Hello everyone. We are going to wait for everybody to jump in and give everybody a couple of minutes to jump into the webinar. And then we will get started. All right, we've got 47 participants coming in, so we'll give everybody an opportunity. We had over 100 people register, so it's going to take everybody a while just to jump in as attendees. I know you all have been anxiously awaiting this webinar, and we've been excited and ready to talk to you guys. We're just going to wait one more minute, and then we'll get kicked off officially. All right, we still have more coming in, a lot of people, great, there we go. All right, okay, we have a lot to cover today, I want to be respectful of everybody's time and get us started while everybody else starts coming into the webinar, but welcome. Thank you for joining our HCC intelligence webinar, 2023, here we come, I think we're already here, but billing and coding impacts, you need to know. My name is Zeta Crosby, and I'm the Senior Director of Engagement and Practice Development here at HCCI, and I have the sincere pleasure to moderate today's discussion with some really amazing presenters who are going to give you guys some great insight and information. Before we get started, I just want to go over a few housekeeping items and logistics. A recording of this presentation and the deck will be available on our HCCI Learning Hub shortly following the webinar. All questions will be addressed at the end of the presentation during the Q&A session. We'll open up the mic so you guys can answer some questions. This includes any questions that were submitted at the time of registration. We had over 40 questions submitted when some of you registered. The good news is we've covered almost all of that, so we have you covered already, but we have a few questions that we did not touch on the deck, but we'll talk about in the Q&A session. Throughout the webinar, feel free to add your comments or your shoutouts in the chat box. It will be monitored by Sarah with us today, and she'll be able to respond to some of those chats and get you some information that shows up that you may have questions about. And with that, let's talk a little bit about our presenters today. Today we have with us Dr. Paul Chang. He is the Medical Director at Northwestern Medicine and Home Care Physicians, Senior Medical and Practice Advisor for the Home Center Care Institute. And Dr. Chang will be making his 37,000th house call in the coming weeks, so I'm sure you guys will learn a tremendous amount from him. I know I have with his experience. We also have joining with us Tammy Browning, Director of New Market Launch and Strategy and Acquisitions for Village Medical at Home and President of Grace at Home, and Nikki Torres, Consultant Practice Development with the Home Center Care Institute. Today we're going to review coding, reimbursement, and policy impacts resulting from the 2023 Medicare Physician Fee Schedule Final Rule and how to best respond to those changes. We're going to identify and apply the correct CPT codes for care management services and discuss documentation requirements to ensure coding compliance. So we're going to start out talking about the changes and impacts with E&M. Including place of service, documentation requirements, prolonged services, which I know has been a hot topic, telehealth, and advanced care planning. Then we're going to talk about some case reviews and coding examples. We'll talk about examples and how you should code those. Then we're going to transition into chronic care management plan requirements and then touch on transitional care management care requirements, specifically face-to-face. And then we'll end with our Q&A session. Where at that time, again, we'll talk about some of the questions that were submitted prior during registration. And also open it up for you guys to raise your hands and then ask our panel directly questions that we may not have covered in the deck. With that said, I am going to transition over now to Paul and Nikki, who are going to take us through evaluation and management impacts. Dana, thank you very much for that introduction. And hello, everyone. Thanks for spending the afternoon with us. And I really hope the next 40 minutes to an hour that the information that we're going to provide will be helpful to you and your practice on getting all the reimbursement that you need to get your practice, to keep your practice going. We have a lot to cover this afternoon. So I will not start with any bad dad jokes. I'm sure my staff, they're very happy about that. So let's get right into it. So many of us on the call, Nikki, we take care of patients not only in the home setting, but also in assisted living facility. Now, there's been a major change to the coding side for assisted living facility for 2023. Can you tell us a little bit about that, Nikki, please? Absolutely. Thank you for the introduction, Dr. Cheng. So some of the major changes that took place this year are the deletion of the DOM codes. Previous to this, you either had the option of a home setting code or a domiciliary code. This year, domiciliary is no longer an option. Domiciliary includes the rest home, the custodial care services. Now, everything is billed under home. And then only home and residence services. So for example, the E&M CPT codes for a new patient are as follows, as you can see on the screen here. The 99341, 342, 344, and 345. That's for new patients. Established patients are as follows. And then, in case you were wondering, there was an elimination to the new patient codes. They're no longer using 99343. And then there's also an elimination of 99326. The other change to E&M targeting this year, that you had to document on time or you document on MDM, which is medical decision-making. Either one is appropriate. You still have to have a medically appropriate history of exam, though, in your documentation. Total time is not. So for example, MDM, or total time, is the sole requirement for selecting these E&M codes. These times can include pre-, during, and post-encounter, and does not require more than 50% of time to be spent in counseling and coordination care. Well, thank you, Nikki. And throughout the presentation, we are definitely going to get deeper into documentation, MDM, what is involved. And also, if you are comfortable billing based on total time, we're going to talk about that as well. Before we move on to the next slide, Nikki, what about the place-of-service code set, about 12, 13, 14? So even though the DOM codes are gone on the backside, what is happening with the place-of-service code set? So place-of-service, there are several different options for place-of-service. Place-of-service refers to where the face-to-face encounter took place. So there is a website, a CMS website, that lists the different place-of-service codes. The ones I'm going to focus on today are the ones pertaining to the home, excuse me, assisted living, and the group home. Home is listed as 12, assisted living is listed as 13, and the group home is 14. There are many more codes than just these three, obviously, but those are what we're going to focus on. For a full list of codes, I can give out the website for that. It's a CMS.gov website, but those, it depends also on the EMR, to be honest, that a patient could be using. Because I know, for example, with our EMR, if it's not entered correctly, it will get fixed in the back end. But some providers could potentially put that in before they build the encounter. But a lot of EMRs default to the office, because that's the traditional setting for these encounters. But for purposes of home-based primary care, typically they'll use home, 12, assisted living, 13, and group home, 14. Those are the more common ones. Well, thank you for that. And I think one of the questions that we had before, and I'm going to turn the next slides over to Tammy in just a second, there was a question about the place of service for a hotel visit, and that's code number 15. Tammy, can you help us regarding the new E&M requirements for 2023? Absolutely, but only if I'm off mute. Hi, everyone. Thanks, Dr. Chang. So, as Nikki was saying, the code sets are now only the 993413345 for new patient visits, and then 99347 through 99350 for established patients, regardless of their place of service, as long as you're seeing them in their home environment. Please note that with the new patient codes, there's only four codes now. Instead of five, the middle code, the 99343, was eliminated, and you can see there that you can document in two ways. You can document based on medical decision-making, or you can document strictly based on time, and the code assignment is one or the other. But not both. We're going to go into a little more detail about the medical decision-making a little later in our slide deck, but please note your time requirements for each level of service for new patients of 15 minute, 30 minute, 60 minute, and 75 minute increments. We can move on to the next slide and look at established patients. And here, your time increments are 20, 30, 40, and 60 minutes. Same type of medical decision-making, and again, remember, it's one or the other, not both. So, if you're documenting based on medical decision-making, you don't necessarily have to be with the patient for 60 minutes to build a 99350, as long as you meet that high medical decision-making criteria. And then we can, oh, Dr. Yang, Dr. Chang is going to talk a little bit about what is involved in that medical decision-making in the different levels. Well, thank you, Tammy. All right, it's going to get a little bit complicated here, so maybe let's do this. Number one, you're going to see all of the information, obviously, it will be available to you. So, if you want to go back and review, you know, what is in the bucket of this and that, I encourage you to do so. So, what I want you to envision regarding MDM are three buckets. Bucket one is the number of problems, bucket two is the amount of data, and bucket three is the risk to the patient, all right? Those are the three buckets to keep in your mind as you are taking care of your patients. Again, I'm talking about MDM right now, I'm not talking about time, okay? To qualify for a, say, a moderate or a high, only two out of the three buckets need to be fulfilled, not all three buckets. That's important to keep in mind, all right? So, let's start with, you know what, Dana, you know, let's just stay with this. The lowest level is a straightforward visit, and I'm really having a hard time imagining us doing a purely straightforward visit, not reviewing any records, not reviewing any tests, or not ordering any medications because the complexity of our patients that we take care of and we see. So, I don't see straightforward as being used very often. Next slide, Dana, please. So, perhaps we could see a patient with a low-level complexity. Now, to qualify or to meet a low level of threshold for a home visit, the first bucket, remember I said the number of problems, right? So, we got two or more self-limited or minor problems, one stable chronic illness, or one acute uncomplicated illness or injury, or one stable acute illness, or one acute illness that requires inpatient abstain, all right? So, what could be a potential example? You can say, well, Paul, you know, I take care of patients, they have a million problems, I understand. But if you're there to do an acute problem, say an ear infection, earache, okay, that could be an acute uncomplicated illness, all right? So, that's bucket one. Bucket two, remember bucket one's problem, bucket two's data. So, data, the amount of tests, information that you need to review and assess, okay? And you can read all of the requirements there. I won't, yeah, belabor just by reading everything, this information's available to you. Just go back one more slide before, yeah. Regarding the unique test, or ordering a particular unique test, the unique test is ordered by CPT code. For example, like your BMP has a unique test number, it's like 80,034 or something like that. So, that is a unique test. And the review of notes from unique source, that does not include providers from your office. It does include review sources from specialists and so on outside of your particular office or outside of your institution, all right? So, real quick, we got an ear infection. I review previous notes or records from the previous ENT doctor, for example. And the last is the risk of complication. Now, this patient doesn't have immunocompromised state, doesn't have diabetes and so on. So, there's a low risk of morbidity from additional testing or treatment. So, I treat the ear infection and I will code this as a low-level service. That will be a 99342 or a 48. Next slide, please. So, to build, I hope you're getting a sense of this. And I'm going to go over a little bit quicker now. To build for a moderate decision-making, again, number of problems. You can read it there, okay? A number of complexity of data to be reviewed or analyzed. Now, you have to have at least one out of the three below categories. One out of three. And in category one, you have three different choices, which you can read. I'll pause there for a minute. I'll pause there for a minute. And then the last would be the risk of complication or morbidity or mortality related to patient management, okay? Again, to qualify for a particular level, you need to meet two out of the three. So, you can choose from bucket one or bucket two or bucket one and bucket three. To qualify for moderate decision-making, a billing code. Next slide, please. Now, this is the highest code, the complex code for a patient. Again, it's the complexity of the number one bucket is the problem. And is it just a chronic stable problem? Or in this case, it needs to be complex. And it's very serious. And we run into patients like this all the time. For example, exacerbation of COPD or CHF. Okay, that would be bucket number one related to the problem that you're facing. Again, bucket two, similar to the previous slide, is the amount of data and complexity that you have to analyze, right? In this case, however, the previous slide for moderate, remember, you only need one out of the three. In this case, you need two out of the three in this particular column here to bill for high complexity visit. And the last bucket is about risk and complication and morbidity or mortality to the patient related to your management. To the patient related to your management. Okay, let me give you a quick example. I said COPD, CHF, patient looks terrible. That's the bucket one. Bucket two, you review previous records and so on and so forth. But you don't, let's just say you don't meet category two or three. You didn't really independently interpret any other test results. You didn't call the specialist and so on. But bucket number three, because of the complexity, you are now talking to the patient or family about needing to be hospitalized, needing acute care, or often we talk to our patients and family about, is this time to transition to hospice care? So you could qualify for a high complexity visit based on again, column one and three. In this case, you're talking about taking the patient to the hospital, or it could be one and two. If you picked up the phone and call the cardiologist and so on and say, hey, I have Jane Doe here. She's not really looking good. What would you recommend that I do? Then you can qualify this based on column one and two. All right, next slide. Okay, so I'm going to stop there. And Tammy, can you help us? Because we take care of our patients and they're really complicated and sick. And can you help us related to coding for extra time spent with our patient? Yep. Yeah, you bet. But I will ask that none of you shoot the messenger. This is not necessarily good news. We're all aware of that. And I'm not any happier about it than any of the rest of you are going to be. Basically, the prolonged services codes that we used to use, the 99358 and the 99359 are no longer being reimbursed readily. They're still out there, but CMS has said they won't reimburse for them. The usable code now is the G0318. The caveat for the G0318 is that it does include a much larger frame of time to collect time spent getting ready to see the patient, exploring options for their treatment plan, et cetera. So up to three days before the visit and up to seven days after the visit, the whole amount of time that you spend within that window counts towards your total threshold of time. It is 110 minutes for the 99350 established patient or 140 minutes for your new patient to build this prolonged service code. I've already seen questions in the question box about, I frequently spend 110 minutes with my established patient. How am I supposed to manage this? My suggestion would be to look at the total amount of time within that 10 or 11 day window, three days prior to the visit, the day of the visit, and up to seven days after the visit. And any work that you do include that within your E&M as long as it relates to the same diagnosis. And then there are requirements for your documentation here is really that you're very specific in documenting the days that you provided services, how many minutes you spent during that time and what service you were providing, and relate it back to the diagnosis or a diagnosis that is being discussed for that E&M service. So that's the good, the bad and the ugly with the prolonged service code. It is there. It is a different level now, but there are several days that are encompassed. Nikki, would you have anything to add to that? I'm gonna mute myself here. I think it was a great addition to what you're saying to look at the total time spent with the three days prior and four days after. That really helped close that gap that's missing now with this new G-code that CMS now put into this nice little system we have going on here. That, yeah, that probably covers the gist of what you were saying. It's a nebulous thing, unfortunately. It's not super clear-cut, but we're doing the best we can with regards to how to manage that, yeah. Yeah, so for this particular code, and I'll just, I'll turn it back to Tammy just a second. So CMS decided that they are not gonna follow the CPT 15-minute increments. They decided to have their own HCPCS code, and that's the G0318, okay? And CMS decided to follow their own Medicare time file. That's why you see, Tammy talked about 110, 140. That's a CMS thing and not a CPT thing. So it's unfortunately a little convoluted for all of us as we try to navigate through this in 2023. And I'm just gonna interject here because I'm seeing messages pop up. I'm trying to pay attention to them as they come up and are relevant, but how would you code for that the day of the visit or later if you spend time after the chart is complete? I'm gonna give you kind of a case scenario, and Dr. Chang, feel free to add in here if you've experienced this so far. But a perfect example would be, I've gone out and I've seen a patient who has a COPD exacerbation. I'm very carefully and closely monitoring them and working with our pulmonologist to adjust meds. And I know that I'm going to call them back later tonight, and I'm probably gonna call them back first thing in the morning. I'm trying to keep them out of the hospital. It's a very intensive home management process. I'm also waiting for a call back from the pulmonologist who doesn't get to me until tomorrow or maybe the next day. I would not code that out today when I finished seeing that patient. I would leave that chart open, would finish all my note from today, but I would leave that chart open. I would add charting from tomorrow. I would add charting from the next day when I speak with the pulmonologist. And when I'm sure I've managed that patient to completion, then I would, or that visit to completion with all the follow-up that I wanted to do in the days following, then I would close my note and code that out. Hope that helps answer your question. Yeah, that's great. And somebody mentioned the payment is terrible. And Tammy already said, don't shoot the messenger, right? Yeah, we agree. Yeah, we had a, no, we won't tell that joke. But there was also a message about only Medicare covers Prolonged Service Codes. Well, the G0318 is a HCPCS or Medicare code. There is a CPT code for Prolonged Services that is more time-based and that is out there, but Medicare won't recognize it. So if you have somebody on commercial insurance, you can bill the Prolonged Services Code, and that's 99417 at 15-minute increments. So if you spend like 32 minutes, you can do your new patient visit, as Tammy said, and then you can add 99417 twice if you have a commercial payer. But Medicare does not recognize the 99417, unfortunately. Nikki, you're gonna say something? Yeah, I'll just say the same thing. The 99417 for commercial payers, I just wanna make sure that was known too. So thank you for bringing that up. Yeah, this is strictly for Medicare people that G0318 code we're discussing. And unfortunately, I mean, the revenue is the same. The reimbursement is the same for both codes, but at least you can bill 99417 multiple times for those increments. So there's that, at least. Yeah, we're seeing, yeah, it pays a pretty miniscule amount for the amount of time that's required for you to do your work, 140 minutes. Just think about the amount of time. For me, it's hard for me to imagine spending that amount of time. Okay, I should stop talking because we need to move along. All right, next slide, Dana. Let's get this bad news off our plates. Yeah. Then I think, Nikki or Dr. Cheng, were you all gonna talk about telehealth? Yeah, Nikki, why don't you start with the telehealth and I'll be happy to add whatever comments as it related to the bill that was passed. No, no problem. So as we all know, with the public health emergency, there were some stipulations made to the telehealth rule. Right now, what's going on, I'm not sure if everybody heard about the Omnibus Bill, but it's extending the telehealth flexibilities for Medicare through December 31st, 2024. So despite what's coming out with regards to the end of the PHE, this bill allows us to keep billing for that through 2024. That being said, these codes can extend to domiciliary, rest homes, custodial care services. And then it's continued. There is still, the big thing here is there's still continued coverage with audio-only telehealth services. So that's the big thing. Everyone's wondering what's happening with audio-only. As of right now, it's not going anywhere, but that remains to be seen going forward. So that's why they take away from the telehealth changes for this year. It's not really a change, it's a continuation, which is nice, yeah. Yeah, so with the Consolidated Appropriation Act, I think at the end of last year that that was passed, there was concern that Medicare was not gonna cover audio-only, which some of my patients, they are not video-capable. There was concern that audio-only was gonna go bye-bye. But with the passage of that bill, they're kicking the can to December 31st of 2024, not this year, but the following year. Nikki, a lot of us talk to our patients about advanced care planning. That's one of the projects here at Northwestern this year to get all of our patients have this done. There is a coding opportunity here as we do our work. Is that right, Nikki? Yes, that is correct. And then just for clarification, advanced care planning, we're talking about the BOLST forms, DNR forms, the Five Wishes forms, any living wills or power of attorneys this is all encompassed in this advanced care planning code. At this point, it looks like the 99497 is for the first 30 minutes with a minimum of 16 minutes. It's documentation in your notes to support billing for this first 30 minutes. If you go beyond that, it's an extensive discussion. You can add on the 99498 for an additional 30 minutes regarding discussing these things with your patients in their homes or in their facilities wherever that visit takes place. Next slide. So what we're talking about here is with this being a national webinar, the caveat to looking at these reimbursement rates is really trying to determine your local MAC. So this specifically tells you based on where you're located, what kind of reimbursement you're looking for. To get specifics, there are websites available for this kind of thing. The one that we use obviously most often is a CMS website. So this slide here gives you an example of where you'd look to check for your specific MAC, your specific location to determine your reimbursement for any PICS codes or CPT codes. I believe there also is a link at the bottom of this slide with the specific web address for that. So keep that in mind when you're trying to bill and determine what code to use. Your location does make a difference with regards to that. All right, so we discussed earlier in the beginning of this presentation, going into some examples to let people know how to use some of these codes based upon knowledge and important examples. So this first case is discussing the new patient, spending an extensive amount of time seeing that patient, doing pre-charting, reviewing records. I think Dr. Chen, you wanna take this example? Yep, so what we wanna do next is to kind of give you a few cases to take what Tammy and Nikki and myself had talked about with MDM time and all that stuff. And we're gonna try to put it in motion because I think all of us work better when we have a real case rather than just a static thing. I'm just looking at a pie chart on the PowerPoint here. So this is a new patient visit. So obviously you spent a lot of time reviewing the system, providing care and so on, and the ears were cleaned during the visit as well. So the point of this is to highlight that you have a chance to build the highest level, especially if you've spent a lot of time with the patient. Don't forget to bill for cleaning of the ears. I think that's 69210 or something for ear cleaning. You can get reimbursed for that work. And Tammy already talked about the G-code. If you spend like crazy amount of time, you can bill the G0318 if you're doing pre-charting and reviewing of this patient's old record beyond 140 minutes of total time. Again, the reimbursement on that is pretty small over what you're doing, and that is billing for extensive visit and also cleaning of the ears. Next slide, please. Tammy, do you wanna go ahead and take this coding example? Sure. So you're conducting a follow-up home visit with the established patient. You have COPD, which is stable, and five other chronic medical conditions, all of them stable. You're gonna continue the same meds. You're addressing which meds those are, and you're counseling regarding the smoking cessation. So there's two different avenues to go with this. There's the medical decision-making avenue, and then there's your time. A lot of times when I'm seeing a patient with multiple chronic conditions, there's a lot of education that needs to go on. There's a lot of discussion about treatment options and treatment plan, and this could easily go over into my 60, 65-minute timeframe, and if that's the case, then obviously you're gonna be able to bill that 99350 for an established patient. But based on the medical decision-making, where all of our conditions are stable, and despite the fact that we're reviewing a good deal of them, I would only bill a 99349 if I'm coding based on medical decision-making in this particular case. And you are gonna wanna put your smoking cessation code on as well. All right, we're gonna hustle through some of the couple of examples to come here because of time. This example is about online digital services, online E&M. Many of us get messages through a patient portal or MyChart, in this case of Epic. You review the image, you review the history, medication, and treatment care. You send a message back to the daughter via the portal. So E&M was made, and the total time that you devoted to this patient was seven minutes. So there is an opportunity to bill for this. Again, based on time, it's the 99421 to 99423 codes for digital online management. And the payment's about $15 to about $50 or so approximately. Nikki, you can correct me if I'm wrong. So again, it's not huge dollars, but we're doing the work. Let's see if we can get at least some reimbursement for our time. Yeah, and that's when you're seeing a patient who is currently on hospice and has active lung cancer. You're primarily managing their hypertension and diabetes. Again, you can bill based on medical decision-making. You can bill based on time. Most likely in this case, I would bill based on time. I'm going to give you an estimate. This is an established patient, and I spent 40 minutes with that patient, in which case I billed a 99349 with the GV modifier. Don't forget your hospice modifier, representing that you're not the hospice physician, you're not part of the hospice care that's being delivered, your primary care, and you're managing their hypertension and diabetes. So this is to highlight that modifier. I believe, Tammy, I think it's the GW modifier. The GV is if you are the hospice clinician involved. Next slide, please. Many of us do knee injections, or I should say some of us do, I don't know. Some of us do knee injections at the home when we visit our patients. And if you are, the point of this slide is if you're going there just to do the knee injection, you should just bill for the procedure only and not add another E&M code to it. However, if you are doing the knee and then the patient starts to say, hey doc, can you look at my blood pressure readings? And you start managing his blood pressure, then you, in addition to the knee, then you can go ahead and bill a separate E&M code based on MDM or time, but you do need to use a modifier 25 for both the procedure and the E&M to be properly billed. Is that, Nikki, is that correct? Sorry, yeah, that's correct. Tammy, I think there were some questions about audio only. And I think if you could take us through the example. Yeah, I'm happy to. So remember audio only through the Omnibus Act is still eligible through December 31st of 2024. So that gives us some time. We have the 99441, 99442 and 99443 codes. It's divided by time increments, five to 10 minutes for the 99441, 11 to 20 minutes for 442 and 21 to 30 minutes for 99443. If this patient had mental status changes, we're able to facilitate an audio only check-in, no video component. And we suspect a UTI, we prescribe any antibiotics and we document that we've spent eight minutes on that phone call, then we would be able to bill that 99441. Any questions on that, Nikki? Sounds good to me. Next slide. So how many of us have done this over the past, how many, oh my goodness, I'm losing track of COVID three years. So we do an E&M 40 minutes video. You can read the rest, COVID, COPD, he's got multi-complexity like our patients. He does have a fever and shortness of breath since he's feeling weak. So he's got some systemic symptoms and you review labs and so on, you prescribe an antiviral. So this is a chance, it's an illustration of a televideo visit that you can build a 99349 with a modifier 95 because this is a live synchronous, with the word I'm trying to say, live televideo visit. So the point here is to use the modifier 95. Some comments on the side, Nikki, I don't know if we have time, about the total time spent with the patient and so on. It does include documentation time as well and talking with patients related to the care or recommendations and so on. And somebody rightly pointed that out, it does not include travel time. It includes the base or direct patient time spent. Correct. All righty, CCM, Chronic Care Management. Not a lot of changes happening as of 2023. Everybody can see on this slide, rather, what the recommendations are for including different factors in your care plan for these patients. Give it a second so that we can do that for a minute. That's good. The one change that did come as a result of 2023 is that the CCM codes require patients to have two or more chronic conditions expected to last 12 months or until their death. And there are specific requirements for those documentations, but documentation, rather, some bigger health systems have staff specifically for this purpose for CCM. Others don't. So along with the documentation requirements, along in this slide, you can see some other requirements, a dedicated team member per patient, the service is separately payable. And then go to the next slide. Yeah, so the big thing is, I'm sorry, go back one slide, Dana. Thank you. The big thing is that the care plan has to be timely available within and outside the practice. And a copy of the care plan must be provided to the patient and the caregiver so they can stay involved in their own care. The monitoring, the revisions. Management also includes follow-up post-discharge and ED visits, referrals, and that sort of thing. Go ahead and keep going. All right, and here are some codes. These codes have not changed in the last year. On the second slide, on the next slide, rather, is an additional code that was new as of this year. And this allows for the provider, not the healthcare team, the nurses and whatnot, but just the provider to build an additional 30 minutes of care with the patient for two or more chronic conditions. So that's a newer code that should be recognized. There is an EHR template, and this just includes everything that needs to be documented in the telephone encounter or in the encounter in the EMR. All this has to be addressed within that EMR to be able to count for CCM. That phone call needs to take place prior to the provider seeing the patient for chronic care management. Next is TCM, transitional care management face-to-face. There is no, sorry, there are no changes with regards to the CPT codes. The one thing that is a bit of a difference here, not difference, but the one differentiation between these two codes is the first one is moderate MDM and a visit within 14 days. The 9-9-4-9-6 is high MDM, medical decision-making, and a visit within seven calendar days. So for TCM, again, for those of us who've been doing this long enough, the 95-97 criteria, all those bullet points, remember, you know, covering how many organ system, all that, that's gone. That's gone for your ENM, and it's gone here. It's gonna be based on your MDM. And again, as Nikki said, seven days or 14 days. So there are some things to include in your EMR for face-to-face documentation, the date the patient was discharged, the date the provider's office contacted the patient, the date in which the visit to face-to-face was furnished or done, and then it must support the overall complexity of the code you're using to document for this encounter. Next is the CM, transitional care management face-to-face, and this is the one that's a bit of a difference and again, this is regarding moderate complexity and high complexity. Those are the only two options we have in regards to charging for a TCM visit. Dr. Chang, you mind covering this slide? Yep. So again, just to summarize real quickly, you know, what goes into a TCM visit? Not only the visit from myself, obviously, but also your office staff's got to make that outbound phone call within two business days. If Nikki, it's not 48 hours, it's two business days. And you can see, again, for the sake of time here, you can see some of the requirements here that's necessary as components for your TCM visit. Next slide. All right. Thank you, everyone. We are now going to transition to our Q&A portion. I know there's been a lot of activity here in the question and chat channel. I just want to use this moment to remind you all, don't worry, this recording, this deck is going to be out on the HCCI Learning Hub. You will have access to it and you can listen to it as much as you would like. You will also find out online on our HCC intelligence tools and tip sheets. We have quite a few resources and tips that will revisit these topics and at times go in a little bit deeper. So I encourage you to go out after and re-listen to this and go through the deck. I know there was a lot of information that we covered. Unfortunately, we only have so much time and we can't cover the whole year, but I think we hit the major pieces. With that said, I want to take us into the Q&A portion and we had a few questions that were submitted at the time of registration. We believe we reviewed most of these. Most of those questions that were submitted were addressed in the deck. So I'd encourage you to go back and read that information and listen to the recording. But for now, I'd like to kind of get us started with a few of the questions that were pre-submitted and then we'll turn it over to you guys to raise your hands electronically and then you can address the presenters directly. But I want to just have a couple of these questions that were asked at time of registration. How does an AWV annual wellness visit get coded as a telemed visit? And I'll let any of you guys take that. I will say that it's, AWV will be coded like a regular AWV in the office, except you have to add the modifier. 25 modifier? Yes. That was the, I'm sorry, Tammy, did you say 25? 95. 95, okay. Great. How do you handle modifiers when submitting two to four codes for a single visit? For example, E&M, advanced care planning, non-face-to-face wellness. What do you have to document when billing by time? I'm not sure I fully understand the question about the modifiers and the multiple codes plus billing by time. Can you rephrase that? I'm not sure it was typed out by the- Yeah, okay. If someone on the call has asked it, if you can raise your hand maybe and provide us a little more information, we might be able to address that for you. And Sarah, if you can keep your eyes peeled. Oh, there they are. You got it, Sarah? I thought somebody briefly raised their hand. Yeah, I thought so too, but it looks like they might've put it back in. They got shy. Okay. I think an issue with that, Daniel, it'd have to be like scenario specific because it's just too general of a question to ask. Multiple CPT codes, multiple modifiers. There should really be more of a specific case example to really answer that question properly. Okay. All right. Next one, do you have any tools or tips on convenient ways to track time while in homes or facilities and charting? Oh, I think there's the cheap way and that's your wristwatch. I'm sure there are expensive vendors that will be more than happy to sell you a time tracking software. But before going to all that, and Tammy and I were talking before we went live with this webinar, she mentioned there, some EHR have the capability of doing this already. Tammy, care to share with the rest of the audience here? Yeah, most EHRs have some sort of timestamp already embedded in them. So be careful to, if there is some sort of timestamp already embedded within your EMR system to document something different from that. Documenting the time in and time out is always a good plan if you're charting as you go. And I strongly encourage that. You know, when you walk in the door, document time in residence, you know, 5.11 PM. And then you could do the same thing at the end time out. Just make sure again that you're utilizing whatever your EMR system offers. Do a little research on that. All right. All right. Anybody wanna raise their hand and address or ask your question? That might be the most simplest. I know we've been having some questions in the box and I believe the presenters have been trying to answer them as they can with their presenting. But this is the time now to raise your hand and ask them directly. Real quick. I think Dr. Wallace has a question. Time-based documents, start, stop time. It's just a total time. Nikki, if I'm correct on that, there's no start and stop. And there's no requirement that 50% of my time was spent in counseling and care coordination. That no longer exists. It's just based on time. You can say something like, I spent 60 minutes in care of patient including review of records, updating chart, discuss current treatment plan and the treatment plan included. And you can just go ahead and list the problems that you addressed today, CHF, COPD, CKD, blah, blah, blah. And then you can go ahead and build on time. And that's total time. Great. I just saw in the chat, someone said they had checked resources. They weren't up to date, but we do have multiple resources that are current with 2023 information. If you wanna go out there, you can check those out and we'll go deeper dive. We do have some resources that will come out in the next week, but what we cover today will be in those updated resources. All right. Thank you, Dr. Chang for doing that question. Any of you who's next? We got some people, Sarah, that have raised their hands up there. You want to open it up for them to chat? Yeah, let's take Renee Walton. What I'm gonna do is I'm going to allow you to unmute. Please feel free to unmute and share your question. Yes, I wanted to ask for a home health certification for billing, is it per patient or is it for the total, like for at one lump time? How does that, how do you bill for that? Home health billing is per patient. Okay, so you just bill per patient the amount of time you spent doing certifications or research. Exactly, and I believe from what I understand, it has to be 60 days between each billing period. So if you've already charged like a G0180 and it's already been, it has been less than 60 days, you can actually do another one for 60 days period otherwise medical will not pay for it. Okay, thank you. You're welcome. Thank you, Renee. Next, I'm going to ask that Mary White be ready to unmute and share her question. Mary, you should. Mute, okay. Hello, can you hear me? Yep, we hear you. Oh, okay, so my question is on CCM. Do you bill it only for Medicare patients or can you bill, is this for all insurances? Do they compensate for the CCM? I want to say that the Medicare-based program, Dr. Chang, is that correct? Yes, CCM is a Medicare, but I do believe some secondary insurance do pick up on the CCM program billing as well, but mainly it's the thinking of Medicare. Tammy? I have found that commercial insurance, commercial payers do not. So Medicare, Medicare Advantage payers will, Medicaid and commercial insurers will not. Yeah, Medicare Advantage plans do fall under Medicaid. Yeah. Yep. Thank you, Mary. Patrick, you're going to be going next, so feel free to unmute and share your question. Hey, just quick question about telehealth visits after the public health emergency expiration date, what types of E&M visits are permissible and what's the coding and modifiers needed for those? Well, that's to be- Right now- Yeah, go ahead, Tammy. Right now we just know what's available through December 31st of 2024. There's no guarantees beyond that. CMS will have to, well, we'll talk about that next year maybe. Okay, great. Thank you. You bet. Thank you, Patrick. Thanks for joining us, Patrick. Next, we're going to go to Bernadine Lewis. You should be allowed to unmute at this time. Hi, everyone. Quick question. If you have not already addressed this, because I came in a little late. The cognitive assessment coding, sometimes I get Medicaid to pay for it. Other times I don't, I get it denied and I'm trying to understand the best way to bill for cognitive testing to be reimbursed by Medicaid. I know one of the thing I was told is that if there is any behavioral health component to the primary diagnosis, Medicaid will not cover it. Any behavioral health component? Is that right? Yeah, so that's what I was told when I called Medicare to ask why the claim was denied. And I was told that there is, like for instance, the patient has, let's just say, R41.89 with behavioral health disturbance. Then they don't want to pay for that code. I'm not sure if I misunderstood or what. Okay, so there is a particular CPT code for cognitive assessment. Is 99, somebody has it in the chat box. 483. 483, thank you. Yes, thank you. And then there are specific components within that assessment that you need to do, including cognition, including mental health. And you have to use a often-recognized tool for assessment of those. For example, you have to use, say, a FAST score for dementia. And you have to use a, let's just say, a PHQ-209 for a depression screening. So there are specific criteria that you have to meet within that visit to justify billing for 99483. So I'm not sure where the trouble for you might be, where Medicare might be denying your services to, for this code. Tammy? Can I ask you a question, Bernardine? Have you paid attention to whether or not they're denying due to the place of service? Is there any correlation to prior to January 1 of this year, if you were billing place of service 13 versus 12? I used 12. So I used 12. They didn't have any issues with the place of service. The issue came in with the primary diagnosis. And what I was told was that I have to send the claim to the behavioral health specialist in order for them to reimburse it. Yeah, it's a sticky one. And I'll tell you that we don't use it a ton in my practice, unfortunately. We started to, but it's a very comprehensive panel of tests that need to be done. It's pretty labor intensive, truthfully. And we found that exact same thing, that randomly some got paid, some got denied. And for that reason, we decided when at all possible, we were going to avoid billing that. Okay, because that's pretty much what I have decided to do, because it's very comprehensive. And it looks like a hit or miss when it will be paid and when it will not be paid. So I simply just stopped doing it. And the one thing that I would say across the board unanimously about all these questions I'm seeing come through is establish a good email relationship with your MAC and ask them questions. I started emailing my MAC about these new coding releases in early December of this year to get clarification, particularly on prolonged services and whether we can bill for three days before and seven days after and what all of that looked like. So the best thing you can do, and there are differences in reimbursement from one MAC to the next. So what I can explain to you at a CMS level across the nation, it isn't definitive because your MAC can do things differently. And so you really need to establish a good working relationship with the MAC and they typically are pretty responsive. Okay, thank you. You're welcome. I know we're past the scheduled five. Our presenters have graciously decided and agree that they'll stay on for another five minutes to take your questions. If you need to drop, go ahead and do so. Thank you for coming. Again, you'll have the recording, you'll have the deck, you'll have access to quite a bit of resources to go along with those. So don't fret and don't fear. We're not going anywhere, but let's continue to take a couple of more questions, Sarah, and then we'll go from there. Yeah, and just to add onto that, I wanna just remind everyone that you also have access to the hotline email. If you come across a personalized question and you want access to one of our subject matter experts and you want an answer, we'll get you an answer. Just send out that email and we'll get it to you as soon as possible. Okay, moving on, Nicole Laufer, I apologize if I butchered your last name. I'm going to give you permission to speak now so you can share your question. You should be allowed to unmute at this point. Hi there, you can hear me okay? We do. Okay, I really just have a clarification. You guys had mentioned when doing an injection and an E&M, you use the modifier 25 on both the procedure and the E&M. Is that correct? Go ahead, Nikki. That, I didn't hear you say that, Dr. Chittington. I do wanna clarify that only because I think it's only, I think it only has to be attached to the procedure. I wanna say it has to be attached to the procedure for the injection. I'm pretty 100% sure, yeah. What you're saying is I did this E&M visit and I did this procedure, and the modifier is saying this procedure shouldn't be encompassed within this normal E&M. It is outside of what I would normally do in the E&M. So you put a modifier on the procedure. Right, same thing for like ear cleaning, you know, that kind of thing. Okay. Same thing for advanced care planning that's done during an annual wellness exam. You're saying, hey, this is done during an annual wellness exam. Don't charge the patient the deductible. It's pay me for it. And it's part of the, or don't charge, nevermind, I'm gonna confuse everybody. It's the same difference. You put it on the added thing you're doing. Okay, thank you very much. Yeah, thank you, Nicole. Before we go to the next question, which we'll take, I just wanna remind people on the screen, you will see information to our HCC Intelligence Resource Center that will give you the email address to that help box. Also where you can find the webinars that we will have upcoming, which I will take now. We're not gonna end questions. Don't worry, don't go anywhere. We also have tools and tip sheets that were mentioned for the webinar. I just wanna just take a second to let you know that our next webinar coming up in March will be based on value-based care. Dr. Christopher Todd will be presenting. If you have any questions about that particular webinar, we will have registration that is going to be coming soon. If you have questions about that, you can definitely send an email to the education box. And with that, I am gonna take us back to some Q&A. So who's our next lucky contestant, Sarah? It looks like Tiffany, right? Yes, Tiffany Hughes. All right, Tiffany. My question is to clarify the telehealth audio only. I know we talked about modifier 95, but my biller is also telling me the place of service should be 10 and not 12 when it's done in the home. Do you have any comment on that? Yes. So that's a headache and very confusing. We had that same dilemma and problem back, I don't know, it's been a while ago now, a year and a half, two years ago, I guess. But we had some claims denied because we were billing out the 12 place of service and they denied them and sent them back and they want them all billed with the 10 place of service, which is an office-based place of service. But nonetheless, that's what CMS wants. So CMS gets what they want, right? That's another reason to go to that web address that I'm gonna go and I'll have Dana send it out. But there are more specific place of service codes. The ones we reviewed are simply the ones that are used most often. But when it comes to telehealth services in the home, that is an option, you're correct. Yeah. All right. Anyone else with any questions that wanna be brave, raise their hand and we can address them here in the final minutes. Isn't this fun? Wow. You know, 10, 12, 13, 15, G0318. Yeah, all the numbers to keep in your head on top of your cretin and clearance and everything else, right? It looks like Renee has another question and we'll take that. Go ahead, Renee. Can you review those place of codes just one more time, please, just for clarity? Yeah, and I did put in the chat the web address. I just realized I could do that. I put it in the chat. But so number 10, going back to that is telehealth provided in the patient's home. 11 is your typical office setting. 12 is your home. 13 is an ASL assisted living. And 14 is a group home. And again, there are specifics to go further. For example, 15 is a mobile unit. You know, so there are other ones besides just the ones we mentioned in the slides. Okay. Yeah. All right. You're welcome. Okay, Nicole is gonna be our last question. All right, Nicole. Hi, Nicole. Are you there? All right. All right, I don't think we have Nicole. Okay, well, thank you all for joining us. I know our presenters have some hard stops here. Again, if you have any questions, please go back and feel free to listen to the recording, look at the presenter decks and reference any of those resources. And as always, you can shoot an email out to our help box and we can get back and do some research and get back with you. Again, we thank you all for joining us. I thank the presenters for coming and giving a lot of information that I know a lot of people are trying to synthesize and it's a lot to take in. So we appreciate the time you're taking to do this correctly. We all want, just like you, to make sure that you're reimbursed for the hard work that you guys do. And it's very important work that you're doing and you should be able to be rewarded financially for that as you give value to your patients and their care. With that said, thank you all very much. And we look forward to seeing you all in March. Bye-bye. Bye everybody. Bye.

HCC intelligence webinar

2023 Billing and Coding Impacts You Need to Know

evaluation and management codes

telehealth

chronic care management

transitional care management

medical decision-making

total time

audio-only telehealth services

modifiers

Medicare administrative contractor