Hello and welcome to the HCC intelligence webinar and virtual office hours. Today's webinars entitled 2021 coding impact for home based providers and practices. My name is Dana Crosby senior director of engagement and practice development at HCCI, and I will be your moderator today. Before you begin, I would like to cover a few housekeeping items with you. Participants are muted, but please use the chat or the questions boxes located on the screen to submit comments and questions. Questions that are submitted will be answered when we transition into the virtual office hours portion of this webinar. The recording of the webinar slide presentation and supplemental handouts will be made available on the HCC intelligence page within several days following the webinar. We will be extending the virtual office hours portion today, and will be hosted an open discussion on coven 19 vaccine administration from 5pm to 530pm Central Standard Time. Joining us during this time will be two additional panelists, Dr. Tom Cornwell executive chairman HCCI and senior medical director for village MD, as well as Dr. Steve Landers, president and CEO of visiting nurse association, health and hospice. We welcome you all to stay on and continue that conversation. Today's presenters are Dr. Paul Chang, senior medical and practice advisor, home centered care Institute and medical director, Northwestern medicine, home care physicians, and Brianna Plintzner, manager practice development, home centered care Institute. The objectives for today's webinar are review 2021 coding changes as a result of the Medicare physician fee schedule final rule, discuss documentation and requirements to ensure coding compliance and discuss the impact of providing virtual services beyond the public health emergency. And now I will pass along to Brianna and Dr. Chang for the main presentation. Thank you for that introduction and welcome everyone. It's great to have you join us for this very important webinar and also I think a very exciting and I'm hoping a very energetic discussion about COVID-19 and the vaccination. When HCCI, when we have done webinars or live presentations on billing and coding, it's usually very well received with lots of audience questions and participation and I anticipate today we'll be experiencing more of the same. And we do have a lot to cover today so we are going to get right into our presentation. The first thing I wanted to talk about is many of us providers, we have complained about the process that's required for accurate documentation, E&M coding for billing purposes and it's given us lots of headaches. And we've heard about this significant change in terms of documentation. Really, it's something new on the landscape in more than a decade. And we've heard about that and it appears to be a positive move in the right direction in terms of reducing some of the burden related to documentation and coding. But Brianna, the good news doesn't quite make it all the way to HBPC. Is that correct? Can you tell us a little bit more about that? Yeah, that's correct, Paul. So I really wanted to start off as, you know, some of you might have heard of the patients over paperwork initiative out of CMS, which is really driving the documentation burden relief changes. But I do want to be made really clear that starting in 2021, the documentation and coding guideline changes only apply to the office setting. So only for CPT codes 99201 through 99205, which we know are not the CPT codes that we as home-based, you know, you all as home-based providers use. You use the home and the domiciliary CPT code ranges. So I wanted to at least, you know, link to the official AMA guidance of the changes. But again, unless you're a provider that's caring for patients in multiple settings, where you may see clinic patients as well as make home visits or visit assisted livings, then you would need to know both guidelines. And this link to the AMA page will go over how, you know, now that we're into January 2021, only for the office can you bill on time alone when it's not dominated by counseling and coordination of care. There's also different prolonged services and time rules or just on MDM, medical decision making alone. But really important to understand that for your home and your domiciliary CPT codes, we're still following the same 95-97 documentation guidelines that we've been doing forever now. You know, this slide is just one example of the established home visit requirements. And actually, you know, in follow up to this webinar presentation, we're going to be providing you with more these handouts for all the established and the new home and domiciliary services. So you can use these as reference sheets. But again, we're thinking about the level of history, exam and medical decision making, or if you're billing on time, you still need to support that it is documented by counseling and coordination of care. You're not using the new guidelines that only apply to the office setting. And I wanted to, you know, kind of start by giving that clarification because I've started to hear some questions there. Yeah, so I was so very hopeful. But I guess us house call providers will have to wait a little bit more. And perhaps the office documentation and coding changes will filter down to us at some point in the future. So we will still have to live with the 95 and 97, what I call the window XP version of documentation for now until we can get to the next operating system. Go ahead, Paul. No, go ahead, Brianna. As I say, I do think there's hope for us. You know, the AMA editorial panel has commented that they're looking at the skilled nursing and the home and some of the other settings for potential changes similar to the office visit code set and in future years. That's also something that HCCI, along with our advocacy partners, have provided feedback and comments to CMS that, you know, we are really appreciative that they're trying to incentivize and prioritize primary care, but that we would like to see the home visits and the domiciliary visits treated in agilis to the office setting. Well, related to this particular change, and we've heard about reimbursement being increased for primary care in the office setting, that has unfortunately had an unintended impact for us house call providers. Again, many of us have been involved and have been hearing and concerned about a potential pay cut for house call providers, given this particular change that we're seeing. So, Brianna, can you help us sort through some of the, what is the final, or what is it in that game show? What's the final answer? What is the final answer when it comes to, are we looking at an 8 to 10% pay reduction, or is it something less? So, if you can help us with that. Yeah, the good news is it's not as bad as we thought it was going to be, right? When we were first preparing for this webinar, we were still concerned, and just to give a little legislative background here, this all happened because in order for CMS to be able to increase the payment, the work RVUs, and change all of these coding and documentation requirements for the office setting, it unfortunately had a negative impact because of budget neutrality on the rest of our E&M and other services. So, there were a lot of specialties outside of home-based care that were upset about this, surgical in particular, because this is across the board. So, I don't want you to think they're just penalizing us. That really wasn't the intention. The relief that we got actually came out of the ominous 2021 budget bill, which was part of the COVID relief package. And so, because there was an additional $3 billion in that package applied across the fee schedule to offset that loss, in addition to the CMS delayed the office add-on complexity code, some of you might have been hearing about if you do clinic work, the G2211, that got delayed three years. So, this is looking at about an average of a negative 2% payment reduction. So, these are off the final fee schedule. You'll notice the 994, excuse me, the 99358 and the 99351s are the ones they had published in the PFS files. So, this is just average calculations applying the negative 2% across the board using the conversion factor. And then here is the DOMS. But what you'll want to do is you'll want to check, and I have a slide to show you how to do that, your locality, because with geographic reductions, you know, you might see a few dollars difference based on your region and your area. But again, you know, unfortunately, any pay cut is, you know, not good news, and we want to prepare for that. But we're only looking at about an average 2% payment reduction, sometimes less. Like in Nevada, you know, most of the codes, it was only about a 1.2% reduction. So, check your locality. The good news is it's not as much of an impact as we thought it was going to be originally. That is great news. Brianna, but can you help me, if I'm a provider looking for my MAC, how do I go about doing that? Yeah, so MAC stands for Medicare Administrative Contractor. And so, what I mentioned earlier about wanting to check your fee schedule and your locality, so the link on your screen here will get you to the CMS page where you can click on your state. It'll tell you who your MAC is, and you see the names on the screenshot there. You go to your MAC's website, and then just look for their fee schedule lookup tool, the right-hand side of the screen, National Government Services in Illinois. I will say they generally are pretty easy to use. But that's what you want to do to look at the fee schedule pricing in your areas. And the MAC is actually, all of theirs that I've checked have been up to date quicker than the CMS national lookup tool. So, the MACs are a good resource for you to figure out exactly what you're going to get paid in your region and your area. Well, thanks, Brianna. Well, you know, 8% to 10%, now we're down to 2%. Maybe it's not as painful as I thought it would be, but it's still a payment reduction. And that stings a little bit for us. You know, we're in the trenches taking care of some very complex and patients who have great need, and we certainly want to be reimbursed appropriately for our time and effort. But the news isn't all bad. I think there are some opportunities for us to get back some of the dollars that might be lost in those other categories that Brianna had talked about two slides ago. So, what E&M services are receiving perhaps an increase in reimbursement? Yeah. So, it's a slim list, but in addition to making some changes to the office visit code set like we talked about, there were certain other E&M services like transitional care management, such as cognitive assessment and care planning and annual wellness visits that CMS lumped into prioritizing. And they got RVU increases and subsequently payment increases. And TCM in particular, this is on average a $30 to $40 payment boost than we saw in even the 2020 rates. And this is the second year in a row that CMS has increased and tried to incentivize and make it easier for providers to formally build TCM services because they really believe it's going to lead to better outcomes. The cognitive assessment and care planning, and we'll talk more about the specific requirements, but that also saw an increase and is really for that, you know, cognitive evaluation, you know, and developing a care plan for patients with cognitive impairment or dementia that can be done every six months as appropriate. And then, of course, our annual wellness visits, you know, CMS and Medicare Advantage plans, especially when it comes to their quality scores, really want to see us doing our due diligence on those preventative services. Well, this is certainly good news. And as the attendees said, as you guys are looking at what's on the slide here, I want you to think about what is doable in your practice. What can you implement, given the resources that you have with your practice? This past Monday, we had a staff meeting here at Home Care Physicians, and we went over some of the coding and the changes and the reimbursement. And we talked as a team regarding, hey, maybe we can do some of the cognitive assessment care planning, because we do a lot of the required bullet points already, which we'll talk about in a couple of slides. And also emphasizing, you know, getting out there seven days after being discharged, not only for patient care, but also in light of this reimbursement change. And then working with your team, you know, how does that work? And how do we know when Mrs. Jones is discharged from the hospital? And how do we route it to the scheduler? How do we route it to the nurses to make those calls? So those are important things to work out with your team and with your leaders to make the process as smooth as possible. And then you can get the reimbursement that you need. So what are, we're talking about TCM, Brianna, what are some of the components to get paid for a TCM visit? Yeah, so I mean, although TCM is not new, because this is a way that you can really kind of help offset that loss, we wanted to spend a little bit of time going over the requirements. So transitional care management is a 30-day service period. It's essentially a post-discharge visit. And the qualifying admissions would be inpatient or observation hospital stay, or patients that return home from a skilled nursing facility or rehab stay. The ER does not qualify, but any other inpatient admission, including observation, does. So the first step of TCM is being notified that your patients, you know, are discharged and you need to get out there and see them for that post-discharge visit. You also want to make sure that within two business days of, or yeah, two business days of discharge, you're making what CMS calls an interactive contact call, which is simply really just a phone call to check in with them. And the number one question I get on that is, well, what's my template? And so because, you know, I think a lot of the misconceptions with TCM is there's a lot of what CMS considers non-face-to-face work as well as face-to-face work. And so here's a template that you can use for your clinical staff during that phone call after the patient returns home, before you're seeing them, to help you capture some of those requirements and make it easy on your team. The second piece of that is what we'd want to see in the provider's actual note themselves. So you're still going to document, you know, your E&M visit, you know, the way that you normally would. And then maybe you bring this macro in and your assessment and plan that's really just tying it all together because you're billing the TCM code as your face-to-face. So you're billing this TCM instead of your normal home or your dom visit when you see that patient for that post-discharge visit. And again, this is just tying all of those CMS requirements together so that you have peace of mind that your documentation supports what you're billing. Yeah, it's really important to have templates, both for the phone call and also for your visit that really saves time. And also make, in terms of time and documentation, and also make sure that I have covered all of the bullet points that are necessary to bill for TCM visits. So work with your team again to come up with a template that's user-friendly. And what are some other changes with TCM? We have heard about being, you know, restricted or bundled in the past. There's been some changes with that as well. Right, Brianna? Correct. I think we really have to commend CMS on trying to make this easier for us. I mean, for the past two years, last year they unbundled a total of, I think it was 16. And this year they unbundled an additional 14 codes that can now be billed in the same calendar month as TCM, as Transitional Care Management Services. So you can find these grids in the final rule themselves. I know you won't be able to see it on this screen, but just for clarity, you can bill TCM in the same calendar period as Chronic Care Management, Care Plan Oversight, Advanced Care Planning, Behavioral Health Integration, Cognitive Assessments, you know, Prolonged Services, RPM, Remote Patient Monitoring, which we'll talk more about later. And, you know, both Traditional CCM and Complex CCM, they've really made an effort to make sure that for Transitional Care Management, when the work is separate and distinct, you can bill that in combination with Care Management Services, which was a big barrier on why I heard many home-based practices weren't formally billing TCM services. But there's really no excuse not to now, especially with the increased reimbursement. So if you're not formally billing TCM services, I'd really encourage you to do so this year. That's great information. You mentioned Cognitive Assessment being unbundled from this. Many of us HPPC providers, we care for patients with dementia. And many of us already through our EHR cover a lot of the bullets here, 10 bullet points here on this particular code. Many of us are already doing this, and we can certainly make a template that covers the necessary components for billing and then get high reimbursement for our efforts. Absolutely. Yeah. I mean, remember, this code pays on average close to $296. This is a face-to-face visit. So this isn't in addition to your home or your DOM code. This is the visit you're doing. Again, here are the 10 requirements and a link to a great resource and explanation from the Alzheimer's Organization on using these. And I have talked to many home-based practices that are billing for this. I know one practice that kind of makes it part of their protocols when they see new patients in a memory care-assisted living, one of their first visits is a Cognitive Assessment and Care Planning visit. And I know another practice that really focuses on their advanced dementia patients and does this every six months for those patients who qualify. So is it important to realize you do have to develop a cognitive-specific care plan separate from your assessment and plan and add in some other documentation? But it really is doable. You can think about what would be most meaningful for your practice so that you can benefit from the reimbursement of this code. Absolutely. I just want to, again, take a look at what's on the screen here. And I'll bet many of us already do this on a day-to-day basis. And we just need to be able to pull all of this information together in one visit and then get the appropriate coding and billing done. Okay. So moving on to annual wellness visits, which we touched on earlier, you know, just some implementation considerations. Again, you know, historically, the problem with the annual wellness visits is they're really just a preventative discussion that really only include vitals in nature. And you also need to know, you know, if your patient is, you know, typically, the reason you'll see me in our resources reference the subsequent code, the G0439, is because the first code is only once in a lifetime when they're new to Medicare. Typically, our patients have been on Medicare. And so you're billing the G0439. But you do have to make sure that annual wellness visit is scheduled exactly 12 months apart of anyone that they may have had last year. So you definitely want to keep that in mind. Also, annual wellness visits right now are on Medicare's approved list of telehealth services that can be done even audio only. So you might think about some creative ways to do that. And you can bill, you know, an E&M and an annual wellness visit together on the same claim with modifier 95. If you're going out and you're doing chronic disease management or a problem-oriented visit, and you also take the extra time to meet the annual wellness visit requirements and have that preventative discussion, you can bill both of that. And, you know, there, I was actually surprised to hear, but I heard from one of our practice advisory members, too, they like to use the prolonged preventative service G codes, which are G0513 and G0514, because they really make a point to have certain providers that do extensive annual wellness visits for their patients. And that's just part of their practice. And they, you know, focus on updating problem lists to grab HCC scores and their quality codes and really make a point to use their annual wellness visits to do that kind of work. Thanks, Brianna. Many practices, as we talk to folks across the country, have chronic care management services. Any changes in terms of billing and coding for CCM? Yeah, so chronic care management, I often get the question, you know, how do I get paid for all of my time in between, right? The non-face-to-face time or those phone calls with family and patients in between your visits. And CCM is really a great solution for that. So, before we get into what's changed, just to recap what we have today, 99490 is what we refer to as our traditional CCM. So, you still have to meet all the other requirements. We have resources on our website. I'm just going to give you a very high-level view today, but it's 20 minutes per calendar month. This can be combined, both your clinical staff and your provider's time. You do have to have that separate and formal comprehensive electronic care plan, but that's our traditional CCM code. The difference between 99491, the second code you see on your screen, if you're more of a smaller independent practice and you're really doing all of this on your own, you're the one taking those phone calls and spending the time. It pays a little bit more if you're closer to the 30 minutes per month to build a 99491. Then, of course, we have our complex CCM codes that are 60 minutes or more per calendar month. Although I will tell you, if you do the math, we have a new code. Last year, we started using a new traditional CCM code, so this can only be built with 99490. You met your first 20 minutes. Now, you did 40 to 60 minutes. You can build this. Last year, it was a G-code. This year, they switched it on us, kind of buried in the final rule. We now have to report 99439 for each additional 20 minutes of traditional chronic care management time within a calendar month. Again, your first 20 minutes is 99490. Your second 20 minutes, you can build a maximum of two units, would be this 99439. I actually heard from a practice, they were already getting denials on January 2nd for using that G-code, so make sure you switch this out if you haven't already. Just know this most likely, check your MAC guidance, but it will require modifier 25 when you're building multiple units of this because there is what we in the coding world call the medically unlikely edit. They need that modifier in order to know that you've really furnished that full amount of time and these services are appropriate to build together. Thanks, Brianna. COVID-19 has certainly brought a lot of changes across our country and across the world. We have seen a significant growth in remote patient monitoring as a consequence of this particular illness. We've learned about practices working with an RPM vendor, for example, again, to help monitor their patient remotely, improve access, improve patient care, as well as getting some additional revenue. Brianna, can you just tell us a little bit about RPM and what opportunities HPPC providers may have in this arena? Yeah, so let's just start with a definition, and I've heard from many home-based practices that have really jumped on in using technology to care for their patients, but it's really, you know, it's using technology to collect and analyze physiological data, so remote blood pressures or glucose readings or pulse ox and heart rates, maybe even a weight for your patients, and then you're using that data that is digitally, which CMS defines as automatically transmitted to, you know, whatever your practice CMR or your telehealth portal to develop a treatment plan and manage that condition. So, this would have to require some sort of technology. It needs to meet the FDA's definition of a medical device, but it does not have to be FDA approved. CMS was very clear to clarify that, but this is a technology that your patients are using that, you know, a lot of these vendors will essentially let you lease equipment and for a percentage, so it is still feasible for smaller practices, but you've identified, you know, maybe your CHF patients or your diabetes patients or your hypertension, and you're going to use, you know, some sort of technology and medical device for that information to be automatically transmitted to you, and then you're going to review that on a monthly basis, and the other important thing I wanted to mention on RPM and in one of the handouts that you'll receive in an email follow-up to this webinar will summarize everything I'm talking about today, but they also really are heavy on what's called care episodes. So, when you first start collecting data and supplying these patients with these devices, important to realize they expect there to be an end goal, right? They want you to get consent when you start rolling and collecting data and then develop an RPM care plan with targeted treatment goals that will eventually be obtained. So, I'm going to go over the codes now, but just kind of keep that in mind. This is really using some sort of technology. It's not your patients calling you to report vitals. That's not what RPM is. You're getting that, you know, remote glucose monitoring or blood pressure or pulse ox readings, and you're using that technology to make treatment decisions. So, the other nice thing about RPM is regardless of what happens at the end of the public health emergency, this is a different subset of ways we can use technology to care for patients. This is not telehealth, so this will never go away. These are care management services that you, just like chronic care management, is the way you can use to boost revenue. So, there's a series of codes. There's a series of codes. The first one you would start with is the 99453, and your clinical staff can do this under general supervision. This is when you're giving that patient whatever medical device you've decided upon, and it's for that initial setup and patient education on how they're going to use that. You only report this once per care episode and only one code regardless of if you're giving them, you know, maybe remote glucose and blood pressure, still one code for that initial setup and education, but then you also can be reimbursed kind of for your practice expense with 99454 each 30 days for them having that device that's transmitting and programming those readings and that data to you that you're making treatment decisions on. So, these would be the first two codes that you would build for once you set up a patient with remote patient monitoring. The second one, and it's really helpful if you have practice management staff or coding and billing to read through the rationale and the final rule because they really put it in a sequence for you. They're saying they expect the second step of RPM is after you get that initial 30 days of data, you as the provider are probably going to spend some time going through that and developing whatever that treatment or those targeted goals are. So, this code is for non-direct patient time. You're not on the phone with the patient. You're simply reviewing that data and creating the care plan and deciding treatment goals and reviewing and analyzing it. It does have to be the provider. This is not clinical staff. So, I mean physician, nurse practitioner, physician assistant, and it has to be a minimum of 30 minutes, but that's when you can build this 99091. And keep in mind, although these are 30-day periods, the requirement is 16 days. So, you just have to have 16 days worth of data within a 30-day calendar period, and it doesn't have to be, you know, continuous like 16 exact days in a row or anything like that. If you've heard about the flexibilities during COVID for the two days, that is going away at the end of the public health emergency and that flexibility is really only for the treatment or, you know, suspected confirmed COVID-19 diagnoses. So, you really do need to, you know, be having some more long-term monitoring for these patients, but then you get about $59 after the first, you know, for just spending the time reviewing and analyzing the data. You furthermore, just like very similar to chronic care management, but this is different. This is, you know, your clinical staff time, again, communicating back and forth because you're going to set parameters. For example, if blood pressures or glucose are out of this range, I want to be notified and, you know, a clinical staff member, if you have it, or you is going to be communicating back and forth throughout that calendar month with the patient about these vitals. So, that's why they created 99457 and 99458. And the difference with these codes from the last code that I just showed you is the interactive contact requirement. So, interactive contact means that it's real-time direct patient interaction. CMS says it has to be at a minimum synchronous two-way audio with the capability of being enhanced by video. So, you at least have to be on the phone, live interacting with that patient, talking about their vitals or whatever information that you've collected, and giving them treatment plans. Again, this can be your clinical staff under general supervision. It does not have to be the provider. Your first 20 minutes is when you use the 99457. Each additional 20 minutes per calendar month is with that 99458. It does cap out. You can't bill, you know, more than two units of the 99458. But again, this is a great way for another care management service. And it can actually be billed in conjunction with CCM, in conjunction with chronic care management, as long as the work is separate and distinct. But if you think about that financially for a practice, if you have a chronic care management program in addition to an RPM program, and you're billing for time and care management for both of those things, that's going to substantially add up. I know one practice that actually had $10,000 of billable revenue in their first five months of RPM. So, this really could be a solution for your practice to think through. And that's why I wanted to take some time to talk about it today. And you can kind of see how that would add up sequentially. Hey, thanks, Brianna. Because, again, because of COVID, many of us have embraced telehealth. But there are some changes related to telehealth as well. You had mentioned something, some terms that put a little concern in my heart, Brianna, about something about going away. And I've heard about this is Category 1 or temporary or permanent in Category 3. Which is not permanent. And that telehealth being billable only with certain house call codes. Can you help us sort through some of my questions that I have? And I'm sure others may have as well. Yeah, absolutely. And so, just to clarify, too, everything that I'm talking about, I'm talking about from a federal CMS Medicare guidelines perspective. And so, if we think back to, I know it's hard to remember, but before the public health emergency, before COVID, the reason none of us were really using telehealth is because the home was not what was called an approved originating site. Before any of these waivers went into place, the patient actually had to travel to a designated healthcare facility to receive that telehealth service. And it was really only for patients who were located in rural areas or healthcare professional shortage areas. If you've heard the term 1135 telehealth waivers, that's where they pretty much blew up access. They said we want patients to not have exposure risks. They can receive telehealth from any setting of care, including the home. We're going to let you even use your same E&M codes, the home and the domiciliary codes for video visits when you're using real time two-way audio. And we're going to pay you at the same rate as in-person rate to not disadvantage providers. But it's important to realize all of those flexibilities and those waivers are in effect because we're in a formal declaration of a public health emergency. So, that's something that the Department of Health and Human Services has to declare for 90-day periods. It was just recently extended for the fourth time through April. So, we have at least until April of 2021 where we'll still be able to use all of our telehealth flexibility and be able to provide these services. But after that, unless we have legislative change, the only way that a patient can receive telehealth services in the home is under what's called the Support Act exceptions, which would be for the treatment of a mental health or substance abuse disorder. So, you know, as part of their, you know, procedures to, you know, protect the opioid pandemic, you know, patients that have mental health or substance abuse disorders can receive telehealth services. And if you're looking for a good FAQ, CMS has kept the link that you have last on your screen very up-to-date. They update it regularly. If you're confused about any of the waivers, I'm talking about them at a high level today. I would encourage you to take a look at that FAQ where we also have a resource on our HCC intelligence tools and tip sheets called telehealth during COVID-19 that'll clarify, you know, when you can bill a video visit and what that is versus audio only and things like that. But it's going to be important for providers to understand when the public health emergency officially ends. And Paul, you mentioned that Category 1 and Category 3 designations in the final rule. I don't want to spend too much time on this because although there are certain home and dom visits, only Levels 1 and 2 that CMS has declared what they consider Medicare telehealth Category 1, which means they're permanently added to their approved list of telehealth services. Again, unless we got legislative change that made the home an approved originating site, this would still end. The only exception for those codes is, you know, for the treatment of mental health and substance abuse disorders. There is still hope for legislative change. You know, that's also why they created these telehealth Category 3 codes where they believe these will be payable through the end of the year in which the PHE ends because they want some additional data. But again, the problem is that 1135 waiver that lets us provide telehealth services in the home is only in effect during a public health emergency. The other important resource, I get a lot of questions because there are certain services that you can do audio only and certain services where you have to have that video, that two-way phone and audio. So, for example, hopefully you know for your home patients, if you're doing a video visit, even if it's on Apple FaceTime or Skype because we have HIPAA flexibilities right now, you can build your normal home and domiciliary E&M codes, but that has to be a video. Advanced care planning, for example, or annual wellness visits, Medicare is telling you those could be audio only. Those could be a phone call. But if you follow the link that I've provided to you here, it'll take you to CMS's spreadsheet, which they keep up to date with their list of telehealth services, and they have different columns, one that will tell you if it can be audio only and one that will tell you if it's the status of if that code is permanent or temporary. So, just another helpful resource as you're trying to wrap your head around telehealth, and you can also, you know, listen to past webinars where we've talked about this in more detail. Paul, anything about kind of how you use telehealth in your practice, you know, kind of any benefits or the video visits, anything you want to add? Well, certainly, we use video visits whenever it is possible. Again, work with your team, developing a flow sheet, if you will, from scripting, asking patients and families about whether they have high speed internet, whether they have smart devices or a computer that they can do a video visit, or do you have to maybe change to a telephone visit only as well, or instead, I should say. So, again, work with your team regarding how to make your visits using televideo smooth as possible, so that it can be a natural part of your work, your day-to-day work, rather than kind of a one-off kind of a thing. But Brianna, we have lots of patients, they don't have smart technology, they only have audio. What are some opportunities for for providers when we are faced with those situations when we can only use the phone and not pull up somebody on a screen? Yeah, so after the pandemic, we did get a new g-code. CMS likes to designate, because they don't have the statutory authority to make the home an approved originating site, because that would take legislative action, they've been trying to kind of slowly mix in, if you've noticed over the past couple years, what they call CTBS, which stands for Communication Technology Based Services. So, these are not Medicare Telehealth services by definition, meaning they're not subject to the same regulations. They can be used before they, you know, during or after the public health emergency, and the most common ones that you'll hear about are these virtual check-ins. So, what's new in 2021 is they gave us a G-2252 for a longer length of time for 11 to 20 minutes. But again, keep in mind, these are very low payments. Right now, again, only during the public health emergency, we can use the CPT codes for telephone E&M services, which are 99441 through 99443, anywhere from a 5 to 30 minute telephone medical discussion that doesn't, isn't related to an E&M visit within the past seven days and doesn't result in an E&M visit. You're essentially treating an acute problem like a rash or elevated blood pressure that you don't feel you need to see the patient for. So, use the current codes we have flexibility. But again, thinking after the pandemic, thinking that every little bit of revenue counts, if you're addressing acute issues over the phone, just don't forget we do have these G codes for virtual check-ins. And then the last one on your screen, which this has been payable for two years now, is the G2010. That could be a patient portal. Your patient just sends you a photo of a rash or a video, and you respond back to them. You don't have to call them, even just back on that portal or that digital platform that you used within 24 business hours. There is a code that's payable for that. So, they're not great reimbursement. It'll be interesting to see what they, what they do. We've heavily, again, advocated that we need some sort of audio only payment. But again, you could be capturing your telephone time through a care management service like chronic care management. But we do have a new G code as CMS is kind of seeing CTBS services as their solution for audio only. Thanks, Brianna. I hope after listening to some of the material that, that we presented here, that we can go away feeling a little bit optimistic that when I first heard about the, the potential 8 to 10% pay reduction, I was obviously concerned. But now I hope we've given you some options to consider in terms of getting back some of the revenues that, that might be lost in the 2% pay reduction. So again, take a look at the slides that we presented, work with your team, see what you can do to get the revenue into your practice that you, that you deserve. Brianna, any final kind of wrap up comments? Yeah, so I think as we think about practice sustainability, and it's been interesting to hear from practices kind of what's their plan, although the 2%, you know, isn't as bad as we thought it was going to be. We know that if you're under fee-for-service, it's hard to be sustainable or to just try and get your, you know, budget to break even. So what kind of things can you do? You definitely need to be maximizing fee-for-service revenue outside of your E&M visits. If you're not doing any sort of care management, you're not doing care plan oversight or chronic care management, or billing for advanced care planning when you're having those goals of care conversations. There's a lot of opportunities for primary care providers in the home. Remote patient monitoring, like we talked about today, take care of making sure you're getting paid for the work that you're doing, because these patients are complex and you're doing a lot. I know some practices that, you know, are thinking strategically on, okay, let's really look at how we can be more efficient. Maybe we need to revisit productivity standards. If you're under fee-for-service especially, you know, does your team have weekly or daily goals of visits per day? And how can you support them? You know, we don't, like Dr. Chang, you say quite frequently, I don't want my providers to have pajama time, right? So how can you use your team? You have an interdisciplinary team, usually in home-based practices. So how can your support staff even get creative? I know, especially in the pandemic, I've heard practices using staff in different roles or using scribes, medical assistants, community health workers to kind of reduce that burden. And in return, then maybe they're able to see a couple more patients a day and that would help your bottom line. And then we're also in a really exciting time in healthcare. We see this move and this shift from fee-for-service to value-based care. So, you know, the request for information, either a request for application for the geographic direct contracting model just came out recently. We have primary care first starting that we hope will be opened up in future years to other regions. You know, I know independent practices that are kind of dipping their toes and joining ACOs as kind of their way to understand value-based care and start getting measured on quality and receiving some shared savings. So really, you know, network with your community, explore value-based care. If you even just go to CMMI's website, which is the Center for Medicare and Medicaid Innovation, you can look up any alternative payment models in your area and have kind of an idea of even just familiarizing yourself what that might look like for you someday, what kind of infrastructure is needed to participate and be successful if you're taking on some risk. Paul, any thing as you think about your own practice in 2021 that you would add that you guys are thinking about? Oh, absolutely. The two concrete things or two things that we really want to take advantage of, again, I spoke with my staff literally two days ago, is going to be focusing on the TCM visits and also the cognitive assessment. So again, look at your practice, look at what opportunities you can implement. What works for me may not work for you in terms of region and staffing and so forth. But there are, again, the news isn't all bad. And I want all of us going away feeling enabled and optimistic regarding, you know, taking charge of some of the financial uncertainty that we're all facing.

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