false
Catalog
HCCIntelligence™ Premier Webinar: Mastering E/M Co ...
Zoom Recording
Zoom Recording
Back to course
[Please upgrade your browser to play this video content]
Video Transcription
Hello, everyone, and welcome to the first of three webinars in our new series. I see people are coming into the queue here, and we're going to give everyone a chance to kind of get in and get situated before we get started. If you haven't already, we encourage you to use your video camera and join us in a very interactive call today. All right, people are still joining. Everybody, a few more minutes. All right, get a couple of more coming in here and we'll get started. All right, I am going to kick us off here and the others can join as we get started. So first and foremost, thank you for joining us today. My name is Dana Crosby. I'm the Senior Director for Engagement and Practice Development at HCCI, and I'm very excited to be your moderator today. This will be the first webinar of a three-part series that is Maximizing Revenue and Value in 2022, Billing, Coding, and Documentation in Home-Based Care. Today we'll be doing Mastering E&M Coding and Documentation for the Home and Domiciliary Settings. Before we get started today, I just want to go over a few housekeeping items. Today our webinar will be 90 minutes. The first hour will be the main presentation, and then the last 30 minutes will be an interactive Q&A, which we hope that you will turn on videos and microphones and share some conversation back and forth during that Q&A session. We do ask if you have questions to hold off on those till we get to the end, but there will be a comment box at the bottom if you want to give any shouts-outs, introductions, and if you are bashful and want to slip in a question there, we'll extract it for you and put that into the Q&A as we go forward. With that, I want to go to the next screen and introduce you to our presenters today who are two colleagues that I have the extreme pleasure of working from, for, or with and learning from. Dr. Chang is joining us here. He's the Medical Director at Northwestern Medicine at Home Care Physicians. He's also our Senior Medical and Practice Advisor at Home Centered Care Institute. He's joined by Brianna Plensner, Senior Consultant and Manager in Practice Development, also at Home Centered Care Institute. With that, I am going to throw it over to Brianna to get us started with what I know will be a very valuable call. Thank you, Dana, and welcome, everyone. We're really excited that you are all able to make the time to join us this afternoon. We're taking a little bit of a different approach to teaching documentation and coding that we're hoping is going to be more practical, really showing you examples. So we're excited and we definitely want to hear your feedback. So the first half of the presentation, we're really going to describe the required documentation components for both the home and the domiciliary, which is the assisted living setting or group home. And how do you accurately represent those E&M levels of service while promoting quality documentation? We're going to point out some common pitfalls and how to make sure you're compliant. And then I've pulled real auditing examples that we've recreated just in text form so that we can go through some documentation examples and I can tell you what feedback I would be providing from the auditor perspective. And we're also going to kind of integrate some ICD-10 examples and how that relates to risk adjustment. And you also have access to follow-up education resources on that. So kind of to set the stage, when I say E&M requirements, and many of you that have had kind of internal or external auditing reviews before, when they hear about scoring your E&M visits or telling you if you documented appropriately to validate the level of service you're billing for, this is what we're talking about. Your E&M visits are your bread and butter. So it's really important that you understand how to get paid at the appropriate level of service. Oftentimes, I really find providers maybe undercoding or not understanding how to bill on documentation and complexity versus when it makes sense for time. So these are the things that we look at, and we're going to talk about each of them in detail. But, you know, your note needs to have a chief complaint. That chief complaint needs to be specific and recognize the medical need for the visit. When we talk about the history element of E&M services, I'm looking at not only of the HPI, which is your history of present illness, but also the review of systems and past family and social history. PFSH is really important for initial and new patient encounters. And then, of course, your physical exam. And then again, both history and MDM, there's three parts to that. So when I look at medical decision making, I want to think about the number of diagnosis and treatment options addressed. So that means when I'm looking at your assessment and plan, how many conditions are listed there that you meaningfully assessed and have a treatment plan for? What kind of data and complexity did you have to review? So did you review and order labs? Did you have to get history from someone other than the patient or collaborate with another professional on that patient's care? And then overall, the overall level of risk, which ties into medical necessity. So each of these E&M components make up the level of service, but we always have to consider that medical necessity is always the overarching criteria for payment and to support those higher levels of service. So in the next four slides, I wanted to give you some reference guides. I encourage you to share these with your provider. I'm not going to go over each one in detail, but looking at the first one, these are our new patient home visit codes. So it's the first time you're seeing a new patient as a patient that's not been seen by you or anyone under your practice TIN within the past three years that's of the same specialty. And so you can see for a 99344, we need a comprehensive history, which is four individual HPI elements or the status of three chronic conditions, a 10 point review of systems and a complete past family and social history. I would also need a comprehensive exam, which is eight or more organ systems. And we're going to talk about the difference between organ systems and body areas. And then I need moderate MDM. And the only difference between that and the 99345 is the level of medical decision making. We need a high level of MDM to support the 99345. Our established patient codes are a little bit easier. So these are your established patient home visit codes. There's only four possible levels, and you'll notice the 99349 and 993450 highlighted. We know from looking at the data that 99349 is the most common for the majority of your home visits during the day. But you'll also notice that they have the same level of MDM and 99350 could be moderate or high medical decision making. So we're going to talk about how you keep that in mind. Again, 99340, there was some sort of exacerbated problem or some, you know, medication change, something you're addressing, but don't be scared of that code because the MDM is actually the same for those two levels. So I did the same thing for the domiciliary codes, not going to go over them, but encourage you to use these reference guides with your providers and share them with your team. So we're going to talk through each element. So what I've done is on the left hand side of your screen, these are all examples that I pulled from progress notes that I've audited or from people that we've worked with at HCCI. So you heard me mention in the start of the presentation that the chief complaint needs to identify a specific medical need for the visit. So the first example, acute visit for leg swelling, I'm good with that. It tells me, you know, that there was an acute need and that's going to be the focus of this visit. Probably not going to be a comprehensive assessment of all their medical conditions, at least not what they're telling me by the chief complaint. I want you guys to look at, and I'm not sure if you can see this, but I'm going to kind of use my cursor here, the second one that just says follow up. And then the last example that just says new admission. So my feedback to the provider, if I see a chief complaint, that's just listed as follow up or new patient visit is I need more. I need you to tell me why you're really seeing that patient for that day. What kind of conditions are you following up on or what conditions are you assessing the patient for? Why were they referred to your program? You know, thinking about the messages and the intake forms that you have from the new patient, what do you know is going to be the focus of the visit or maybe some primary concerns that the patient and the caregiver let you know about. The third example, the provider did a good job of saying, okay, these are the diagnoses we're going to focus on. You know, told me that the patient's having some poor appetite and they need to discuss goals of care. So that's a, that's a strong chief complaint. It doesn't have to be bulleted like that, but they are go ahead and identifying those things. And then also the third one, I see this often, I would say this is a so-so example. So it tells me at least that they're, you know, it's not a new patient or follow up patients being seen for an active management of chronic diseases. I would still encourage that provider to be a little bit more specific and tell me which chronic diseases are going to be the focus of their visit. So what I've done is just giving you an example on the right-hand side of the screen. These were a couple of chief complaints that I rewrote in our audit feedback education. So again, really describing what's going on with the patient and what's going to be focused if it's post-discharge patient, you know, you're starting to paint the picture, picture of medical necessity with that chief complaint. So the second part of the E&M visit is going to be your HPI. So each box is a different HPI example that I pulled from documentation examples. So let's go ahead and start with the upper left, this first one. So it's a new patient visit and they tell me what the past medical history is and the patient has a son and daughter, but I don't know anything about those conditions. You know, how is the hypertension? What medications is the patient on? Were there any recent lab results for the hyperthyroidism? It's also an unspecified dementia mentioned. So I don't know if the patient's been having behavioral issues, especially for a new patient visit. I really expect more detail and kind of getting a baseline. It's the first time you're seeing the patient, you're going to have to establish a treatment plan for all of those things. So how is the patient presenting you today? The HPI is in the patient and caregiver's words. If you have an acute complaint, it's a chronological description of those complaints. Otherwise it's kind of giving you a baseline of their chronic diseases. So the second example, I have a little bit more information, I'm still using a little bit of vague terminology. The patient reports he's doing better and then they give me some review of systems finding about no abdominal pain and GI symptoms. He's eating well, feels he's getting stronger, no nursing concern. So it's just not an extensive HPI. One of the tools, which I'm going to kind of flip to really quick that you have in your handouts looks like this. So this is actually an audit tool. So when I say I'm scoring HPI, this is what I mean. So these are the unique elements, or you could give me the status of three chronic conditions. But if I don't have four unique elements, or if I don't have the status of three chronic conditions, I'm automatically going to have to drop this level of history. So we'll come back to this, but this is kind of what I mean. So that way, when I look at this example here, this would be kind of more of a limited HPI. And then finally, our last example, you know, this, I was able to get to an extended HPI. It was a palliative care visit, excuse me. You know, it was recently started on remerin, that tells me what's been making something better or worse. The appetite has improved, he's been sleeping better, he had a recent episode of nausea, and that was given at least one time last week, no further episodes or no further symptoms. So a little bit more detail, still has some room for improvement. This example, again, I know it's a little bit small, hopefully you can see it okay. We have kind of them setting up the visit. One thing I will say, though, is the provider used the term routine visit, this is kind of one of those things when I see I'm like, we really want to avoid that terminology. Routine visits, these patients are sick and have a lot of chronic medical problems, it's kind of starting to shoot yourself in the foot about medical necessity, so I like to avoid the term routine visit anytime you can. The other terminology that I at least would just point out as just feedback for educational is the provider used the terminology past medical history significant for, but then she goes on to describe active medical conditions that she's going to be treating. So when we think of HCC data validation and we think of what an auditor thinks when they hear past medical history, that's telling me something that's either historical or might not be active. I would encourage the language of active medical problems include or chronic diseases include. And I know that's a disconnect between how providers and how auditors are trained, so it's a little bit frustrating, but if you're giving me, you know, information about active chronic conditions, you just want to avoid this past medical history terminology. The provider also did a good job of saying, hey, she had to call the daughter to collaborate on any needs. And then here's what I mean. She gave me the status of four, I only need at least three chronic conditions and how the patient and caregiver have been managing each of those issues. So this would be an example of kind of that bulleted HPI approach where the provider is giving me the status of three chronic conditions, I don't need that chronological description of an acute problem. And she did so in kind of a nice formatted way. This is just another example I put together, again, kind of two sides of the coins. We know that these patients have chronic medical problems. If your visit is really focused on addressing multiple of those concerns, maybe consider the bulleted HPI approach. Again, if you give me the status of three chronic conditions, we're talking about how the patient and caregiver feels that they're managing these conditions, what are the recent blood pressures, recent sugars, how are they doing with their CHF or their dementia? All of those things will get you to an extended HPI credit. We also have some acute examples here too. If I look at this last example, radiating low back pain tells me two things. It tells me kind of, it describes the pain and it tells me the location. Then it reports the patient as pain as a seven out of 10. So that tells me the severity of her pain. So I'm already at three HPI elements. Then it began two days ago and she tried Tylenol with no relief. So I know duration, I know how long it's been going on, and I know what's called a modifying factor. I know anything that made the problem better or worse. So with just one sentence, I'm still able to get to an extended HPI for an acute problem. So this is just kind of an example of the two different approaches and teaching your providers to really understand what HPI is intended to be. So we've talked about chief complaint and talked about HPI. Now I need review of systems. So a complete review of systems is going to be a 10 point review of system. I'm going to show you an efficient trick with that, but the first one, this was all I had for review of systems. So I have two systems, it was positive for weight change, and then it also said negative for weight gain. So I'm assuming that weight change is a loss, but anytime there's an abnormal finding for review of systems, you want to be as specific as possible and you need to elaborate on that. Now what I learned when I met with the provider for this first example is the patient had dementia, there was no independent historian. So in that case, what you need to do is just tell me why any element of the history was limited. So for example, limited ROS or limited history due to a patient with dementia and no independent historian available. If I saw that in your documentation, I wouldn't be able to count that against you and I'd be looking at the other E&M elements to score your visit. The second example you can tell, again, there could be up to 14 systems, but I have at least 10. So it's a complete review of systems. There's a lot of negative responses, but it's still completely documented. What I mean by an alternate approach. So it is always an option when there's so much that goes into your documentation and it's so time-consuming. Dr. Chang likes to talk about avoiding that pajama time, right? How can we save our providers documentation efficiency so they're not documenting late into the night? What would be actually more clinically meaningful to me is for the provider to document any abnormal or positive findings or pertinent negative findings that you think are important to document and then use the phrase, and you can build this into your template, all other systems were reviewed and negative. When I see that, I'm still crediting in a complete ROS, the same as if you documented a full 10 point system, as long as you at least elaborate and document on the abnormal findings. So it just might save you some clicks and just make sure, again, you're being as descriptive as possible for any of those abnormal or positive findings. So that's review of system. And then, so here's another one. So again, what, how did this provider could have maybe saved themselves sometimes is the bolder, the positive findings. So if they would have just documented that and then use that, all other systems are reviewed and negative. They probably could have saved a lot of time with all this other negative ROS findings that we have documented in this example. All right, so we're still on history. It seems like a lot, but we're still at the top part of that progress note. So the last part of history is that past family and social history. And again, this is going to be important for new patient encounters. For established patients, you can always, if there's no changes, mark the history as reviewed. But usually what I see is a missing family history for new patients. And that is going to bring down the entire level of service. It's probably not going to get you to 99345 if I don't have the family history. And that's kind of a silly thing to miss out on that billing opportunity for. So you'll notice here, and again, this is a real audit documentation example. Father and mother passed away in their 60s from heart disease. It tells me which relative, what the relative disease is, and the age that they were deceased or if they're alive and deceased. But then the sisters is less specific. I know that she has sisters, plural, with breast cancer and blood cancer history. But I don't know if they're alive or deceased, and I don't know the age that they passed away. They do give me relative social history information. So what I would have changed here is just building a family history template that has these kinds of things. So what immediate relative, are they alive or deceased? If they passed away, what disease history did they pass from and what age did they expire? So here's an example. Father history of CAD, deceased at age 70. Again, you may not have all of that information every time. That's where those new patient forms can be helpful to try and get as much information as you can in advance. If the patient doesn't know and there's no relative that can share that, again, just document that rationale. Tell me why it's not there. So we're moving on from history. I see some comments in the chat. That's great. We're going to get to questions at the end, but I still encourage you to put the questions in the chat if you think of them so you don't forget. We definitely are going to come back to that, but we're going to move on to physical exam. So physical exam, anyone want to put in the chat just how many organ systems, does anyone know off the hand, is a comprehensive exam? So it would be eight organ systems, if you thought. And then there are certain EMR templates that will be set up, so Dr. Cheng and I were talking about this, to have body areas and organ systems. That's completely acceptable. But when we're talking about comprehensive exams, I only care about systems. So if you can customize your template, I prefer organ systems only. All of those body areas findings typically relate back to an organ system. So these would be the organ systems on the left-hand side of the screen, and I would need at least eight of them to support a comprehensive exam. There could be more, but that's what we need for the eight. All right. So we're cruising right along here. We're going to talk about the assessment and plan now, and again, these are each audit examples that I pulled. So in this particular audit example, I noticed a lot of Z codes being used. So this wasn't a surgeon that was seeing the patient, but they're using the aftercare Z code. And then the other thing is they're coding a sign and symptom. And so what I mean by that is from an ICD-10 diagnosis guidelines perspective, in the outpatient setting, we always code confirmed chronic diseases or confirmed active diseases, and we don't assign the diagnosis codes for sign and symptoms that relate to those diseases. So from what the provider is telling me, the shortness of breath was an exacerbation of their COPD. COPD carries a risk adjustment weight. Shortness of breath does not. So what I would have encouraged that provider to do is instead code the COPD, and then I would have also questioned the use of those aftercare. They did, this provider was using a SOAP template. I do need to be able to relate what the plan instructions are for each diagnosis. I can tell they're trying to, you know, they're prescribing the inhaler for the COPD exacerbation, some medications and some PT and OT are reviewed. One thing I noticed on here is it says provided patient education, depression and anxiety counseling, but there's nothing noted about depression and anxiety. I have no idea what counseling was provided, if they did a PHQ, anything like that. So don't not document anything that you did in your visit as well, because that's going to add to that level of medical decision-making and help me understand the complexity of care that was provided. So again, this is a different progress note, new example. What I like about this one is the provider did a really good job of at least, there's very specific treatment plans for each ICD-10 diagnosis. I do have two different kinds of pneumonia, so that's questionable. And then I also have acute kidney failure, but she later on tells me the patient has hypertensive chronic kidney disease. So I would have probably expected a chronic kidney disease diagnosis with the stage one through four, rather than that acute kidney failure diagnosis. The other feedback that I would encourage this particular provider to think about is in order for me to support the level of medical decision-making, I need to understand if the problem was new to the patient or if it was a chronic issue and what the status is. So we talked about status and HPI as reported by the patient and caregiver. What I'm looking for in your assessment and plan is your clinical impression. Is it stable? Is it worsening? Is it uncontrolled? What is that key word that's really gonna paint the picture of complexity? I find myself rewriting that over and over in audit reports. We really need to be specific and use terminology that tells me the status of the patient's illness based on everything you've done in your visit. What is your clinical impression, the assessment of that disease, and then what is your treatment plan? The little mantra that I like to use is condition status plan. Every diagnosis that you're gonna list in your assessment and plan should describe that. It's also, doesn't have to be the patient's problem list. So if you're not addressing all of these things in detail, it doesn't need to be documented. The last point is to kind of an HCC diagnosis potential. I don't know for sure without talking to the provider, but I noticed that the BMI, if the patient had protein calorie malnutrition, that would be an HCC diagnosis code that we would wanna make sure we capture for this patient. So here's another example. Again, I can tell if the problems are acute or chronic, which is helpful. She told me that the depression is stable. We have what they're doing with medications in some labs. So again, not bad. I probably wouldn't get to above a 99349 for this because there's not a lot of intervention going on. But I still am having to kind of assume that the status is stable for the first chronic conditions. And again, as a non-clinical auditor, that can be pretty subjective. I don't wanna have to infer your clinical judgment. So make it really clear and anything else that you talk to the patient about, about how to manage those conditions and their current treatment plans, make sure that's documented. So we're gonna kind of wrap up here with just a few more points. So these are all the links that you see included here. This is to the CMS Evaluation and Management MLN Guide. It's a great source of education for your providers. This is just me kind of reiterating. I would never tell you a provider to do something that's not supported by documentation guidelines. So this is telling you about, you know, understanding if the clinical impression of the diagnosis, that it has a medical plan of care, all of those things. This is what I really like to stress. And again, this is from the documentation guidelines. And again, so I'm thinking about your assessment and plan. For each diagnosis you're gonna list on there, I need your assessment, you need clinical impression, what kind of decisions or management plans are you considering for that patient, or did you order? If it was meaningfully assessed, meaning you had to consider it, evaluate it, or that particular diagnosis impacted your care for that patient on that date of service, then it's appropriate to be listed there. But even in the documentation guidelines, it's telling us to use these status words. So again, improved, well-controlled, I have non-compliance concerns, it's worsening or declining, you know, failing to change as expected. Really encourage you guys to think about those status words in your documentation. And again, we know that these patients typically have 12 plus medical problems. You're not gonna address every single one every time. So prioritize your assessment and plan. And if you're not able to address the patient's, you know, their leg edema was under control, so, you know, you're not really addressing that, don't put it there just because it's on the problem list, unless you had to consider it in the treatment of that encounter. Again, when we're thinking about documentation efficiency, I don't need everything that happened with the patient and the history of themselves. I need to know how they've been doing since the last time you saw them and how they're doing today, and what you plan to do to keep that patient out of the hospital or keep them stable, or what discussions and treatment discussions went on during your visit. That's really what your assessment and plan is intended to be. And you all have access to the HCC online course that goes over this in more detail, but MEET is the acronym that we use for what we call HCC data validation, meaning if you coded an ICD-10 diagnosis code for your E&M visit, I'm gonna go to your assessment and plan and I'm gonna see, did you monitor? Did you evaluate? Did you assess and address? And did you treat that problem? So off the right-hand side of your screen, Dr. Cheng actually has a smart phrase that he uses for chronic heart failure since that's so common in his practice. Again, any of these asterisks he's gonna have to customize, but it's just kind of showing you an example, the kind of level of detail. Again, MEET is a best practice. I just need to think of that condition status plan. I need to see that it was evaluated, that was considered in your treatment decisions for that encounter. You have a full calendar year to capture all your patient's HCC diagnosis code. So it doesn't have to be every note, every visit. I only care about what was really addressed at that visit for the patient. This would be a good read. There's a link on the slide here and you have access to the slides in the HCCI Learning Hub if you go to the My Resources tab. But I thought this was a really good kind of reminder for us and when we think about documentation efficiency and it just gives you kind of a best practice to note documentation. Are your notes up to date and are they accurate? I wanna avoid cloning or copying and pasting that's contradicting each other in the record. Is it thorough, but at the same time, is it organized in a comprehensible way? And you kind of have to balance that comprehensive note with the succinct and synthesized. More words don't always mean better documentation. We wanna make meaningful choices and use the right words to represent the complexity and the health status and whatever work you've had to do to treat that patient on that date of service. And internally consistent, again, this is where maybe I'll see something that might've been carried over from a previous note in HPI or review of systems, but it's not supported by what the provider documented in the physical exam or the assessment and plan. That gets into record integrity issues. So this particular white paper was really focused on the hospital setting, but I think there's a lot of best practices that we can derive from that. So the other thing, everything we just went through, we're trying to show you, how do you get to the right level of service, not using time? We're just considering documentation and complexity, which is really important. There are times when we do wanna bill on time. If you're billing on time in the home or in a regularly setting, the only time that's acceptable is if the visit was truly dominated by counseling or coordination of care. And I need you to three things. I need you to tell me the total visit time that greater than 50% was dominated by counseling and coordination of care. And then I need specific details. I need you to tell me what kind of counseling or coordination went on for that patient. So in the first example, I actually don't need to know, she said 35 minutes spent with the patient today, 30 minutes of which I just need greater than 50%, but then I also don't know what counseling or coordination of care occurred. The second example, I know 60 minutes, the provider has start and stop times in their time statement. She used the greater than 50% language. This is a little bit generalized. I would encourage it to be a little bit more personalized to the patient encounter, but she is telling me kind of those details. Again, it's a little bit more generalized. If I see that elsewhere in the note, then that's okay, that's supported. I only need start and stop times if you're billing for prolonged services, but it's not a bad thing to just include in your time statements either. Again, so I have total time, I have that greater than 50% language, but I don't know what kind of counseling or coordination occurred, happened. And in this last example, the provider was trying to kind of use some keywords, right? She's telling me it was a comprehensive care plan that was medically necessary for the 60 minute visit. You just saying that doesn't validate the medical necessity. I need to see your whole note, all of your documentation really supporting the work that you're being done. So if you're wondering when to bill on time, these are the three things that make up a compliant time statement. Again, I need total time. I need you to actually use this exact verbiage, greater than 50% was dominated by counseling or coordination of care, but then you should be personalizing that. And it doesn't, again, it doesn't have to be super long. If you look at this last example, it was dominated by counseling, what to do when emergency symptoms arise and a plan for support. So these are some templates you could start with, but really important to be specific about what kind of counseling and coordination went on if you're billing on time. Otherwise, during an audit, we would say that's not supported if I don't have all of those things and you billed the visit on time. All right, so we are gonna shift over to some of the case examples here. And again, thank you everyone for the questions. We are gonna come back to some of those and move into the examples with Dr. Chang, I think. Rihanna, thank you. Thank you so much. I always learn something new when I listen to your presentations. I've been jotting notes like, oh, I can improve my documentation in this aspect. So even after many years of doing this, I'm still looking for opportunity to improve. What we hope to do in the next half an hour or so is take some of the static knowledge that was presented and make it into a more working knowledge, a more interactive way to hopefully help you internalize some of the information that Rihanna has presented. And what we hope to do is take you on a ride along. It's a kind of a virtual ride along. What I hope to do is give you a glimpse into say a average day in Dr. Chang's house call practice. And you can come along for a medical visit, but this time we have the pleasure of having Rihanna come along with us, not to provide medical advice, but to give us some advice on, hey, what should I be thinking? What should I be coding here? What did I miss? What are the tension points about, should I code this level or that level? So that's what we hope to do in the next half an hour or so. So next slide, please. And I want this to be interactive and feel free to put chat information in the chat or questions or answers to our questions. Feel free to do so. So the first case, let's just say it's Monday morning. Dr. Chang comes to the office. He's getting ready for the day. The first patient that he's seen, it's a new patient to practice. And before he gets going, I spend about 35, 36 minutes going over the inch and a half stack of past medical record that's sitting on my desk. And then we head out today, you're riding along with me, and we visit a new patient at home. We spend a lot of time with the patient. We do a comprehensive history, a 10-point review of system, and an A-plus organ exam. And I was there addressing nine chronic medical conditions. And also during the exam, the patient has some wax in the ears, and we took time to clean the ears with both water irrigation and using the curette. So I wanna give you a moment here, just think about what, let's just say the patient's at home. It's not a dom code. What billing level would you use for the visit? And also what additional billing opportunities are presented here in this coding example? Give you guys just a couple minutes because we do have several cases to go through. But just think about that. And if you can't put it in the chat, maybe you can write it out. And then Brianna, what are some of the opportunities that we might wanna think about in this particular example? Yeah, so let's start with kind of what you did before you saw the patient. So you've mentioned that you spend about 35 or 36 minutes on kind of pre-chart review and getting ready to see that new patient. So again, we're talking about fee-for-service right now and what those extra billing opportunities are. Someone pointed out in the chat extended care codes, and that's exactly right. So the first code that I would point you to for your pre-chart review is something called prolonged services, non face-to-face. So we have prolonged services when we're talking about our total visit time with the patients. And then we also have prolonged services that happens before or after a visit. It has to be directly related to that E&M encounter and it have to spend at least 31 minutes doing that. If you do that, then for this particular code, Dr. Cheng could potentially bill 99358 for prolonged services face-to-face in addition to his visit code. And so I'm gonna pull up another resource that you have in your learning hub called the E&M Guide for House Calls. So we know it was a new patient. So I'm looking at my new codes. He told me he did a comprehensive history, a comprehensive exam. And then if we think about MDM, one of the things that I included, and again, this kind of matches an audit tool. So he said he had nine medical problems. So I know very quickly I'm gonna be exceeding what we need for maximum MDM care. He probably looked at ordered some labs, maybe talk to somebody else from there. And then if the patient had two or more stable chronic medical conditions, I know that's already at moderate. If there was exacerbations, I know I could potentially get to high. So those are gonna be the things I knew at two out of three that I'm considering when I'm thinking about the overall level of medical decision-making. And so if we go back to our E&M chart for new patients, it would probably be pretty easy to think that we got to a level of high MDM. If we didn't, then we know we could at least at the very least support the 99344 for that patient. In addition to, let's not forget our prolonged services, the other resource that you have looks like this. It's a Superbill, this prolonged services, non-face-to-face, this 99358 right here is the code that we were talking about for what he can do. And then also he mentioned the ear cleaning. Again, it would have to be using a curette because the CPT code that we have for serum removal actually does have that terminology, but we would also put a modifier 25 on our E&M code and we would go ahead and build a 69210 for the ear cleaning that happened in addition to the prolonged services, non-face-to-face and his E&M code. So I'm gonna bounce back to our presentation here. All right. Well, thank you, Brianna. So we wrap up that visit and we drive to our next house. And this is a patient that I'm seeing post-discharge from the hospital after admission for treatment of CHF and COPD exacerbation. Obviously, I've taken the time to review the hospital records, review any imaging studies that were done at the hospital and also laboratory exam, laboratory studies as well. I do a detailed history covering nine points of review of system and I do an eight point organ exam on the physical. And I did take the opportunity to discuss advanced care planning because during transit, by that I mean, from the nursing home to home or hospital to home, it is a good time for us to take at least a moment to talk about goals of care conversation with their loved ones. And finally, I took some extra time to talk to the daughter going over the assessment of plan during this transitional care visit. So I'm gonna pause here and give the audience a few minutes just to think about what code you would want to submit for your services. The 99496 or the 99495 transitional medicine, transitional care code, as well as possibly advanced care planning discussion code. Brianna. All right. So you may or may not be using the transitional care management code. So again, we wanna talk about tools in your toolbox when we think about fee for service billing and pulling back up the super bill just so you can actually see what codes we're talking about. We have two different types of TCM codes. So rather than using our Homer or domiciliary codes, we maybe wanna consider billing with the TCM codes when you actually see that patient. So although TCM is a 30 day service period, let's say Dr. Chang's clinical staff, he had a nurse call the patient before she went out. She did that interactive contact call and you can notice the payment here. This does both of these pay more than a 99350. And we know that the 99346 pays more than the four or five. There's two differences. If you saw the patient within 14 days of discharge and we got to moderate medical decision-making, then we're gonna bill the 99495 for the post-discharge TCM visit. These payments have been increased in the past few years. So people used to not be using them because the home codes used to pay more and that's no longer the case. So definitely take advantage about or think about TCM visits if you're not doing it and you're in fee-for-service. If you get to see the patient within seven days of discharge and Dr. Chang mentioned things like he summarized hospital records, he reviewed labs and imaging and talked to the daughter. All of those things are making me think that it's pretty easy to get to a high level of medical decision-making. And let's say he saw the patient within seven days as a best practice because we know many of you are out there doing that, then I would instruct Dr. Chang to bill that 99496. But we're not done, right? Because he discussed advanced care planning. So let's say just the advanced care planning, not counting everything else that we talked about, it was at least a 16-minute discussion. Again, this patient just came home from the hospital, new transitions, new things to think about, if at least 16 minutes. And the reason we say that is because advanced care planning from a billing perspective is a time-based code, but there is a potential to bill for the TCM visit in addition to 99497 for that advanced care planning conversation that occurred during the visit with the patient. And Brianna, I forgot to mention, and yes, we try to see our patients within seven days. And yes, we often do follow-up blood tests after their hospital stay, to follow up on their kidney function, potassium, sodium, anemia, and whatever. So that would also add to the MDM as well, correct? It would. And then I wanted to mention too, there was a question in the chat about that interactive phone call with the patient's daughter. So yes, TCM has both non-face-to-face and face-to-face requirements. So you do have to make that call to the patient or their primary representative, and that call needs to be documented within your EMR. it should be part of your templates. In the advanced coding online course that you all have access to for registering for this webinar series, it talks about TCM in more detail and I actually give you template recommendations for both that interactive call with your clinical staff. It does have to occur by a licensed clinical staff member. And then the provider, again, that post-discharge visit, it includes one, so you're not billing an E&M and the TCM. It's one TCM visit with that interactive phone call and all of those things that Dr. Chang described. Build a template for TCM, it'll make your life easier. But reviewing those hospital medical records, following up on any referrals or treatments, patient and caregiver education, all of that is part of the TCM service and does need to be documented. All right, as in real life, we're rushing along, seeing the next patient. And this is a follow-up patient. It's not a new patient, it's not a TCM visit. The patient has a stable COPD and five other chronic medical conditions. I do a detailed history, a 10-point review of system and an A-plus organ exam during my visit. I reviewed all the medications and I decided to continue all the medications without any changes and no laboratory studies. I didn't do any blood tests or order any x-rays. I did take the time to talk to her about quitting smoking. So counseling was provided. So Brianna, I often find myself wondering, should I build this 99349 or 99350? Because overall, the patient is pretty stable but she's got lots of medical problems. And also, I spent some time talking about quitting smoking. How can you help us with some of the billing considerations here? Yeah, so that's a great point. So again, we're kind of debating between this 99349, 99350. We know it's a patient that's got a lot of medical issues but they're pretty stable. There's not a huge exacerbation or anything that's going on. He mentioned a detailed history and the comprehensive exam for medical decision-making purposes. I know for number one, the number of diagnosis and treatment options that I'm gonna get to this extensive level, right? Because we know we have at least six chronic medical problems. Whether they're stable or not, that's still gonna get me there. We don't really have a lot of labs or data and complexity to be reviewed. And that's not gonna be the case every time. So let's say that the second piece of MDM was minimal or limited. But Dr. Chang mentioned he's continuing medications. It's not prescribing new medications. That's still prescription drug management. And the patient has at least two or more stable chronic illnesses. So I know for the overall level of risk and complexity, I'm still gonna get to that moderate. So again, MDM is a two out of three. I have extensive number of diagnosis and treatment options. I don't quite get there with the amount of data but I still have moderate risk. So the overall level of MDM is gonna be moderate complexity. So if we go back up to our coding grids, I could still get to moderate or MDM here. But again, taking into account the full patient's health and from a medical necessity standpoint, if the patient was truly stable and we weren't changing too much, I'd probably end up coding this as a 99349. But again, just because of the overarching level of medical necessity, what I don't wanna see is this 99348 because I see that sometimes. You're still doing a lot of work for a lot of chronic conditions. If you look at what the actual E&M requirements are, low MDM or complexity, most of the time these patients are gonna be at moderate. And so that's why we know this code, the 99349 is the most common for our busy house call providers. What about the smoking sensation? Oh yes, good point. Thank you. So again, if we go back to our Superville, so there is a code, a little bit of reimbursement but every little bit adds up in fee-for-service if we're in fee-for-service models here. So thinking about our smoking sensation, you would have to spend at least four minutes on that smoking sensation counseling. And it is, I believe it's 99471. Here we go. 99406 would be the code that Dr. Chang would bill for that smoking sensation. So again, in his problem note, I don't need total time for the visit because we're billing the visit on documentation and complexity. But I do need a section of his note to talk about the patient's willingness to quit, what resources were provided. Did Dr. Chang talk about the risks to that patient's medical conditions? Yes, it only pays $15. But again, we wanna get paid for all the work that we're doing. And so since the smoking counseling occurred, then we're gonna go ahead and bill for that. All right. Speaking of getting paid for the work that we're doing, so between patients, I'm rushing, trying to get to the next patient but there is a message coming in from my patient's portal. It's from the patient's daughter. Say, hey, you know, mom's got this rash. Can you take a look at it? So between visits, you find a safe place, you park your car, you take a look at the picture of this rash and you say, you know, this looks like shingles and you prescribe a medication, antiviral medication for this suspected shingles case. And you send a message back via the portal with the instructions to the patient's daughter and also any curing instructions regarding the wound and any follow-up recommendations in case the condition worsens. So Brianna, this is work. This is time out of my busy day. Can I get paid for this or do I just kind of eat it? Yeah. So some of you might be familiar. Medicare rolled out some kind of a group of services that's called CTBS or communication technology-based services. And there is a HCPCS code G2010. And I'll go ahead and put that in the chat. That's for review of an image or video. And you have to provide feedback back to the patient. Oops, sorry. That was to someone individually and not the group. You have to provide feedback within 24 hours and reviewing that image can't be related to an E&M visit that you had with a patient within this past seven days. You know, Dr. Chang in this example was able to go ahead and address the problem and provide the prescription. He's not gonna go make a visit for that same thing. So he could bill that G2010. Yes, it only pays about $12, but again, in fee-for-service, we're trying to just get paid for the work that we're doing. So that might be something we keep in mind here. Thank you, Brianna. So the next patient I'm seeing, I'm pull up to the house and I'm seeing the patient for follow-up of high blood pressure and diabetes and other medical conditions. What's a little different about this case is that this patient is on hospice services. And we, as typical, I shouldn't say typical. Well, it is for me, I do a 10-point review of system and an eight plus organ physical exam. And I continued medication the same. Obviously, I shouldn't say obviously, when patients are on hospice, we do less laboratory studies. So no labs and no imaging studies were done or ordered. Now, not many, no, I shouldn't say, not all of us that make house calls follow patients on hospice care. In our practice, we continue to take care of our patients, whether they're on hospice or not. But some providers, once they transition to hospice, they let the hospice service take over the management of the patient. So if you do continue to take care of patients while they're in hospice, Brianna, is there some other modifier I need to be aware of in terms of, in addition to coding for the service I provided, is there something else I should be aware of? Yeah, so when patients enroll in hospice services, they are still entitled to Medicare Part B services through their what's called attending provider. And that attending provider could be a physician or a nurse practitioner or a physician assistant that does have to be documented with the hospice. But we have two different modifiers. If you're gonna get paid and in order for that E&M claim to not get denied, when your patients are in our hospice and you're continuing to see them, you either need to use the GW or the GV modifier. And the GW is gonna be used, so for this particular example, hypertension and diabetes are not the patient's terminal illness. And we know that that was the focus of the visit. So the provider's gonna use the GW modifier because their visit was not related to the hospice terminal diagnosis. If they were still providing support for the patient because of their hospice diagnosis and if it was really related, then that's when we're gonna use that GV modifier on the claim. So again, from kind of a logistics office standpoint, your team needs to have a way to know which patients are on hospice, have that documented, make sure the insurance is updated back to Medicare, although we are starting to see, you know, the hospice VBD come into play here. And then you need to know their start date and their terminal diagnosis in case you do run into any denials. Usually that's documented in your EMR and kind of the backend. But all the provider needs to know is that they need to use the modifier or your billing team if you have billing support and coding and billing staff that are reviewing claims for your providers to either add the GW or GV modifier based on if it was related to the patient's terminal diagnosis. Thank you, Brianna. So this is a real case. I had to go see a patient yesterday. One of my nurse practitioners said, hey, you know, Paul, can you go? This patient needs really swollen and painful. Can you go and drain the need for both therapeutic and diagnostic purposes? So I went ahead and did the procedure, examined the knee, drained fluid out from the knee yesterday and sent it off for analysis. As it turned out, this patient's suffering from an acute gout attack in his knee based on the crystal analysis. So Brianna, should I bill for an EMR or should I just bill for the procedure itself? How do you keep me in compliance here? Yeah, so when we're doing a procedure on the same day or maybe we're just doing the procedure, so the question is, are we doing both? Can we support the modifier 25? The definition of modifier 25 is it is a separate and distinct service, right? That was performed on the same day and E and M service on the day is other services or procedures. But Dr. Cheng said, you know, his nurse practitioner already saw this patient recently. He added the patient on, you know, to his schedule and he really just did the injection and was on his way. So for this particular case, we're only billing for the procedure. We're just gonna see that procedure note documented, you know, pre and post status of the patient, instructions that were given, and we're gonna use that knee injection, which I believe is 2610, but we could go to our little Superville here. There's a separate little procedure section. I know that a joint injection, if that's part of your practice, some practices do procedures, other don't, but 2610 would be what Dr. Cheng provided. Now, let's say that Dr. Cheng was seeing his patient. He did a normal, you know, he showed up for his house call. He did the E and M visit, and then he noticed, you know, the patient's significant knee issues, and he happened to have the injection and all of that with him, and he did both during the same visit. You can bill for an E and M visit and a procedure if you use modifier 25, but your documentation really needs to support that it was separate and distinct. I don't wanna see your chief complaint for your visit as patient, you know, knee injection or, you know, patient reports. I need to see separate and distinct services if you're gonna bill both. Thank you, Brianna. I'm finishing my day, but before I can get there, a family member sent a message to my nurse. They're really concerned about mom's mental status change and wondering what's going on. So I spent some time, eight minutes on the phone, talking with the family, doing a review of system over the phone, and I said, you know, this could be a urinary tract infection, and I prescribe an antibiotic, send it to the pharmacy, and I discuss with the family, you know, any follow-up instructions related to this treatment plan. So Brianna, eight minutes of my time spent advising and counseling this family. Is there an opportunity for me to bill for this service? Yeah, so again, right now we're talking about fee-for-service billing opportunities, and right now during the public health emergency, which, you know, it has to be renewed every 90 days, but we know for quite some time that Medicare has been paying for telephone E&M services, which are time-based. It doesn't have to be a visit. Again, the kind of caveats to billing telephone E&M services is it can't be related to a visit you just have with a patient within the past seven days, and it can't result in you needing to go see that patient face-to-face. But these codes right here, they're all just time-based. Dr. Ching's just gonna open his telephone encounter, his care management encounter, and his EMR. He's gonna document the total time of the phone conversation exactly what he did, mental status concerns, concerned about a UTI, prescribed antibiotics. He said he spent eight minutes, so I know I can bill this 99441. Again, these are only gonna, whenever the PHE is officially over, Medicare will stop paying for these codes, and we're gonna have to use the G codes for virtual check-ins, which is something very similar to office visits. So important for us to kind of know about those services as an available option. Right now, the current PHE is scheduled to expire in March, March 16th, so we'll have to see what happens as far as if that gets extended again. Perfect. All right, last visit of the day, and it's a tele-visit. I'm back in the office, getting on my tele-visit platform. This is the patient's concern that she's got COVID, that she tested positive on one of the home testing kits. She had had some symptoms, or respiratory symptoms for last two to three days, and I do an eight-point review of systems over the telehealth video, and I do a limited physical exam, getting what information I can through the video. And after going over her history, going over her medications, I decided to prescribe the new medication, Nirmatrevir, Ritonavir, or it's much easier to pronounce, would be Paxilivir oral medication for the outpatient treatment of patients with COVID-19. So for my time spent doing this telehealth and management, Brianna, what can I bill for my services? And is there a modifier I need to use for this particular scenario? Yeah, so hopefully everyone knows since we've been in the PHE for quite some time now that you should be billing your normal E&M visits, your home or your domiciliary visits if you do a telehealth video visit. It does have to be a video visit to meet Medicare telehealth requirements. Right now, these are all because of the 1135 waivers. You know, they have a different policy when that PHE ends. Yes, we know it'll be a more limited exam. So we'll be looking at those E&M codes or maybe deciding, you know, if it wasn't focused on the medical need, if we could use time to support that E&M code, but you're gonna bill your normal home and domiciliary visits. So maybe a 99348, if it was really just for the COVID, would probably be what the level of service you would get to. But again, you would need modifier 95 for a Medicare telehealth service during the PHE, but you should be using your home and your domiciliary E&M codes when you're doing these video visits. And then there was a question about the audio only after March 16th. We know that Medicare's final policy going forward is they're only gonna continue to cover Medicare telehealth services for mental health, for the purposes of mental health or behavioral health conditions. The codes that you can use, again, I don't have a crystal ball. We'll have to see if it gets extended, but in your resources, there's a virtual check-in code. It's a G2012. It pays significantly less, only about $15, but it still would offer a way for you to get paid for telephone time with your patient. Here's the code I was looking for, this G2012 for a five to 10 minute or G2252 for an 11 to 20 minute phone conversation. Thank you, Brianna. So the office is now settling down. It's quieting down after a busy day, but my work is still quite not done yet. I'm calling family members and caregivers, giving them update on the patient's conditions. Some, I spent a few minutes. Other calls, I spent quite a long time discussing their condition and possibly goals of care. I'm also in the office reviewing and signing for 485s for home health services. I'm responding to clinical messages and also reviewing some remote patient monitoring data that's coming through my dashboard, including heart rate and blood pressure and weights and oxygen and so forth. So to finish up here, Brianna, help me with some of the coding opportunities here that I have, even though I'm not seeing patients, but I can still be getting some reimbursement for my time. Is that right? Yeah. So a couple of different scenarios here that we'll throw out. So let's say Dr. Cheng comes back to the office and it's not just kind of a quick touch base. Let's say he has an extending conversation with a patient's son or a patient's daughter about the visit that he had today and discussing the treatment plan. Maybe there's some discussion about what's going on with the patient's heart. Maybe there's some discussion about what's going to go on and goals of care. Again, keep in mind that prolonged services, non-face-to-face, if it's a minimum of 31 minutes and if it's directly related to an E&M visit, that might be an option. The only kind of caveat with that is prolonged services is bundled with chronic care management, just the non-face-to-face code. So let's say we're going to talk in the next webinar series more in detail about some of these advanced coding opportunities, such as chronic care management or care plan oversight. Those are all ways to get paid for your non-face-to-face time too. And if you check out that advanced coding opportunities resource, I've summarized all of those guidelines in much more detail for you. But also Dr. Cheng mentioned about signing the 485s, right? So even if you're not doing care plan oversight, which is 30 minutes per calendar month, what we can be getting paid for is the oversight. You're the ordering provider for home health for the patient and you're signing an initial 485 or you're continuing home health services for the patient. So you're looking for the G0180 or the G0179 that's being billed when you're at the end of the month. Maybe you have a process that's getting billed out here for those services. Let's see if I can find it really quick. But G0180 is the code for your initial, if it's an initial plan of care with home health and G0179 is for the recertifications that can only be billed once every 60 days. We've also thrown in some bonus resources. There's one on telehealth during COVID-19 that goes over all of those kinds of nuances in more detail. And then there's also the remote patient monitoring. Again, we'll get into some of those more advanced in the next webinar series. But thinking about other ways to add revenue and monitor your patients at home. There is no possible way we could have covered all of the billing opportunities. That's why there are two more webinars that's coming your way that we'll be able to share with you even more coding and billing opportunities as we continue to do this amazing work that we love and getting paid for it. How awesome is that? So as Brianna said, under fee-for-service, we fight for every dollar. We manage Coumadin in our office. So yeah, that doesn't pay a whole lot, the 93793, but it's still a few dollars that brings in. So all the dollars do add up at the end of the day. So with that, I think that's... Do I turn it over to Brianna or Dana? Yeah, Dana, if it's okay with you, I stopped sharing my screen just because I think for the Q&A part, I kind of wanted to see faces and take the slides down. But at the end, if you want me to pull back up the final slides, just let me know. I will. All right, so we are going to pivot into our Q&A. As we've said, we love interaction. We love to see faces. So I think, Brianna, you guys have addressed most of the ones I captured in the comments. I think I have one to throw out there, and then we'll give you guys all an opportunity to become brave and jump in with some Q&A. I think the one that we still needed to address potentially was regarding the diagnosis to use instead of aftercare for surgery. Yeah, so, and again, maybe the aftercare, you know, I'd have to look at the full encounter, but generally the aftercare code is going to be provided by the surgeon or whoever did the surgery. You know, you could certainly, you know, if that patient had osteoarthritis, you know, what other chronic conditions are you managing? Remember, just prioritize that assessment and plan for what conditions you're really primarily responsible for treating, and that's kind of what I want to see coded and represented there. Great. All right, you guys. Let me see. I can catch up on the chat really quick. I think I was good. Oh, so there was a question earlier about why have the HPI requirements been removed for the office visit but not the home? Dr. Cheng and I are probably just as frustrated as you are. Those of you who may or may not know that the coding and documentation guidelines for the office visits only, office only, it doesn't apply to us in the home, in the domiciliary, not even the nursing home setting changed back in 2021. There is still hope for us that maybe they'll adopt those policies for us later on. What the, you know, this is part of CMS's patients over paperwork and trying to reduce documentation burden and incentivize primary care, and of course, they forgot about the hospital providers, so we still have to use all of the E&M elements we talked about today. I need history exam, medical decision-making, considering that overall medical necessity, or if you're billing on time, it has to be dominated by counseling and coordination of care, and I need that compliant time statement to build the visit based on time rather than documentation and complexity. Again, I don't have a crystal ball, but that potentially could happen in the future. We're just not sure what CMS is going to do. And then I think we hopefully touched on this. If not, you guys are welcome to unmute at this point, too. We just wanted to make sure we got through the presentation, so if you'd like to just unmute yourself and say hello or have a comment or a question, please jump in, or you can raise your hand, and Dana will call on you, but there was something about an 85-year-old man seen for a follow-up visit. Chronic medical problems had been reviewed and stable, except as noted below, so again, that was kind of similar to the example we talked about with Dr. Chang. You're going to comment on any changes on those stable conditions since the last visit. You could still probably get to a 99349. That's really where I'm hoping that home visits E&M guide is going to be helpful for you. Pull up those that, you know, maybe just even in a staff meeting, maybe pull up one note for each of your providers and kind of go over them together. I wouldn't want you doing that every day, but, you know, if you kind of take that time maybe once a month or during a staff meeting or even just by yourself, you know, kind of when you're not sure on if you're going to code the 99349 or 99350, that might be a worthwhile activity to look at. We got another one who popped in here. Can CPO be billed concurrently with CCM or TCM? So it cannot be billed concurrently with chronic care management, but we did get relief that it can be with transitional care management. I think it was back in 2019 they finally unbundled all of those care management services with TCM. You have to pick one or the other. So care plan oversight, you're either billing for CPO for your, if you have a lot of home health and hospice patients you're overseeing, or you're billing for chronic care management as the primary provider for all of your patients' needs. But that doesn't, just for clarity, you could still bill for the home health signatures and oversight if you're the ordering, you know, provider for that. So the GO180 and the GO179, that's not technically care plan oversight, that's home health certification and recertification as the ordering provider. So you could still bill for those two particular codes and CCM. You know, I don't know about others out there, but all this documentation, all this writing and typing and so on, I find it very fatiguing. So I encourage, you know, I come up with my own template. You saw Brianna pull up one of the smart phrases that I use. So I encourage you to work with your vendor, work with what your EMR is capable of doing, and come up with templates and smart phrases or macros so that you don't have to keep clicking and keep typing all this stuff over and over again. Again, just to simplify your documentation so that you reflect what you did. You don't spend time typing, but really spend more time caring and get proper reimbursement for it. So be creative, share smart phrases with other team members in your practice. Again, you know, I'm not as smart as all of us combined together, right? So come up with creative solutions and make your life a little bit easier while still satisfying the coding requirements. And I think that kind of leads to a good point. And I'm still kind of, because I was sharing my screen, catching up on the chat and seeing how we can tie these things together. But we hear a lot at you, right? And you have a ton of resources with lots of different coding opportunities. How I kind of recommend practices digest that is look at that advanced coding opportunities handout and think about which of these services aligns with my clinical model. What are you already doing that you might not just be getting paid for? And then really pick the services that best align for that. So that to your Dr. Chang's point, we're not creating extra work. Yes, we're going to have to create some templates and workflows and maybe a little bit more work in the beginning to set up. But the biggest question I get from people is how do I get paid for all my non-face-to-face time? And generally that's going to be some sort of care management service, whether it's chronic care management or care plan oversight, or the prolonged services, non-face-to-face codes, because that's really the opportunity. And there was a comment in the chat about, isn't it better to do kind of the home health certifications and that prolonged services, non-face-to-face kind of rather than TCM or CCM? It depends. So like you said, I had one practice where, because you still have to enroll your patients in chronic care management, they still tended to do the 99358 for their new patient visits before the patient's really set up and they have that 20 or plus minutes per calendar month. And it's not bundled with TCM. It used to be up until 2019, but you can build prolonged services, non-face-to-face and TCM, transitional care management concurrently. You can also build TCM with any of those care management services we discussed. It used to not make sense to use the TCM codes from a reimbursement perspective. That has changed because of the payment increases that we saw the past two years. They increased CMS did TCM reimbursement by about 30%. And again, so, you know, TCM is really not bundled with anything. The only thing you have to watch is that CCM code with the prolonged services, non-face-to-face that is bundled. But again, if you think of the process it takes to enroll your patients in CCM and then kind of there on after you might have some flexibility to think about a workflow there. We have another one that's come in Brianna for CCM and billing 99491 and additional 20 minutes. Do you add a second code? Yes. So we have different, we have three different types of CCM services. And again, we're going to talk about this more in the next webinar. And even if you're not in the next webinar, take the online course, you already have access to it by registering for the series. It talks about CCM, TCM, prolonged services, all of this in more detail. You could even take that before the next webinar, but we did get a CCM add on code for what the 99491 is when the provider is doing all of the CCM time. It's the 99491 is 30 minutes per calendar month of all the provider's time doing chronic care management. And if you add, let me share my screen again, and I'm going to go back to the super bill here where we have the different CCM codes. So if I go to the qualified provider CCM services, I have the 99491. Let's say the first 30 minutes was spent. Let's say that you spent an additional, let's see, where is it? I might've not put it on with the other one, but it is, there's an add on code for provider CCM. I might have to flip to my other resource. Let me go to this one. Sorry about this guys. Move my little screen here. So this is the advanced coding handout that I was talking about. Here we go. So 99437, provider CCM add on code each additional 30 minutes. So if you're doing provider CCM, the most you could possibly be billing for per calendar month is 60 minutes. I'm trying to make this bigger. So this is if you're a qualified billing provider spends all the time, but let's say it's a combination of your clinical staff and your providers. Then that's when we want to build traditional CCM. We have 99491 for our first 20 minutes, and we have a new add on code 99439 for each additional 20 minutes that can be built up to two units. So a total of 60 minutes per calendar month, just for traditional CCM time. We do have complex CCM codes too. This really takes a higher burden of proof of the sick patient and the provider's involvement. And it actually, if you add it up, pays a couple dollars more to build traditional CCM. So I'm a fan of this, or if it's all your provider's time, this rather than the complex CCM codes. All right. We still have more time for Q&A. You have two... More discussion. You're with your peers. Yeah. This is a free shot to ask any questions. I did have a question. I wanted to find out what is the best way to find out if the reimbursement is being extended for the audio visits? How can you find that information out after March 16th? Yeah. So for the telephone E&M codes specifically, Medicare did already say they're going to stop paying for those. So generally, the best way to kind of stay up to date is just signing up for the CMS listserv or their emails or have your practice manager. They generally send those kinds of policy up. We did get the final rule in November that confirmed they've never paid for those telephone E&M codes. Again, their rationale was, well, we already have the virtual check-in codes. Yes, they pay significantly less, but those G codes aren't considered telehealth, so they're not tied to the public health emergency in any way. So in CMS's eyes, they're like, hey, we did this for the reasons of the public health emergency. We're going to stop paying for this. Telehealth is only going to be for mental health, although that's of course subject to change. There's a lot of moving legislation. So any of your associations, HCCI, we launched a blog. Check out our website. I'm trying to always put blog posts on there with updates and things like that, so you can rely on HCCI as a source of education. But even just subscribing to a CMS listserv, they do monthly what's called MLN Matters articles that are super informative and kind of will give you some guidance and tip sheets there as well. Nice to see you, Renee. You know, on the flip side, on the operation side of this, just something to keep in mind, you may want to provide your front office or your provider some scripting as you're billing for some of the services that traditionally, like a telephone service, that has not been billed to their insurance before. So sometimes we get upset phone calls from patients, or maybe not upset, just confused. Like, you know, what is this charge for? All I did was talk to Dr. Chang. And so to give your providers and your front office a scripting for them to go on, to let them know that these are services that are covered under your insurance by Medicare, that this is not kind of something like a scam or anything like that. So that might take some of the heat off of your providers and also clarify some confusions for your patients and family members. All right. Any more questions? Now go ahead and pull up the screen again, just in case. Don't be shy. You can use the chat for others. Heidi Warpinski. Just a quick question going back to the topic that you were discussing previously with the CCM codes and that additional time for billing. Do you have any advisement as it relates to components that are essential in the documentation, particularly when additional office or not office staff, but other ancillary team members or interdisciplinary team members are involved in that process? Yeah, that's a great question. So CCM really is a process. And so it kind of, it does need to have some food for thought. So when you first roll out CCM services, you need to have verbal or written consent for the patient. A lot of EMRs now will have some, so they usually call them like some sort of time module, or maybe you're using another vendor to do that. But you need an electronic comprehensive care plan for CCM services to be in the EMR. And then as far as the ongoing communication, even if you're, if your EMR doesn't have like a CCM module or a time tracking module where it would actually allow any interdisciplinary team staff to add minutes in each encounter, you know, you could look into kind of, you know, tagging it with a certain care management workflow. But what I would expect is each staff member throughout the month, they need to know how many total minutes they spent and just a little description of what the work was or what they did. You know, was it a phone call with the patient? Were they, you know, going over medications or providing resources, placing referrals? CCM is a time-based service that if you can use the time tracking in your EMR, that's really helpful because at the end of the month, then you can just run a report and you know exactly how many minutes you've spent. I have seen some providers while they're waiting for that, where they just have one care management encounter kind of running all month, or they have a certain way they tag those encounters within their EMR that lets them run reports. But what I need from the other team members is exactly how much time they spend on each encounter, each interaction with that patient, and then how that time was spent. Great, thank you so much for that clarification. You're welcome. I love CCM. I think it's just an easy, like, how do I get paid for everything I do every day? If you're in fee-for-service anyways. All right, we still have time. I'll let you guys think through some questions. While you're thinking through there, just wanted to remind you guys that if you did sign up for the three-part series, the second and third webinars will be in March and April. We will continue to cover these topics. And then as well, if you participate in the series, you do have the three online classes available for you, as well as tips and tool sheets. So if you log into the HECI Learning Hub, and I put the link here in the chat, you'll be able to access this information within the next 24 hours. That includes a recording of this call, as well as this presentation. So I know we threw a lot at you guys today, but to Brianna's advice, you know, kind of go back, kind of sift through it, come to the next webinar, or if you want, and bring questions. If you don't, I got another question. Let's do that. Can CCM be used for nursing home patients? It can be used in the nursing home setting, as long as they're not in a Part A stay. So, you know, they're not in that, you know, 30-day post-S, but if it's in the long-term nursing home setting, where that's the patient's place of residence, then yes, you can do chronic care management in the nursing home, as well. All right, I'm going to flip to the next page, Brianna. Yep. All right, so once our call ends, and you think, oh my gosh, where can I find stuff about today, but all of other maybe topics, and also get in touch with our experts here, we do offer HCC Intelligence Resource Center. There's the hotline, so you can, you know, make a call, you can make an email. There are quite a library of tools and tip sheets for you to access and utilize, and again, our webinars as they move forward. With that, I think we have about five minutes. If no one has any questions, any parting wisdom, Paul, Brianna, that you would like to share to this group? I have a confession to make. I have the HCCI tools, no, no, no, the Superville taped on my desk, because it, I can't keep all of this, all this information straight in my head, right? You know, like, you know, oh, we know which, which level, you know, what, and so forth. So that's the confession. So it's, it's, it's taped right from the center. It reminds me, you know, hey, you know, look at your coding opportunity, opportunities, make sure you maximize, you know, every chance that you, you have, because for my practice, we're still very much under fee-for-service. So like I said before, we're out there fighting for every dollar for the services that we're providing to our patients. Yeah, and just to thank you all for, I know, you know, you're all, a lot of you are busy clinicians or managing practices, and it's hard to make the time. So thank you all for being here. I know it can be frustrating sometimes, you know, to be like, why do I have to remember all this? You know, I always try and tie it back to quality care. If we get paid appropriately for the work that we do, we can provide better care for our patients, maybe more staff, more, you know, opportunities and things like that. So we're hoping this will get easier. Thank you for your kind comments about the resources. You know, HCA wants to be your partner. This isn't a one and done. It's why we have this series and all these resources. And my fabulous colleague, Rachel, who you all might get emails from, she's your secret weapon too. She stays super connected with people and helps me make sure we know what resources we need to provide you all. So thank you all for your time. Really great to see everyone here today, and we hope this is beneficial. If I could just say one last thing. I came last year, as you know, to some of the seminars, and I want to say based on the seminars and the support you guys have provided this past year, I've decided to do a solo home-based primary care practice here myself in Charlotte, North Carolina. So I want to say I'll be launching in May. So I just want to thank everyone, you know, the support that you guys have provided. It just gave me a full, just so, just made it so effortless for me to want to just move forward with the program. So I just thank you guys. So thank you. That is so good to, you know, that's so good to hear. You know, this, like Brianna said, this is why we do what we do. We want to support clinicians like you, whether you're small, whether you're big. This is just, that's just terrific news. So, so thank you so much for sharing. Yeah. Thank you. Yeah. Okay. Well, that's a great note to end on. Again, remind you to go back to the Learning Hub in the next 24 hours. All of this information will be available. More importantly, the slide that, the second to the last slide also gives you direction on how you can get ahold of us. We will not, we're not going to go away here between now and next month. You know where to find us and we look forward to seeing you guys again soon. Thank you. Take care, everybody. Bye.
Video Summary
In this video, Dr. Chang and Brianna discuss the coding and billing opportunities available for home-based primary care providers. They cover various topics including advanced care planning, follow-up visits for stable chronic conditions, telephone E&M services, and telehealth visits. <br /><br />When it comes to advanced care planning, they suggest using separate codes (99497 or 99498) to bill for the discussion, depending on whether it is the first time or subsequent. Alongside this, they highlight the chance to also bill for transitional care management visits and any applicable E&M codes.<br /><br />Dr. Chang and Brianna provide guidance on coding, documentation, and reimbursement for each of these services. They recommend using templates and smart phrases in electronic medical records to simplify documentation and ensure compliance with coding requirements. They stress the importance of being proactive in finding coding opportunities to ensure proper payment for services rendered.<br /><br />Brianna emphasizes the need to stay informed about changes in Medicare policies and guidelines, suggesting subscribing to CMS listservs and utilizing other resources to stay updated.<br /><br />Overall, this video offers valuable insights and recommendations for home-based primary care providers looking to maximize reimbursement for the services they provide.
Keywords
coding
billing
home-based primary care
advanced care planning
follow-up visits
stable chronic conditions
telephone E&M services
telehealth visits
transitional care management
E&M codes
documentation
reimbursement
©2022 Home Centered Care Institute. All rights reserved.
×
Please select your language
1
English