do so. I have no idea what it was, but then they started making these, you know, silastic ones that have this inner bumper that just no palm keeps it in, but is pliable enough that you can pull it out. Does that answer the question? I'll take silence as a yes. Yes. Thank you very much. Okay. I wasn't sure who asked. Everyone else is going to be joining us in about another minute, but we'll all be staying in Maine. So you can continue to talk or if something you want to share something in chat, please do. And then Brianna will lead us through a few minutes of our coding for procedures. Then we will have a break and then we will get back together for advanced coding. So everyone will be joining us soon. Here we go. I think it's starting to begin. There will be a countdown. I'll be back with you in just a minute. Hello everyone and welcome back. Before we continue I just want to thank you all for your grace as we moved through those rooms. As you know Zoom can sometimes take on a mind of its own and apparently we you know need to throw something in a volcano for next time or I don't know do some sort of sacrifice to the Zoom gods so it goes a little more smoothly but you all were wonderful and we appreciate it very much. Brianna is going to lead us through some common procedures in the home and coding for those procedures what you just went through and then we will have a break but before she does I just want to assure you we're going to be putting up more resources in the Learning Hub. You do have all of your procedure guides in the workbook so you will have step-by-step checklists with photos to remind you of what you just did with faculty and then we will provide more resources for you to serve as a refresher and with that I will hand it over to Brianna. Thank you. Great thanks Janine. So we're going to talk about coding and billing for the procedures that you just went through as well as wound care. It really does not take that long but we'll go through this and then we'll have a little break. So as you all just went through the break up there we go I was like where's my slide so let we're going to start with G-Tube and so it seems like many of you was performing these services in the home. If you are hopefully you know that there is a billable code for it 43762. Everything I'm going to talk about is from a traditional Medicare fee for service standpoint by the way I should say the caveat with all of these and I and if you have commercial payers or very specific Medicare Advantage just keep in mind that these kinds of procedures weren't exactly built to bill in the home. So I have heard nuances with certain payers here and there questioning their services at home so if you get those things you know just make kind of keep that in mind. It is a rarity a lot of times if you explain the situation to the MAC if you're getting a denial and submit some sample documentation you know sometimes I've heard successive practices that have gotten denials where they're like oh okay but generally not an issue to be in the bill bill it in the home. This is the CPT code for it and it even says without imaging or endostopic guidance so really just a retune check. The trick with this is if you're doing a G-Tube and your E&M visit you really need to have a separate area of your note that's going to serve as your procedure note because that's when we're getting into that modifier 25 territory on your E&M code where you have to prove to me the procedure was a separate and distinct service that should be paid and separately reimbursed outside of your visit and it just didn't add complexity or time to the overall service that you're already billing for. The best way but obviously it doesn't always happen if the patient if you're changing it because the patient actually had like a leak or a clog really critical to document that on your documentation because that's supporting the additional medical necessity of why you had to do the change at home. So again it doesn't have to be its own like separate note but it should be like a separate area within your progress note that's very clear that it's the procedure and that you're showing that that work was separate and distinct from your other documentation and there is a Z code a diagnosis code. I recommend using a different diagnosis code like don't just associate your chronic conditions for your E&M with the procedure. What are you doing for the procedure? Showing that separate diagnosis code is also supporting that that's separate and will get it paid the first time much more likely than if you're not you know associating a diagnosis code that's really talking about the work that you're doing specific to the G-Tube. Any this I'm sorry this is the payment for it so it does actually pay you know almost $300 again this is the national medicare fee schedule. It is allowed every 20 90 days that's talking about the equipment itself so you know from a kind of just management standpoint to making sure your patients and caregivers are educated about having the extra G-Tube at home so that if you show up and they have to change it and that's bare and sometimes that DME coverage can cost lots of headaches. We threw these slides in here really just as resources for you. I will tell you the learning that we had with G-Tubes is if they get their internal nutrition supplies from a different vendor than the actual G-Tubes itself sometimes we saw as a practice that those were being denied and they can just be a headache even just getting your patients the supplies that they need. So again from that just DME coordination standpoint you know and realizing that unfortunately there are some things medicare doesn't cover that can be you know a you know a cost to your patients. So that's where you know financial assistance programs through senior services and local area on aging can be a huge benefit to make sure you're connecting with patients with those resources when they need it. The feeding pump guidelines again we really just put some of these things in here more as resources. Any questions on billing for G-Tubes? Okay so this is where I'm going to tell you I don't recommend billing for trach tubes at home and actually it was just a couple years ago I had a question and some where I kind of went down a rabbit hole. I even reached out to a national auditing society for a second opinion on this. Really did my research on the code definition for the CPT the only CPT code that exists for trach tube changes today and I think this unfortunately just comes back to the they don't understand home-based primary care and this code wasn't built to do in the home. But you'll notice in the full code description here it says not you know root not used for a routine change and before the establishment of a fistula track which is the problem that we run into with using this code. Now what you can do instead is if you are and it only pays $35 too so it's not like you're missing a huge substantial amount of revenue. What my recommendation to do this instead is you still want to document that you're you're doing the trach change at home because that's going to add to the overall complexity of your visit and potentially even the time of your visit. So if you're doing this at home I would make sure you're supporting a higher level of E&M service than you typically would for that date. Now if you if it's extra time but usually especially if you're you know explaining the patient's trach the additional education and time that you had to provide the the change for it you can support that higher level threshold the 99350 for if it's an established patient and that at least kind of in a way gets you the additional reimbursement for doing these things at home. It's just the right thing to do thank goodness the patient has you and they don't have to go to the ER for this but from a true coding and documentation guideline perspective they just didn't build this code for for you know routine changes at home. You can check with your MACs. I had one practice reach out to me and tell me they kind of went to bat with MAC stands for Medicare Administrative Contractors so everyone has their own in their own region. I have some resources in our advanced coding talk about how you find that but you know if you made the case to them about what you do and provided a sample documentation you could ask for you know permission to build this service at home but again you're you're fighting for $35. There are certain procedures that you absolutely can do at home again knee injections absolutely one of them 20610 that's your code for billing in a major so this would be like a shoulder or a knee generally the knee injections are the only ones that I've been hearing doing at home. The kind of caveats with coding that you need to think of again knowing if it's bilateral or if it's right or left and then if you're doing multiple joints using modifier 59. Now again separate procedure note you need to show me that if you're also billing an E&M visit that this additional procedure was medically necessary and it was separate and distinct from the other work that you performed so you know those are Medicare's favorite words. You really want to make sure that if you're just going to the home let's say you added the patient on at the end of your schedule because they were on your way back and you're just stopping to do a quick joint injection that really doesn't warrant billing the E&M visit because in this code itself when we have procedure codes Medicare always builds in a little bit of and CPT what they consider pre-service work and after so that initial assessment just to do the injection if that's all you're doing then you should just be billing for the procedure. Now logistically most of the time you don't run out just for a joint injection but if you did if you're that person on your team that this is your skill set and you're asked to see a patient and that's really all you're doing then you're only billing for the procedure but if you're doing your normal comprehensive visit in addition to the joint injection then absolutely bill for it but you need to kind of make that case for me in your documentation that separate area where you're going over you know not in your chief complaint definitely don't put joint injection in your chief complaint for that note because that's telling me you were there to see them for the joint injection rather than you know managing their chronic conditions and other issues that may have been going on with the patient. And then billing for oh I should say to make sure you're billing for the correct medication if you're the if you as the practice are buying for that that's those J codes and we have this on the procedure handout too I think the handout is a little bit more clear on this but you know you that's you got to be careful you got to bill for the right amount of units and medications too if you as the practice are buying it for the patients. And it pays about 65 nationally again with a 0.79 workout for you. Any questions on billing for joint injections? Okay all right so wound care you got to hear from Michael so with wounds again we have extra documentation and you heard Michael talked about it you always want to know the coding for wound debridement is specific to the depth of tissue that was removed and they also want you to measure before and after debridement so if you're not measuring wounds when you're debriding them that's going to run into problems from a documentation standpoint and you also are going to want to keep in mind the depth of tissue that's being removed because that's how these codes were built. There's different types of debridement generally these first two the 11042 or 11045 are what typically most people are doing in the home. It's the first 20 square centimeters so if you're doing more than that the error that I see a lot happens is people trying to bill 11042 twice that there is a different add-on code this 11045 if you're debriding additional tissue that you would use so just make sure that you understand how much debridement is being done again kind of that separate procedure area and your note you're measuring the wounds and then you're you're billing the appropriate code based on the depth of tissue that's removed. Michael are you still on do you have any tips or anything you want to add on how you approach documentation and coding for wounds? He might not be. I know Michael does do some of the more advanced you know the I've added the other codes for the muscular fascia depending on what type of wound debridement is being done in the home. So when oh go ahead. There he is. It's really hard to get the higher code the greater square cm. Yeah I didn't think so. I'm like you know again I'm not clinical so I'm like well maybe they are but I know I chatted with you about that. I'm like I don't think you'd be doing more than this but in the home it would be really difficult. Any other best practices on documentation that you like to do that you wanted to share Michael? I wanted to make sure I gave you a chance if you wanted to chime in. I think I think you what you've covered here is good. Okay the other kind of tricky part that I'll come into with wounds is when there's multiple too right again and some of this just comes down to feel like there's so many things you're doing in the home documentation takes so much time as it is but again making sure you're numbering the wounds that you're identifying the different sites if there are multiple of them even if you're not debriding again like all of these things are adding complexity you need to kind of paint that picture of everything that's going on with that patient in the home and all of the things that you have to do to treat those patients but especially if you're billing for multiple wounds make sure they're numbered measurements probably the biggest error that I see is not seeing that in the documentation both pre and post procedure and the total amount of tissue debrided. Here's what it pays again from a CMS national fee schedule standpoint along with the associated work RVUs this really comes down to everything that you're doing in for in the home just making sure you're billing for it you know don't just do a wound debridement and forget to bill for it if you are providing that service. Okay so we heard about g-tube trach and the knee injections as well as wound care again trach is really the only one I do not recommend billing for in the home because of that unfortunately language about it being prior to the establishment of the fistula track but these services are important and vital to the patients that you care for at home and they're super appreciative that they have qualified providers such as yourself that are able to perform these services so thank you for that and with that Janine do we have time for a break while I check the chat map? Absolutely so since we have you bringing us through to the end of the day with advanced coding let's go ahead and take 10 minutes we'll give all of our faculty a break and then Brianna will get back together so that puts us at okay yeah we'll call it there you go thanks for bringing us to the break slide okay we'll see everybody uh 10 minutes from now and Brianna you're already queued up with your slides so you're good to go. Great thank you. Okay, everyone. We're going to rejoin for our final session in just a minute. If you can hear me, please return Brianna You are doing your own slides. So I am here for your support as we continue. We are going to be doing advanced coding and more ways to sustain your practice. So everyone get your questions together because you will have Brianna all to yourself until 434 35 central time. To get all of her knowledge and get some questions answered. We will be moving through her session a little more quickly, just because procedures. We wanted to give you all plenty of time there. But all of the information that she's going to cover is in your learning hub. You've got all the slides. You've got your workbook. They we just uploaded The coding chart that super bill coding chart for your reference. And of course, we are happy to provide you with anything else you may need. Just send us a note. Brianna, we are ready when you are. Okay, thanks. Janine. Welcome back everyone done to the end of the day, we're almost wrapping up. I'm going to try and make a lively coding talk for us so we can finish our day just as engaged as we started it. And there's a lot of codes. We're going to go over not expecting to retain everything all but more. My goal from this session is to make you aware of the services that are available. That very well aligned with the model of care that you guys are already doing. Again, these are things that you're already doing. These are services available for you. Everything is that I'm about to teach us from again a Medicare fee for service standpoint. So although you heard us speak so much about value based care. The reality is a lot of us are still relying on fee for service revenue today. Or even if you do have value based contracts, you, you know, may need to know fee for service billing to get, you know, new patients attributed to you or you may still have a part of your population that's fee for service. What I would say for those of you like Caitlin that are on the call that really are more value based care is Sometimes I try and remind myself that all of these billing models and these services that CMS has put out there, especially even the care management ones. They really tried to do from a quality standpoint. So think about the principles with TCM and CCM and do you have those kinds of systematic things in place for your practice. That's what I would offer you as far as making this valuable. I'm also going to ask for a little bit of participation in the chat. I'm going to spend less time talking about things that most of you guys are already billing for So if you can put in the chat if how familiar you are with CCM. I'm going to start with chronic care management. I tend to spend a little bit more time on this because I think it's important. But I would like to know if all of you are already familiar with this as we move along. So chronic care management myth. It's, it is a time based service, but there's a lot more to it than just spending 20 minutes per calendar month with your patients. So Really important from the start when you roll out a chronic care management program that you understand all of the requirements identify what kind of support staff, you're going to need. How are you going to do care plans and things like that. A couple people so far familiar with it. So again, patients have to have two or more chronic conditions to at least be eligible for it. This is non face to face time. The number one question that I get in billing is, you know, how do I get paid for all the phone calls with patients and family or how do I get paid for You know, all of the follow up after visits or before visits and things like that. Chronic care management or some sort of care management service, you have to be billing for something. How do I get paid for all of the follow up after visits and things like that. If we're going to talk about some other care management services like CPO and things like that. You have to be doing something Billing for some sort of care management service. If you're in fee for service in order to be sustainable and it's really just getting you paid for all of that work that you're doing. You do have to get consent. It can be verbal or written but for new patients or patients that have not been seen within the past 12 months You need to get that consent during a face to face visit and it does require the use of a certified EHR technology. They want that relationship with you as the billing provider on the care team so they can get access to you. Again, you need that separate comprehensive electric care plan. That has to be provided to the patient and caregiver, but all of these things you can see management of transitions home and community based services. These are all things that you're doing already is just getting a build in So here's just some examples of some consents, what that might look like in your EHR. Again, just during that face to face visit, making sure you're talking about them. I also get a lot of questions about what that care plan actually looks like. So we have a template for you in your appendix. CMS makes recommendations. These are their recommendations on what they expect to see in that CCM comprehensive care plan. So anytime see CMS recommend something I'm always going to recommend that we follow their guidance. Here are the actual codes. 99490 is your traditional CCM so that's most common. It allows you to bill for your clinical staff time as well. So it can't be your administrative front office, but it can be clinical staff and the provider. If you're a solo provider and it's really all your time, then I would recommend considering the 99491 if it's just 30 minutes and all your time. The problem with the complex CCM codes is you have to support additional higher level of medical decision making and we do have an add on code for traditional CCM. It used to be a different code. It changed this year. So you can still bill for up to a total of 60 minutes per month of non face to face medical and care coordination time with your patients and caregivers for rolling out a chronic care management program. And you would do that with 99490 for the first 20 minutes. And you can bill up to a maximum of two units of the 99439 to account for a total 60 minutes per calendar month, excuse me. There's also an option to bill if you're, this isn't required, if during that face to face visit, and this can only be done for new patients, that during that face to face visit you're spending a lot of time really developing that care plan for this, then you can go ahead and bill for the GO506. The language is pretty vague. You know, again, they want to see that you're doing that you as the billing provider. So this can't be your clinical staff are talking to them about CCM, you're starting the care plan, you're going over those kinds of things. Essentially, this is just giving you a billable service for your time creating that care plan. What do you have to think about from an implementation standpoint? Do you have the clinical staff, if they do, can they set the care plan up based on your assessment and plan so that you just have to review and sign off on it? How are you going to track your time? Most EM, EHR should have a module for that. If not, you could keep an open, you know, care management encounter, but you have to track dates of service and minutes, exact minutes and in a specific activity of what they've been doing. So don't just try and, you know, say at the end of the month, you spent this time, it needs to be recorded in real time as you're getting those calls and doing those things for the patients. So you're going to want to think about how you're going to track that time and how are you going to allocate that and bill for it at the end of the month. What kind of templates and macros and smart phrases can you provide? Thinking about that care plan. Oops, I hit too fast. Sorry. How are you going to get that to the patient and caregiver? Yes, it can be made available on their patient portal, but a lot of if they're not, if you don't have a good patient portal use, then you can't count that as delivering a copy of that, the care plan to the patient and caregiver, you're going to have to go another route like email or mail or show and document within the EHR that you actually provided a copy of the care plan to the patient and caregiver because that is a requirement for Medicare. There was an audit report. I don't know how many of you have heard of CERT for the comprehensive error rate testing. And these are just some of the pitfalls. I was surprised to see the electronic signature. So again, like they actually really want that that care plan has to be electronic and they were dinging providers for not having signed the care plan. Insufficient time documentation. If you're not telling me the exact amount of minutes on each date of service throughout the whole 30 day calendar month, that's going to get you into trouble. Missing consent is another big one. And again, specifics on how the time was spent, not just 20 minutes talking with patient's daughter, 20 minutes talking with home health nurse or 15 minutes, whatever the time may be. What was that conversation? What was clinically relevant and discussed? This is why it's important again from a fee-for-service sustainability standpoint just shows you kind of the differences, depending on how much time per month that you spent doing these kinds of things, what that reimbursement is going to look like for you and your practice. Any questions on CCM before I move on? Feel free to just use the chat or unmute yourself. Okay, TCM, I feel like has the like the biggest myths. I hear so many things that I think people just have misconceptions about. So a couple years ago, important for you to realize Medicare has raised the reimbursement increased how much they're paying for TCM visits by 30% in the last two years. So the highest level house call visit used to pay more for TCM and TCM used to be bundled with a lot of different care management services. That's no longer the case anymore. It is absolutely financially a good idea to provide and formally bill for TCM services and it's not it's unbundled with things like chronic care management on all of these things that used to be. So yes, I thank you for queuing me up, Dr. Milady. CCM and TCM can now, it used to not, but as of 2020 they unbundled those. So CCM and TCM can be billed for the same patient within the same calendar month. The patient does have to have a qualifying discharge. So just going to the ER is not a TCM visit if you're following up with them after that. Inpatient and observation hospital stays do count. If they're coming home from a SNF, so if they're again not like assisted living, but if they're in a skilled nursing home and they go home or they go to an assisted living and you're doing a follow up visit that also is a qualifying discharge. The second step of TCM is making what they call an interactive contact call. Now notice it says licensed clinical staff. So problem is medical assistants are not licensed and that call to the patient and caregiver has to be done within two business days from when that patient was discharged from the hospital or discharged from that inpatient setting. So you need to make sure you're getting notified of timely discharges and that someone from your team or yourself is calling to conduct a call to check in on that patient before you actually go make that face to face post discharge visit. There are certain non face to face services, all things you're going to be doing and the visit itself that are all included in this TCM. TCM is technically a 30 day period, but you're billing for it when you go make that post discharge visit. And I'm going to show you how you can document that. So we talked about interactive contact. This is what I recommend as far as a template for that call itself, because what I've done is taking a lot of those non face to face components that Medicare requires is for TCM services and started to show you and prove that you're doing that. I can't just be calling the patient. Hey, you know, Dr. So-and-so, or, you know, Michael is going to come see you on Tuesday, the 25th for your post discharge visit. Great. Nope. It has to be medical in nature, and this is going to start making that case. For you as the providers, you can see that they require all of these things. So I also recommend a template for your note. And here's what I would recommend that template. You could just create the smart phrase or macro, throw it in the bottom of your assessment and plan. The nice thing is I don't, you don't have to worry about the history exam and medical decision making components. If for TCM visit, focus on a meaningfully visit with the patient doing what kind of history you need, the exam that you're going to do anyways, and then really their follow up from the hospital. How are you going to keep them from preventing another readmission? But make sure these things are documented just because, again, this is just the template and then you customize. This is so you don't have to remember billing and coding restrictions and regulations and it's just show and then you would customize it with unique patient specific details per the encounter. TCM visits also too, they have to have a medical decision making of moderate to high complexity. I'm skipping ahead. I'll go back. Oh, so here's the two different codes. This is the slide I wanted to get to. So you have two options. Again, when you bill this code is the day you see that patient for the face to face visit. So when you go and you see them for the first time out of the hospital, you've made that interactive contact call already. And now you're going to document in your note. Usually moderate medical decision making is a really easy bar to get to, especially if they've gotten out of the hospital, but if you're there's also a time frame that you, it depends on how timely that patient leaves the hospital and then you actually get there. And notice this is calendar days. This isn't business days. So 14 calendar days of discharge, you see them within 14 days, you can build a 99495. That requires the moderate medical decision making. If you see the patient within seven calendar days of discharge, you can potentially build a 99496 but you also have to support a high level of MDM. That's another pitfall that I see, excuse me, is that TCM, you know, the high medical decision making might not be supported. If it's not, you need to build a 99495. Yeah, that's a good question Talisa about the certified MA. It really comes down to the kind of how your state licensures are set up, you know, and in a little bit of legal. When I've gone down the rabbit hole, I couldn't really support that being a licensed clinical staff member. But that would really be a decision for your compliance and legal department and if they want to take the risk with a certified MA. My recommendation is no, it really needs to be an RN or licensed professional. It can be newer established patients, though. So don't also think that you can't do bill a TCM visit. This is just to show you, Dr. Milady, to your point, all of these services used to be bundled with TCM. Again, they're no longer. You can build TCM and prolonged services. You can build TCM and CCM. CCM is still bundled with a lot of these things, but TCM, that transitional care management, is not. And they continue to unbundle it because they're really trying to prioritize TCM visits. CMS again thinks this is a quality thing and they want to see this go into practice. So thinking of the prompt notification of discharge is going to be important. You know, that patient and caregiver education about, you know, notifying you, create those templates, make it easy on your providers. Make sure you have a scheduling priority that you're getting these patients in with seven to 14 days, because if for whatever reason you don't see them within that time, then you're not going to be able to bill for it. And again, that interactive contact call has to be conducted. There is a caveat with that I should have, that isn't worth mentioning. If you have two failed attempts to reach the patient and caregiver and all of your other TCM requirements are met, you can still bill for it. CMS actually published that in an FAQ. They said they expect attempts to reach the patient and caregiver continue until they're successful. But let's just say they just really aren't answering the phone, but somehow you show up and you actually still do the visit. You can still bill for it. But again, you know, make all attempts to reach that patient and caregiver, you know, to make sure that that call is done. So yeah, about the seven to 14 days. If the call is not done at all, you can't bill for it because that interactive contact call is a requirement of TCM. Now, if you're trying to reach the patient, like I said, and it just for whatever reason you're not able to get there, but there would have to be in your EHR two at least documented attempts where you were trying to make that interactive contact call and it failed. And I don't know if maybe Dr. Cheng, you want to pop in on the chat. Any clinical criteria for determining the seven to 14 day visit timeframe? You know, any thoughts you have there from a clinician perspective on how you would prioritize patients? I mean, again, we know that the sooner you get to these patients post discharge, the better, you know, for preventing a readmission. You know, I think within seven to 14 days is reasonable, but Dr. Cheng, I'd appreciate if you want to chime in on any clinical considerations on who you would prioritize within maybe the seven days versus the 14. Yeah, those patients, we try to get to majority of our patients within seven days. I think it's from a clinical service standpoint, clinical care standpoint, and also from a reimbursement standpoint. So that's what we try to do at our practice. Obviously, those patients with respiratory distress from, say, CHF and or COPD, those are the patients we try to prioritize in terms of, you know, getting them seen sooner than later. Again, work with your team, work with your staff in terms of you may have to bump some patients off your schedule for the following week in order to facilitate a visit this week for your TCM visits. Again, we try to see them within a week for clinical purposes and also for from a reimbursement standpoint, particularly those with respiratory distress from different underlying causes, because we know those patients tend to bounce back to the hospital. Yeah, and just to highlight Dr. Cheng's point about the reimbursement, again, this was increased, so $281 for the 99496 or $207 for the 99495. Again, this has to be in your toolbox of fee-for-service billing. Again, pitfalls to avoid, I think we talked about all of these things, but also the misconceptions. Now, let's say you go and make the TCM visit and you really need to make a follow-up visit two weeks later. You can bill a separate and distinct E&M visit. I think that's one of the biggest misconceptions. It's just if the patient's readmitted, then you can't bill two TCM visits within the same 30-day periods. But if you can support a separate and distinct medically necessary visits, then absolutely. I would not recommend waiting 30 days before you bill the TCM visit. You're going to want to drop it. When you make that visit, you know, that's just kind of creating some more work and delaying reimbursement on the long end. It is a 30-day period, but the only reason it really becomes important is if the patient's readmitted, then you just have to know you can't bill a second TCM visit within 30-day periods. When you go ahead and make that face-to-face visit, instead of billing your normal E&M house call or domiciliary visit, bill the TCM then. That's your face-to-face visit. Just treat it as your TCM. How many of you guys are familiar with advanced care planning? We talked, obviously, from a clinical standpoint about it yesterday, but how many maybe in the chat are actually billing for it? Again, this is in addition. These are things you're already doing. I'm just trying to show you how to get paid for the work, the complex work that you all are doing. We bill for it a lot. Great. Then I'm not going to spend too much time on it. What I am going to show you is a template recommendation. ACP is time-based. It's when you're having that goals of care conversation, talking about their patient preferences, how do they want to be cared for if they are no longer able to make decisions for themselves. In order to bill from it, again, from the billing perspective, that conversation has to last at least 16 minutes, and it has to be solely on the advanced care planning. If you're billing for advanced care planning and an E&M, I need 16 minutes just on that advanced care planning discussion. You need to make that case that that conversation and that documentation is separate from the rest of the work that's supporting whatever level of service you end up billing. If it's 16 minutes, 99497 is for the first 30 minutes, but using CPT time rules, when you pass the midpoint of 30 minutes, you can bill for it. It has to be at least 16 minutes. If you spend at least 46 minutes, if it's a really complicated case, or I know we have a palliative care provider, that's when you can bill both 99497 and 99498. If you do offer these during an annual wellness visit, you can add a modifier at 33 so there's no co-pay for the patient, which is a nice benefit if you're doing advanced care planning as part of your annual wellness visits as well. Here's the template that I would recommend. Advanced care planning is on OIG's active work plan, so they are doing a lot of audits on advanced care planning right now. They're trying to gather data. They say it's for, again, a quality standpoint, but the thing that's missing, I think, is you have to document that there was a voluntary discussion, so in the form of consent. You made the patient and caregiver aware of what kind of conversation is about to have, and they consented to having that conversation. Medicare encourages you. That's the exact language they use to let them know there may be a co-pay, but again, it's really about documenting the voluntary nature, and then consenting to have the conversation. Who was present? That exact total amount of time. Tell me the minutes, and then what were the preferences? What was discussed? Don't get in the habit of using these generalized templates and then not customizing it. How do they want to be cared for? What kind of things went into that decision? All of those nuances that we talked about yesterday doesn't have to be a novel, but make sure you're being descriptive enough that you are describing the situations, and Talisa, yes, you can bill ACP and the annual wellness visit. Medicare actually recommends that. If you go to the annual wellness visit fact sheet, it says that advanced care planning is an optional element of the annual wellness visit. They encourage you to do that, and there would be no cost sharing for your patients from a co-pay perspective. You would just need to add modifier 33 to the advanced care planning code. Just an example documentation. Again, in the sake of time, guys, I realize I'm going through this pretty quickly. If you do have questions, you are going to get follow-ups from the HCCI team, and there also is always an opportunity for our learners that are attending today to have a follow-up one-hour consultation call if we need to talk more specifics on coding. Again, it has to be exact total minutes, don't give me greater than or less than, make the case if you're billing both this and your E&M, use that template and then don't miss the opportunity too. I mean, sometimes it's like, oh boy, this seems like kind of a little extra work, but it's worth it for the revenue standpoint because it pays about $86 or even more than that if you're having that extended conversation. Right now too, I mentioned in the telehealth talk, don't forget these can be phone calls. Let's take advantage of this public health emergency. If you're doing this audio only, you can bill advanced care planning as a telehealth service by adding modifier 95. So right now while we're in the public health emergency, it's also a little added bonus. Feel free to put any questions I missed in the chat. I'll keep keeping an eye on that. So this is a different option. Care plan oversight is another form of care management services. You have to pick like this or CCM. CCM is still bundled with a lot of services. So you couldn't bill for this and CCM. I see this a lot more with solo providers that are doing everything by themselves, but this is specific. The problem is it's a little bit more restrictive whereas CCM is your whole management of all of the patient's chronic conditions. Care plan oversight is specific to patients that are active on home health or hospice and your oversight of those services. And it requires 30 minutes per calendar month of you as the billing provider's time. It cannot count your clinical staff. That's the other big difference. For them are care plan oversight and it has a list of billable activities versus non-billable activities. So it's very important if you're billing for care plan oversight to understand what you can count and bill your time for and what you cannot count and bill your time for. And again, just understanding these things. That's why I personally like CCM better. I think it's more flexible than care plan oversight, but for the independent providers, if you're keeping track of your 485s, you're documenting all those phone calls back and forth with those home health and hospice nurse, it adds up to 30 minutes of your time per calendar month. And you think that this would be easier than chronic care management that has to have that separate care plan until you're able to hire clinical staff, then perhaps this is an option for you. I will tell you I've had an unfortunate experience of learning a provider that went through a significant CPO audit. She wasn't using exact amount of times and her documentation was very vague and it was almost a $300,000 audit with UnitedHealthcare because they went back through previous years because of how much she was billing for this. So you really need to understand these kinds of services before you bill for them. So again, each minute on each state of service, what the specific activity is and not just talk to home health nurse. What did you talk about? What kind of clinical advice was given? And it needs to be maintained within your EHR and then it's billed at the end of the month. I believe the question in the chat was about CCM and RPM. RPM is actually not bundled. I'll double check that on the app, but the nice thing about remote patient monitoring is they really are considering, it gets a little tricky because if you're doing RPM and CCM, you need to make sure you're not, what's called double dipping. You're not double counting time for the same activities and then billing both. Remote patient monitoring, you're really focused on that physiological clinical data that you're collecting from the patients and you're reviewing with it. Chronic care management, more focused on all of their chronic conditions. So you have to be really careful. CCM and the CPO is bundled. So not home health, there's a different code, which I'm gonna talk about next for home health certifications, but these care plan oversight, what we just talked about, this GO180 and GO179, this and CCM is bundled. Yes, you cannot bill both, pick one or the other. What's not bundled is this. Oops, I went the wrong way on my keyboard here, sorry. There are two codes and this is just a gimme, you're doing this. For billing, when you sign the 485s, when you're signing that home health certification and recertification for home health, this is not bundled with chronic care management. A lot of people think it is because it's grouped under that CPO category. I actually just even confirmed with a recent practice. I checked the CPT code book. I checked the NCD edits. There is nothing that says these two particular codes is bundled with CCM. GO180, when you receive, when it's initial, you're a new start of care for home health. You get, you're first putting that patient on home health services, skilled home health services. And you get that 485, you bill this the date that you sign it. If the patient is continuing on skilled home health services, and it can only be, it has to be exactly 60 days apart when you sign the recertification for home health, that's when you can bill the GO1790. Now, if your home health agencies are super delayed about getting you those, and you can run into some signature issues where you actually miss out on billing the GO179 if they're not exactly 60 days apart. But this is just something, again, have in your toolbox. From a documentation standpoint, they wanna see communication with the home health. They wanna see that those 485s are signed and maintained in your medical record, and that you were the one who ordered the home health. Like you, the provider, are the one that ordered the home health, that you oversee the home health, and you're also the one signing all the orders for it. This used to only be billable by physicians, but because of the CARES Act legislation that we got that allowed for physician assistants and nurse practitioners to now, thank goodness, they can order and sign and certify their own home health services. They can also bill for this now independently. Still be 85% of the fee schedule, but you can bill for it. I know certain states, I have heard some pushback, but if anyone needs the language from that, the federal government and CMS has finalized that as permanent policy. It's not one of the things that's temporary during the public health emergency. From a federal standpoint, nurse practitioners and physicians assistants can sign and independently certify patients for home health services, not for hospice, but for home health. And it no longer has to be a physician signature or order. There's a lot of education still going on in that. And if you're in a limited practice state, I'm still hearing some state policy barriers from certain states on that, but it was finalized as federal policy. Let me just make sure I didn't miss any questions before we move on. Any questions on home health certifications? Are you guys, I'm just curious too, how many of you are kind of aware of these things and billing for it all? Feel free to put in the chat. This is a newer one within the past two years. So cognitive assessment and care planning visit. Again, you'll see it's just the higher reimbursement. I think, I believe it's $283 is the national fee schedule. What this is, so we kind of wrapped up talking about our care management services, and now we're thinking about face-to-face visits. This is for a patient with cognitive impairment or dementia where you're really trying to diagnose or stage their dementia, and you're really focusing a face-to-face visit with that patient, really just on care planning and resources for that cognitive impairment or for that dementia. You can see it does have 10 requirements. So again, this is where templates are your friends. I actually, CMS has been pushing out a lot of education on this service. Again, they believe it's a quality standard of care service to offer for patients that have dementia or cognitive impairment. So they're actually doing a lot of education. They have a new webpage that I've downloaded as a PDF in your workbook that Janine was so kind to include for you. The link is also on the bottom of this slide where it goes over more detail. They actually even recently updated it even more to see what they want in that cognitive specific care plan. It's not as comprehensive as a CCM care plan, but you do still have to have a separate and cognitive care plan when you're doing this. So again, I know some programs that have rolled this out, like they might have a memory carry program or they use this code specifically for their dementia patients that are in a memory care facility. Not all the time, it can be billed once every six months, but if you're doing a face-to-face visit, that's really just focused on the patient's mental status and you're doing a standard assessment, you do have to use a standard tool like the FAST or something like that. You have to do that comprehensive medication review, evaluate their neuropsychotic and behavioral symptoms, their safety at home, talking with their caregiver and their caregiver's need, and then connecting them with the appropriate resources that they might need, as well as doing the care plan. Face-to-face visit, I'll have to check about that, Nicole, as far as if it's an inpatient. This is generally an outpatient service, so my guess would probably be no, but I'll double check on that. Again, don't forget about annual wellness visit, guys. It's just tools in your toolbox. Just know with annual wellness visits and implementation consideration is generally you guys as home-based primary care providers are billing for the GO439. It can only be billed once every 12 months and it has to be an exact 12 months apart, but the initial AWV code is actually only for patients that are new to Medicare and it can only be billed once in their lifetime, so chances are they've probably already had that when they come to your practice, maybe not, but that's something you can use your EHR real-time eligibility tool when you're verifying insurance and things like that to check, or there are some kind of more archaic Medicare websites and phone numbers that you can call and verify if your patient's ever had an annual wellness visit. So again, this is gonna go into your front office staff or your clinical staff when they're scheduling annual wellness visits, making sure that they're exactly 12 months apart and that they're telling you as the provider what kind of annual wellness visit it needs to be. The other thing that I really just wanna drive home is when you guys are spending extended time with these patients, this isn't an every visit, every time thing, but prolonged services face-to-face. So when each of our CPT codes, we know we should only be billing on time if the visit was dominated by counseling and coordination of care. If you're billing on time, then I need a compliant time statement in your documentation that tells me I spent 90 minutes with the patient, greater than 50% of it was spent on counseling and coordination of care. And then you have to describe that, discussing their needs for social isolation, maybe during COVID and offering support and connection with family or something like that. You really need to make the case and describe the nature and the context of what kind of counseling and coordination of care went on. But if you exceed the threshold, then you can bill for prolonged services. I really only recommend doing this when you've exceeded the highest level, because there is some language in the Medicare claims processing manual that says although CPT codes are not always based on time, they would expect that a prolonged services code that goes above and beyond the normal visit and is based on extended time would only be billed when the total time is exceeded, that that threshold is exceeded. So easy way to remember this, 90 minutes. Establish patient 90 minutes, I can bill prolonged services face-to-face. You can bill the 99350 and the 99354, but you have to have the compliant time statement included in your documentation. It's really important. I have lost my chat button, Janine, if you can help me out if there's a question. So come back to questions in a minute here, but help me out with the chat. Really, again, kind of your takeaway or your homework from all of this is you need to decide for your practice, what are all the tools in your toolbox? Which services, what am I already doing? Now I know that there's a coding opportunity that exists for that service, and so how do I get paid for that appropriately? How do I add those CPT codes to my provider's favorite list so they know how to bill for them? How do I create those templates so I make it easy for them? How do I create just an internal cheat sheet? Or you can use the HCCI cheat sheet, because we have those for you, as your provider education tool so they understand what to bill when. I am happy to help you with chat. There is quite a bit there, so as I'm talking and wrapping this up for the day, Brianna, you could go ahead and answer some of those. Okay. And again, we're going to be saving these chats, and we are going to be sharing them in the Learning Hub within the next couple of weeks. So, yeah, I think there's probably... Yeah, I'll come back to it, and if we don't answer as... Even with your superpowers, within the next five minutes... We'll make sure I follow up in writing then, if this isn't... Yes, I was going to say, maybe the chat, while I'm bringing us home, and Paul and other faculty are giving final thoughts in a few minutes, that might be a good time for you to pop in there, and of course, we can always follow up after. Perfect, and then I think that the comment on the Prolonged Services Non-Face-to-Face Code, that's the 99358. That code is bundled with CCM, keep in mind, if you're billing for that, but when you spend 31 minutes before or after, it has to be directly related to that face-to-face visit. I think Paul mentioned it earlier. Maybe you're reviewing extensive medical records. Maybe it's a family care conference. It has to be associated with that face-to-face visit, but 99358 is the CPT code for Prolonged Services Non-Face-to-Face. Again, you need to tell me total time. It has to be at least 31 minutes, and then you have to describe specific details, not just a generic statement of why that went above and beyond and why it should be paid. I think it's $113 for the Prolonged Services Non-Face-to-Face Code as well. How do you stay up to date for this? I mentioned the MACs earlier. What I did is look at all of the attendee rosters and where you all are located. Here is your MAC, and here is the link for your Medicare Administrative Contractor. Have your practice manager or somebody in your team subscribe to their listservs because they do weekly updates with coding and documentation, education, and resources. If they have a policy change, it's just super easy to subscribe and be up-to-date on it. That's what I do. I also included an audit tool for you. In the Essentials course, I go into much more detail on basic E&M coding. How do you know you're coding at the right level of service? I think it's only fair for you as providers to actually understand how I, as an auditor, would score that. We've included that as a resource for you, too. A lot of these services that we talked about today, if you really, as you're building out and talking with your team on how you're gonna implement it, take advantage of the CMS Care Management page. Again, I've provided the link for you here. They generally have fact sheets and FAQs. They do a really great job. There's a couple of them. I think their TCM ones are down, but HCCI has resources on that that they continue to update and make available. I am expecting an RPM resource somewhere soon. I've actually commented on it with our policy groups on how they need one, but these are the ones that exist today, but I foresee more coming available. And you can also subscribe to just the general or your practice manager or whoever on your team would be appropriate for this CMS listservs. And again, they do a weekly Medicare Learning Network newsletter. That's part of the easy way I keep up to date, too, is it just flags me to make sure I read these kinds of articles and stay up to date on coding and documentation requirements and changes. And then this is my favorite resource that we've created. Again, when I told you your homework is to go home, think about all these billing opportunities and how you're gonna integrate them in your practice. What are you already doing? What do you wanna consider on a routine basis that you're gonna provide education with or kind of educate yourself with and then build the templates, cheat sheets, make it easy for yourself. Take a look at this advanced coding opportunity resource. It really goes over every fee for service reimbursement opportunity that I think exists with home-based primary care and how you can bill for it, all of the requirements. I told you everything it's bundled with on this resource, too. It's really a great resource to kind of understand what's my billing model gonna look like. Yes, coding is complex, but I can make this easy for myself by creating templates, do these kinds of education. And then I can just fairly get reimbursed for all of the complex work and extensive things that you have to do for your patients. And then I'll just end by saying, for all of you on this call today, too, I hope you consider the HCCI as part of your team. We are here to help you. We are a resource for you to try and make sense of all this and make it a lot easier for you because we wanna see you be successful. And if we can support you in that journey, we are here to do so. Look at that, Janine, 429. Oh my gosh, you are all of the faculty. You guys blow my mind. That's perfect timing. Look at that. I think you still have, so we've got, we're gonna invite Dr. Chang back to give some final thoughts. And then I will bring us through just some logistic things. You're about to get an email from me regarding claiming credit and how to fill out an evaluation. So with that, Dr. Chang, if you're ready for us, Brianna, will you go ahead and drive? I will go ahead and drive, yes. I don't think there's really- No, not really. I was like, I think I have one slide. Yeah, it's late in the day. There's not much driving left. Well, I just want to say that thank you for hanging in there with us. We've given you a lot of information. Hopefully it's been helpful. And we do want to hear from you. Complete your workshop evaluation in the Learning Hub and stay connected with us. As Brianna said, look to us as part of your team. We're here to help you. We are all passionate about supporting you, whether you're in a big program, small program. We want to help you and meet your need, whether it's staffing issue or billing or some clinical issues that you are struggling with. And do we have time for questions? Are there questions in the chat box? Are there questions in the chat box that we can quickly address? I don't want to keep people online too long. It's Friday afternoon here. And I would just like to note that there's going to be, so you just received an email from me, everyone. And then there's going to be additional follow-up next week reaching out to you to see if you have any other questions. So if we weren't able to get to it this afternoon, because I know we ended with a big topic with a lot of questions. Brianna, I already see her focused on that chat, trying to get as much information to you as possible. I just want to thank our faculty. You all have been phenomenal. This is a big two days and just the back-to-back sessions and the wealth of information you all have provided is just incomparable. Also to our attendees, I've had the benefit of watching the chat and just getting to listen for the past two days. And your contributions to one another and to home-based primary care are so deeply appreciated. So I just want to make clear to you, if something comes up later, if you think of something, always reach out to us. We want to hear from you and we want to make sure that we're supporting you. With that, if there's any questions anyone has, please feel free. We had said we'd be together for another 15 minutes. If we get done early, that's great. But we do have time built in right now. You know, I like to... Jeannie, thank you for that. And I often end these sessions, whether it's essential elements or advanced application sessions, I like to end with a clinical story because you all have been so inspiring to me. So thank you for, and I said this before, thank you for your energy and your passion. The clinical story this week is, I saw this patient Monday. I saw her at home because of more and more decline to the point that the patient is no longer walking. And that the family is just in a lot of distress in terms of trying to find some help for mom. And somehow they stumbled across us. And we made a house call to the patient and the daughter. And we did the visit and so on, and we did the blood test. And as I was going over the instruction sheet, you know, I review, you know, you need to do this, change this medication, you know, follow a phone call. So as I was going down the list of instructions, the daughter just started to cry. And, you know, I said, oh, Paul, did you say something wrong? I said, oh, did I say something wrong? She said, no, you've given us hope. And here I thought I was just giving her a list. And, you know, I want all of us on Monday and me included to be that hope for our patients that they realize they can get great care at home from you all. Let's be that hope to our caregivers that we are here to guide them and support them through some potentially challenging times ahead. And together, let's be that hope, a hope of a fix to this broken healthcare system that is so inadequate in taking care of our elderly complex patients. Let's be that hope in these areas. And I'll just wrap up by saying, thank you for trusting us with two days of your time. We know two days, it's a lot of time and we don't take that responsibility lightly. So please give us feedback, positive, negative. We want to know, we want to improve. We want to meet your needs better in the future. So with that, I will end and answer questions. We've got a lot of lovely comments coming in in the chat. It's been our privilege. Thank you all. Thank you everyone. Thank you. All right, take care, everyone. We'll be in touch and again, reach out to us. We're here to support you far beyond this workshop. Take care. Thank you so much. Thanks. Bye-bye. Everyone go enjoy their weekends.

Chronic care management

Billing and coding

Home-based primary care

CCM

Non-face-to-face time

Multiple chronic conditions

Consent from patients

Certified EHR technology

99490

99491

G2061

Electronic signatures