We are right at four o'clock. I would love to take this opportunity, welcome everybody to the most important billing codes you may not be using. This presentation from the Home Center Cured Institute is our first of many offerings for our webinars and virtual office hours, which are a part of the HCC Intelligence. Our presenters today are Brianna Plensner. Brianna is HCCI's practice improvement specialist. She's a certified medical coder, certified professional medical auditor, and holds a diploma in medical insurance billing and coding. Prior to joining us, she served as a practice manager for Home Center Cured Physicians, which is a house call program that is a part of Northwestern Medicine in Chicago. We're also joined by Dr. Thomas Cornwell. Dr. Cornwell is the CEO of HCCI and founder of Home Care Physicians. He's made over 33,000 house calls and has received many awards for his innovative care, including the first ever House Call Doctor of the Year Award. He's received extensive local and national media attention, including features in the New York Times, Time Magazine, and PBS. We're also joined remotely by Dr. Paul Chang. Dr. Chang is the chief medical officer for HCCI and medical director for the Home Care Physicians. The HCCI House Call Program has made more than 111,000 house calls to home limited patients since its founding in 1997. And personally, Dr. Chang has made nearly 32,000 house calls to more than 28,000, excuse me, 2,800 patients over his 19-year career. So we have a wealth of knowledge here with us. I would like to also welcome everybody that has joined us this afternoon. We're very pleased to have you here with us. We hope to be able to share with you not only information about billing and coding, but also answer any questions that you do have. The layout for today's webinar and office hours is we will have a formal webinar presentation, and then the remaining 30 minutes will be an open office hours where you can feel free to ask any questions that you might have. We'll do our best to field any questions. We do have handouts available, and you can actually download those by clicking on the handout itself and saving that to your computer. If it for some reason does not work, we will absolutely make them available after the presentation. My name is Danielle Feinberg. I am the coordinator for education and research, and I'm very excited to welcome you all here today. So without further ado, I'm going to turn it over to Brianna. Thank you, Danielle, and thank you everyone for joining us today. I'm going to go ahead and advance. We're going to start with a disclaimer. What we're going to review today is billing and coding guidelines that follow CMS guidelines. It's important to also check with your local carrier as well as your internal compliance and billing departments. Guidance does change from MAC to MAC. Again, thank you, Danielle, for the introductions. We have myself, Dr. Thomas Cornwell, and Dr. Paul Chain on the line today to help answer your questions. So the goals for today are to identify some common overlooked opportunities, ways for you to maximize your reimbursement in the fee-for-service world, and we're going to talk about four services in particular. We're going to talk about advanced care planning. We're going to talk about prolonged services, non-face-to-face. We're going to talk about new anti-corregulation management codes, as well as home health certifications and recertifications. So we're going to talk about advanced care planning first, and I'd actually like to start with a quick poll. I'm going to open up a quick 30-second poll, and I would like you guys to answer how many of you are currently billing for this service today. So we know that providers are having these end-of-life conversations with patients, but I'm curious how many of you are billing for it. So I just opened the poll. I'm going to leave that open for 30 seconds, if you would take the time to respond, and then we will be sure to share those poll results with you. Right now, I'm showing 67% of people are answering yes, 32% are no. So advanced care planning discussions, right, those end-of-life discussions with their patients and the caregivers. I'm going to go ahead and close the poll out. I'm happy to hear that it seems like the majority are familiar with this code. Again, about 62% of you said that you're billing for this, about 34% said that you are not. And what advanced care planning is, when we're talking from a billing perspective, is it's a face-to-face discussion with the patient or caregiver discussing those goals of care. You may or may not be completing an advanced directive form and, you know, could involve talking with other family members and caregivers about their decisions and what they would like to happen at the end of life. I'd like to invite Dr. Cheng to talk a little bit about kind of your experience and the importance of having these conversations with patients. Yeah, I will address it two ways. I know we're talking about billing and coding. I'm a clinician. I practice nearly full-time, four days a week, and I don't want to create more work for us. What I want to emphasize is that I want to remind us or introduce a new idea to those of you who are not doing the billing and coding that this is the work that you are already doing. So capture it and get proper reimbursement for it. So that's the billing side. And, of course, clinically, it is very important to talk about advanced care planning with our patients. Many household programs, as we sample across the country, they have a mortality rate of 20%, 25% annually. So it is a very important topic for us clinically as well. Thank you. So the next slide here, we've included which provider types can bill for this service. So it does include both physicians as well as our advanced practice providers or if you had a clinical nurse specialist or a certified nurse midwife. So all of those provider types can bill for E&M. They can also bill for advanced care planning. Another frequent question that comes up is if there's frequency limitations. How often are you able to be reimbursed for this service? And the answer is, as often as it's appropriate to have this conversation, for example, perhaps the patient had a status change or you needed to have a follow-up discussion involving the family and the caregivers and you spent that 16 minutes face-to-face with the patient, you can bill for it. So I mentioned that 16 minutes. This is a time-based code, CPT code 99497. That would be the code you report. It's for the first 30 minutes face-to-face of that advanced care planning discussion. And using CPT time thresholds past the midpoint would be your minimum of 16 minutes to bill. Now, if you did have an extensive conversation, there is an add-on code 99348 that could be reported for each additional 30 minutes face-to-face. And this could be a standalone service. You might just be having an advanced care planning discussion, but chances are you may also be performing an E&M visit and an annual wellness visit. As long as the 16 minutes is spent just on that advanced care planning discussion that's separate from the other work that you did during your visit or your annual wellness visit, it would be billable. And we'll talk a little bit more about that as well. So documentation requirements. CMS provided very limited information, but these really summarize this as well. A brief description. It doesn't need to be paragraphs on paragraphs, but what did the patient tell you? What was their preferences? Maybe there was some counseling you provided. What was important to them? And again, very important to have your total time. From an auditing perspective, start and stop times, time in and time out is always recommended. But be sure that you document that time as well as who was present and who engaged in that discussion with you. And if you did complete those advanced directive forms, you would include that in your documentation as well. And we're going to talk about consent as well. This particular service does provide verbal consent, so that would be another part of your documentation. This next slide, I wanted to kind of just show you an example of why it may be important to check with your local carrier. MAC is Medicare Administrative Contractor. Sometimes they do like to publish additional guidelines that you need to follow for your local area. This is NGS, which is National Government Services for Illinois, Wisconsin, and Minnesota, which actually does align, but just an important, again, to be aware of your local carrier guidance. So if you were billing for this service, like I mentioned, on the same day as an E&M visit, same day as your home or your domiciliary visit with a patient, you would need to append modifier 25 in order for a payment to be received. That identifies advanced care planning as a significant separate service that was performed in addition to your visit so that it can be paid for. Advanced care planning is a great opportunity to include when you're doing your annual wellness visits because the co-pay is waived, so the patient's not responsible for any additional charges for that advanced care planning discussion when and if it's performed in addition to their annual wellness visit. And in that scenario, you would need to append modifier 33 to identify it as a preventative service. So you could create some scripting. It might be a way to convince your patients to want to talk to you about that. It's a great add-on opportunity with those annual wellness visits. So oftentimes, you may not be talking to the patient directly. You're typically talking to their POA or a family member, a responsible caregiver. You would still be able to bill for that service if that discussion was had with a caregiver or a family member, but you should document why the patient lacks cognitive capacity to have that discussion and who you are discussing their wishes with. And again, I talked about that verbal consent. Part of gaining verbal consent from the patient or caregiver is also making them aware of that applicable cost sharing. You don't want an upset patient calling your office saying, I was billed for a service I didn't receive. Medicare does state that we need that documentation. Again, so diagnosis codes. There's no specific codes that support medical necessity. Perhaps you're coding the condition for which what prompted you to actually have that advanced care planning discussion with the patient, or you may just be coding an ICD-10 code such as Z71.89 for other specified counseling. And I know, Dr. Chang, you have kind of a methodology that you use in your practice on how you actually add this to the problem list. Did you want to talk a little bit about that? Sure. I'd be glad to. It really depends on the capabilities of your EHR. In our practice, we use Epic. And the reason I created an advanced care planning note under the problem list is for two reasons. One, it's a place where I can put something there so other providers who touch the patient, whether it's the ER, the hospitalist, intensivist, and so on, they can go there to easily find the information that they need to help take care of critically ill patients in the hospital. So that's one of the reasons. The other reason I created this note on the problem list is for tracking purposes, for quality, documenting that we have done serious discussions with our patients about their goals, about their wishes, so we can care for them according to their wishes. Great. Thank you. So lastly, here's the payment for advanced care planning, $86.49. That's the CMS national payment rate. When we're talking, again, about ways to get paid for the work that you're already doing and kind of surviving in a fee-for-service model, this really does make a difference for the time spent having these important conversations with your patients. So next we're going to move on to prolonged services. We're specifically going to be talking about the non-face-to-face prolonged services opportunity. These codes were made payable with an active status as of 2017. And 99358 is the CPT code that would be reported for your first hour of non-face-to-face services. Again, following that past the midpoint CPT time threshold, that would be a minimum of 31 minutes where you would be able to bill for this service. Now, it can be on a different date, either before, after, or perhaps on the same day as your E&M visit, but it must directly relate to that face-to-face visit. So not an acute issue that comes up in the meantime that doesn't relate to a visit that you were planning to have or had previously. When we talk about prolonged services, it's qualifying provider time that goes above and beyond the typical amount of time you would spend on that service. And again, it's important to know which codes cannot be billed together during the same calendar month. Chronic care management and transitional care management are an example that could not be billed during the same 30 days as this prolonged services non-face-to-face direct care. But again, it's a way to be reimbursed for your time, the extensive time you might spend preparing or a follow-up conversation you need to have with the family members or the caregivers after a visit or reviewing medical records. It's really getting reimbursed for the work you're already doing, like Paul mentioned. Again, another kind of caveat is be sure you're not double counting time. So if you're billing for, like we talked about, chronic care management or maybe care plan oversight, if you're already reporting your time with another service, you wouldn't, in addition to report this, as well as your total time does need to be documented. So make sure that you have that documentation about what the discussion was spent on, you know, brief description doesn't need to be super long. But what did you spend that 31 minutes on and your total time or your start and stop time for that service. And if you did have an extensive conversation for 60, 76, excuse me, minutes or more, there is an add-on code to CBT code 99359 would be appropriate in that scenario. And Tom, before we move on, did you want to talk just a little bit about how you've kind of implemented this within your practice? Right. You know, so most of my house call career, I always prepare before I especially see new patients. These are very complex patients, and I want to know both, get a lot of information into my note before I even go out there so that I can handle all their complex illnesses at that first visit. And so for the longest time, I've been spending significant time before going out. Well, now I learned about this code and have been billing for it. And so virtually all new patients, you know, 99%, I bill this 99358 before, because I review the chart before I go out. That adds, and so most of my patients are level four, which is 99344, which is about $180 where I'm at. And so this adds another 115, and so most of my new patient visits now are $295. And then I would say about 80% of my new patients, I also bill for advanced care planning. And so that gets the visit up to actually about $380. The reason why I don't bill 100% is because if our patients already have like a post form filled out, I will review it, but usually that does not require the 16 minutes. And so I discuss advanced care planning on all new patients, but just don't bill for all of them if I don't have the 16 minutes of time. Thank you. So again, a really great way to get paid for the work you're already doing. The only other guidance I wanted to make you aware of with this code is CMS did release a publication where they said, although we understand that the CPT typical threshold times are not required to bill, they would expect only time excess of that would be reported using prolonged services, not face to face. And if you really think about that, they're saying, you know, if you spend 31 minutes preparing for the visit, and you're only face to face with that patient for 10 minutes, maybe because you spent so much time preparing and it ended up not being a complex visit. Well, that's not an example of qualifying extended time. So that wouldn't be where I would recommend using this code. But, you know, you could consider an organizational policy on how consistently your providers are going to document their service. Perhaps you do want to record that total face to face time for the visit as well as your prolonged services to be on the safe side. But don't let this shy you away. Again, you're going to care for the patients the same way, you know, Paul, I know you had some input you wanted to share on this about, you know, how this is really just an opportunity where if you had that extensive time that you're spending already, you could bill for it. Right. Again, going back to the theme, we are not asking you to do more work. It's actually capturing revenue for the practice, for the work that you are already doing. Having started using this code, it's not like, oh, all of a sudden I'm spending only 15 minutes with my new patient. I still spend the same amount of time before this code existed as after. Again, for me, from a billing side, it's revenue. Chart review, for me, on a clinical side, provides structure. By that, I mean, we just finished the essential element course here in Chicago last week, and we talked about a very complicated patient, and one of the group discussions that we had was, where do you start with somebody who's so complex? And reviewing the chart gives me that structure, gives me some talking points, so that when I go into the home, I'm not completely caught off guard, so to speak. I have some focus, some ideas, so to make my visit more efficient and take better care of my patient. Great. And Brianna, if I could just, I just want to add something really quick to that because Paul reminded me of something, and that is, to me, there's also a psychological benefit to this, and what I mean by that is, when I used to get after some of these complex patient visits, you send for medical records, and you get that inch-thick paper, and your shoulders kind of drop just thinking, oh, man, this is going to take me forever. Well, it's really nice to know now that as I am reviewing these records, which is needed to provide the best care for this patient, my valuable time is being compensated to do what is right to review those records, and so it's just nice that Medicare is realizing that with these complex patients, there is time both before and sometimes after the visit that we primary care providers are spending time to give them the best care, and now they're compensating us for that. Yeah, that's a great point. Thank you. And before we move on to the next service, I did want to address a question that came in prior to the webinar about if there's, what place of service would you report when you're doing prolonged services for a patient that you're seeing in the home? So this service can be paid in the office or outpatient, as well as the hospital and skilled nursing facility setting. The place of service that I would recommend reporting is where you were when you did that non-face-to-face time. So it might actually be place of service 11 for the office if that's where you were spending that non-face-to-face time preparing for the visit. So next, we're going to talk about anticorregulation management. There's two new CPT codes that replaced previous CPT codes that were actually didn't have an active payment status, but these both do. The first is CPT code 93792, and this would be if you have a patient that is new to switching to a home monitoring system for their INR, and you or, you know, your clinical staff under your direction are spending time educating them on the setup, ensuring they understand how to use it as far, that includes a demonstration and how they're going to communicate those results with your office. Again, this must be a face-to-face service, but you are able to bill for that service now. And again, going back to, I think the key thing here is monitoring under the direction of the physician or qualified healthcare professional. You know, this might be a little bit more limited because you're going to be in the home probably involved in that education anyways, but if you were spending your time or you and your clinical staff in conjunction were spending that time, you could bill for it. The next service, CPT code 93793. So this is a great way. Think about how many patients you have on warfarin therapy where you're responsible for their INR management, your review and your interpretation of that new test result, their instructions and their dosing, and as far as placing that order and when they're supposed to schedule their next draw, those are the only documentation requirements and now you can bill for it. It would not be billable if you did this, if you did the INR during your face-to-face visit, but for that non-face-to-face management of their INRs, there is a way that you can bill for it now. Again, it cannot be billed during the same 30 days as chronic care management, so just keep that in mind, but this is a really great code to be aware of and get paid for the work that you're doing in between visits monitoring their INRs. And the reimbursement for the second option, you know, managing that non-face-to-face INR in between is $12.24. That may not seem like a lot, but it actually does add up, and I know this is something that Dr. Chang and Dr. Cornell have implemented in their practice. Paul, did you want to speak to that? Yes. A little bit of revenue, it does add up, and I had a chance to take a look at our last quarter's billing for the anticoagulation management, and dollars do add up, so that's one thing I want to emphasize. The other that this touches on is the EHR and trying to be efficient with your EHR. Again, documentation is important, but also minimizing clicks. Is there a template that can be set up to do this with minimal navigation from page to page, with minimal clicks from one part of the screen to the other? So that touches on another part of the billing for the services. Thank you. Thank you. All right, so the last service we're going to talk about, at least in this beginning part of our presentation, are home health certifications and recertifications. Before we dig into this, I do want to call out attention, this particular service, the two HCPCG codes that we're going to talk about, is only billable by physicians as of right now anyways. I know we have several nurse practitioners on the phone. There is actually a current legislation that's underway, the Home Health Care Planning Improvement Act of 2019. If that passes, that would allow advanced practice providers to certify patients for home health, because right now they have to be certified by a physician. That's why this service would only be payable by a physician. But what advanced practice providers can bill for is care plan oversight. I don't have time to cover that today, but the GAPNA, actually, a friend and a faculty member of HCCI, Deborah Wolf-Baker, has a great CPO or care plan oversight toolkit. If you just Google GAPNA CPO toolkit, you'll find additional information on that service. So what qualifies a patient for home health anyways? Why are you signing these certifications and recertifications? They are 60-day episodes. I think another common source of confusion is what's the date of service? There was recent guidance that the Medicare Learning Network published the date of service for the claim is when the physician actually signs the certification or recertification. They're not paying you for signing it. They're assuming that you're having that oversight and that management, but it's billable on the day you review and sign that plan of care. As well, if it has to be a Medicare-covered home health claim, so if the patient was just paying for private duty services, that wouldn't be an example of when you could bill for this service. So for certification, so an initial start of care, a new home health episode when you're first certifying that patient, G0180 is what you would report when you sign that. Again, throughout your documentation and your medical record, as long as you have communication back and forth between the home health agency, you're keeping that 485, which is the actual document for the certification on file within your medical record. Those are the kinds of requirements you want to keep on hand, but you would bill for this when you sign an initial certification. And then for a recertification, you would submit G Code G0179. These do need to be exactly 60 days apart, so make sure you have some sort of back-end billing policy where you're making sure you're not billing sooner than it's paid for. But again, it does add up when you're reviewing and you're signing that recertification. This would be a service that you can go ahead and report. I'm going to show the reimbursement rates and let Paul kind of speak to kind of how this adds up again in his practice, just a relative example of how you're doing this. Right. So again, it's the same thing, capturing revenue for the work that you are already doing. At our practice, we average roughly between 40 and 50 search and research per month. So again, doing the math you see here on the screen, the dollars, they do add up. Thank you. So the next slide, I want to give you some additional things to think about. Because one of the handouts that I've included is an Advanced Coding Opportunities Guide. It has additional details on all of the services that we talked about today, in addition to the ones that you see listed on your screen here. I always like to highlight chronic care management. If you think about the extensive care coordination needs that these patients have and the time that you and your clinical staff, you know, not just billing for provider time, but the time that your clinical staff is spending managing these patients, you know, 20 minutes per calendar month is really obtainable. And chronic care management allows you to bill for that service. What we're going to do shortly here is switch over to our open forum. We're going to take as much time as allows. So between now and 5 p.m. to answer the questions that come in. If we don't have time to get to your questions today, we will compile a follow-up email of all of your questions and answers and send that out to the group along with the handouts. So, Danielle, you want to turn it over to you? Yeah. And actually, if I could, just because Paul put some numbers together, just to give you some numbers, as Paul said, you know, what we are doing is just billing for things that we've always done. We've always managed our patients INRs. And Dr. Chang noted that in the first four months of this year, we did close to 200 INRs, which comes out to $2,400. And again, this is money that you're not doing any extra work. You're just billing for what you're doing. And for the certs and reserts, it was actually for four months this year, it was $5,000. Again, just for billing for, and we know that's not a recent code, that's an older code, but we just want to make sure that people are billing for what you can. Yeah, that's a great point. You know, although this isn't a new service, I thought it was a great one to highlight. And Danielle, are you able to compile the questions? I am. So our first question is, what is the POS for non-face-to-face prolonged service? Sure. So yeah, that would be wherever you were when that non-face-to-face time occurred. So actually, in the previous practice I worked in, it was typically POS 11 for the office. It is payable in the office and outpatient setting, as well as a hospital and skilled nursing facility. Those are the places of service where that code would be payable. So it's just where you spent your time. Perfect. And it looks like we have a follow-up question to that. Just wanted to clarify, NP can bill for CPO, but not for home health cert and resert, right? That is correct. At least right now, you know, we're hopeful that that legislation may change. But the care plan oversight, there are some caveats to that, but that is billable by your advanced practice providers. The home health certifications and recertifications are not, only because as of right now, a physician is the only provider type that can actually certify a patient and has their name on the order for start of care for home health. And I would just like to add to that, for the amazing nurse practitioners that are on the line, both Dr. Chang and I and HCCI are strong supporters of the legislation. We've been supporting that for years as different legislation has come up. I'm on the board of the American Academy of Home Care Medicine. They have for years been supportive of that. And so we really believe that those of you that are caring for these patients, you are ordering the home health, you should be able to sign the orders. And so we're working on it, along with GAPNA and others. Perfect. Our next question is, can ACP be billed concurrently with the TCM visit? So thank you for giving me a moment to verify. I have a lot of information in that advanced coding handouts, but advanced care planning, you may bill it in conjunction with an annual wellness visit, with an E&M visit, with a transitional care management visit, and in conjunction with chronic care management. So that's a really nice one that doesn't have, you know, concurrent billing concerns. Excellent. Next question. Have you billed EM with modifier 25 or ACP code with modifier 25? I am seeing it should be with ACP, but wanted to see your experience with reimbursement. In my experience, again, you'll want to check with your local MAC, but all of the MACs that I've checked, you do need it in order for it to be paid. We had an issue where a practice was not billing modifier 25 when they were doing advanced care planning and an E&M visit, and it was denied. In my previous practice, I appended modifier 25 to the E&M visit when we did advanced care planning as well. Our next question. Are G0180 and G0179 only billable for Medicare and not other payers? That is correct. It is. So typically, G codes are only Medicare beneficiary charges. So if you see that G, that's kind of your way to know. But it's talking about the Medicare skilled home health benefit, and that's why it's only payable for those. Although sometimes commercial payers will add them to their fee schedules. So again, you just have to know who your payers are. Check with them. Ask with them if you're not sure. Check their fee schedules if it happens to be on there. But typically, it's a Medicare paid service. Medicaid will not reimburse. All right. G0180 and G0179 are very popular. Our next question is, can APRNs bill for G0180 or G0179? Unfortunately, not right now. It has to be an MD or a DO. It has to be a physician unless that legislation passes. What an APRN could bill for is care plan oversight. You know, that has some pretty extensive guidelines. So we just didn't have time to cover that today. But like I said, GAPNA has a great toolkit out there on care plan oversight. But I did want to take a moment on this final slide here. These webinars are part of our HCC Intelligence Resource Center. We have a free hotline as well as an email. That phone number you see on the slide and that email. Please feel free to reach out with us with those questions. You know, myself and HCCI is fortunate to have a network of faculty experts with experience in this field. And we will work together to get you the best answer for your question. Perfect. Next question. For recerts, does the DOS have to be the date the MD signs the recert? This may cause issues if the recert was signed before 60 days from when the cert was signed. Yeah, that's a great question. And that's a problem that I've struggled with too. There was very clear published guidance on the Medicare Learning Network that did say the date of service for the claim is when the physician signs the certification or recertification. So that's how always I've billed it. Again, check with your organization on what their billing policy is. I know I have worked with some practices that don't do it that way. But the guidance does tell us it should be the same date of service, excuse me, that the certification was signed. Continuing on with our questions. What about CPT code 99491? Yes. Okay. So chronic care management. We can talk a little bit about that. There is information included in that handout, the Advanced Coding Opportunities Guide. But what 99491, that is your traditional chronic care management, whether it's 20 minutes or more per calendar month. Your providers in addition to your clinical staff time is counted for that. And that is traditional. There is also complex chronic care management. That's an hour or more when you're doing complex management. I just want to double check one thing really quick. Yes, okay. I just wanted to make sure there wasn't another code. But 99491 is traditional chronic care management, that 20 minutes or more in a calendar month. So within a 30-day period, your time, non-face-to-face time is counted. Coordinating care for the patient, talking with the patient and family members. It does have to be medical in nature. It does have to be your clinical staff and your providers. So not your administrative, you know, receptionist or front office team. Or just confirming an appointment. It really does need to be medical in nature. That care coordination that you're doing to help keep that patient at home and healthy. Perfect. Our next question. Can CCM be billed for long-term custodial patients living in a SNF? So for skilled nursing facilities, I believe you can. But I'm going to make a note to verify that and follow up with you after the webinar. That is something that we, you know, know assisted living and home-based and house calls in the home because that is what the Home Center Care Institute's mission is, is to help providers go to patients in those facilities. We do not do any kind of training for skilled nursing facilities, just to let you know. Can I bill 99358 with or without a house call? So 99358, that's the prolonged services non-face-to-face. So it does need to be related to an E&M visit. Now, if you're saying not a house call, maybe you saw the patient in the office. As long as it's related to an E&M visit, yes. So you have to have a face-to-face visit that that relates to. It doesn't have to be on the same day to service. Your face-to-face time could be before or after the visit. Another point, important point to make that I don't know if I mentioned earlier is for that 99358, that your time does not need to be continuous as long as it's all occurring on the same date of service. So for example, let's say you start preparing in the morning to see the patient. You have the face-to-face visit. And again, on that same date of service, maybe you have an extended conversation with the son that wasn't able to attend that home visit. You could still bill for your time as long as you're only counting your non-face-to-face time on the same day to service. It just has to relate to some sort of face-to-face visit that could be another office or outpatient visit. And Brianne, if I can ask a little question associated with that. There's no guidance I know in terms of how close to the visitor or how far away it can be and still bill it. But that is a good question from our audience that sometimes you prepare for these visits, but something happens. They end up in the hospital or something happens to the caregiver and they have to cancel the visit. If that happens, you cannot bill for it. But I have had instances where then it was rescheduled two, three weeks later and I had done that time. But in general, most of my 99358s are definitely within a week of seeing the patient. And the reason for that is I don't wanna do it sooner than that because there's just greater opportunity that something might happen during that time where you end up not seeing them and then you cannot bill for the code if you do not see the patient. Yeah, that's a great point. It does have to relate to the face-to-face visit. It is a time-based code, so you have to have that total time and that documentation. I have not found at least any guidance that gives you a set. It must be within a week or two weeks. I would say that would be something I recommend. You have an audit policy or an organizational policy on. Your provider should just be doing it consistently. Just decide what's best for your practice and then go forward with the policy so everyone's doing it the same way. We have an excellent follow-up question to that. For non-face-to-face prolonged services, can one provider in a practice review the documentation and prep the chart and bill the 99358, but then a separate provider do the actual visit and bill for the E&M? That's a great question. Again, I wouldn't recommend it. That's probably, actually even on the FAQs, I don't know if that particular question has come up, but it's talking about the work that you did, that the provider did that directly related to their face-to-face visit. So I would expect that to be the same provider that's billing for the service. It is tied to that face-to-face visit, and I would think that it needs to be that same provider so that it wouldn't be, they could say, well, that prolonged services wasn't tied to that visit because it wasn't the same provider. That's my opinion and my recommendation as far as how I would handle that. You know, Brianna, from a purely clinical side, I would like to be the reviewer of the record because I wanna get to know my patients before I step through the door. So billing aside, if you would keep with me and help me make the visit better, I think it will be difficult for Dr. Cornwell to review the chart and then trying to give me his information or his edits, and then for me to read his edits before I go into the chart. To me, that just seems, from a clinical side, seems a little awkward. Thank you. You know, and maybe, Brianna, too, we didn't talk about documenting. You know, how do you show the work you did in terms of doing that 9935A? Because it's 31 minutes of work, and what I do at least is I actually start my HPI where I develop my problem list from all my review. I actually put all the different kind of chronic problems into the HPI. In my HPI, I also put information we get ahead of time on ADLs, IADLs, who the POA of healthcare is, and so I have all this information in my HPI before I go out, and then I actually put that documentation into another encounter note. For me, it's a telephone encounter note, and then I just label it as a billing 99358 encounter, and that way, if Medicare ever audits, needing proof for showing that the time I spent, I have it in there. Yeah, that's a great point. As far as the documentation goes for 99358, make sure you have your total time, and then what did you do? What did you spend that time on? So like Tom mentioned, what he does is he's reviewing, if it's a new patient, Home Care Physicians utilizes a pretty nice, detailed medical history form in advance, so brief description of what you spent that time, what specifically you plan to do maybe for that patient or for that visit, some conversations that you might've had, what did you spend during that 31 minutes and your total time, that's what needs to be documented. I do always recommend start and stop times, but again, check with your local carrier, your MAC and your organization on what they prefer. And Dr. Chang and I are on Epic, and you can also develop smart phrases just for consistency with your documentation for both the 99358 in terms of making sure you have all those parameters that Brianna just talked about but also for my ACP, I have the same kind of spiel that I give all my patients, and so I've created a smart phrase, and it makes it for sure that I cover everything, but then also I'm not having to retype everything when I do it. A smart phrase is just like a macro for those of us that don't have Epic. Tom, absolutely, that was the point I was gonna make is using your EHR, not typing everything over and over and repeatedly having some kind of a macro or a smart phrase so that you can quickly document what you did. And the other point I wanted to make was not only time, but also you can, for example, I have a patient record that's sitting in my inbox. It's on a new patient. The patient record from an outside institution is 104. That's 104 pages, okay? So not only can you document a time, you can just say, you know, I've reviewed over 100 pages of patients, past medical records, and then depending how you wanna phrase your macro and whatnot, you know, updating the problem list, relevant blood tests, imaging studies, et cetera, were all reviewed in these 104 pages. That's a great example. Thank you, Paul. Okay, next question. If non-face-to-face is done prior to an office visit and the office visit is canceled, how long do we hold on to the non-face-to-face? So that was the scenario that Tom was mentioning. You know, hopefully that's not happening all the time. Maybe you're able to get that visit rescheduled, you know, within the next week or two. Like I said, I have done extensive research on this. I have not found clear-cut guidance from Medicare on what that exact timeframe is. The language that I've found is they love to leave gray areas. They set a reasonable amount of time. So I would recommend your organization, you know, defining what that reasonable amount of time for you is. You know, and sometimes you do have to miss out on that opportunity to bill for it if the visit never occurs, because it must be tied to a face-to-face visit. But, you know, I would say I think within, I don't know, two weeks is reasonable, but consider what's best for your practice. Work with your internal billing and compliance department as well as checking with your local MAC. Excellent, thank you. When documenting 99358, can you document in your E&M visit note or should it be documented as a separate note? There could be an instance where your non-face-to-face occurred on the same date of service. I would recommend separating it out because it needs to be non-face-to-face time. Your progress note is your, you know, what occurred on that date of service when you were face-to-face with the patient. I have seen some practices that will create, like, a separate section within their progress note where they're able to document that information, and as long as the date of service on when that occurred and the documentation is there, I wouldn't see a problem with that. But work with your EHR vendors. Typically, there's, you know, either a telephone encounter or a care management encounter, some sort of other encounter where you could clearly identify that that's your prolonged services, non-face-to-face time, just so it's separate from your face-to-face visit, and you can show that that time was extensive and beyond what you did during the visit. What about G0181 or G0182? Can APRN bill? Yeah, so G0181, I have my pick in here. That's Care Plan Oversight Services. Absolutely, an APRN can bill for that service. Okay. Just document your time well. Really document your time well because I don't think, but in the past, those have been heavily audited codes, and so just make sure you get that 30 minutes well-documented in your chart. And there was a time where they couldn't. I believe the regulations changed in, like, 2013, where Medicare actually has very specific guidance for advanced practice providers that are billing Care Plan Oversight, so just make sure you look into that service before you're billing for it or reach out to us for assistance. When is the TCM code supposed to be billed? I read in the CMS regs, on day 30 of the TCM period, my biller sends immediately. That's a great question. So transitional care management, that's follow-up post-acute discharge, whether it be the hospital or observation or coming back from a rehab stay. Typically, so your TCM visit is actually your face-to-face visit with that patient as well, so what needs to happen for transitional care management is you need to have interactive contact or verbal or electronic contact with the patient or caregiver within two business days, so you need to have that documentation. There are certain care management requirements as well as face-to-face requirements such as medication management that need to be documented. You need to see that patient. You need to have that face-to-face visit within seven to 14 calendar days of discharge, but the way that I've personally billed TCM and it follows the regulations is it's reported as the face-to-face visit. When the physician actually goes out there, they're completing that transitional care management. Their nurse has already talked to them. They've already reviewed the records. They've already done the medication management, and then that TCM code becomes the code that you report on the day of your face-to-face service. And that's a very interesting question because I've never thought of this before, but you can't bill a lot of other things during the next 30-day period because it's bundled into the TCM, but really there's no actual, and help me here, Brianne, there's no actual things you have to do in the next 30 days. It's just that all the other CCM and INR and stuff is kind of bundled into, whatever you do during the next 30 days is kind of bundled into that TCM. Would you agree with that, Brianne? Yeah, so as long as, I mean, there is a list. We've specified it in the advanced coding guides of certain non-face-to-face services, typically all things you would do before and during the visit, but as long as you've met all of those requirements by the date of the face-to-face service, they're just expecting that you're managing that transition, you're preventing that readmission within the next 30 days, so they do put a 30-day service period on it, but that's why, in my experience, we've reported it as the face-to-face visit because you've typically done all of that work, done all of that review by the time that you're seeing the patient for that post-discharge visit. Just to let everybody know, too, we've got about four more minutes, so we'll get to a few more questions. If we do not get to your question today, we will certainly send out follow-up information to the group with answers to the questions as well as as many questions as we could catch. We did have a couple of questions come in ahead of time as well as, like I said, the incredible questions we've had here today. You've definitely kept our subject matter experts on their toes with all of your questions. We will answer one or two more questions. I do also want to remind you that our very next webinar and office hour will be coming up on Wednesday, July 17th. Again, at 4 to 5 p.m. Central Time, and it will be about clinical conundrums, and we will always do these on the third Wednesday of every single month. You can look at our HCC Intelligence page in our resources link for dates and times as well as registration information. We'll answer one or two more questions, and then we'll follow up with everybody, and I do want to take a second to thank Dr. Chang, Dr. Cornwell, and Brianna for taking time out of their busy schedules to answer all of our questions and just share their expertise with us today. So our final two questions is, in regards to ACP documentation, I suggest my providers note some individualized, distinct details when using SmartPhrase. What are your thoughts? I would absolutely agree. So SmartPhrases are great for your base. Usually when you have SmartPhrases, you'll notice those little asterisks or those stars. It doesn't need to be a lot, but you did something different for every patient, or that advanced care planning discussion went a little bit differently. What was that specific patient's preference? Did you fill out a form? Did you not fill a form? Was there maybe family members involved? Anytime you're using macros or those SmartPhrases, they're a great way to help efficiency and have the bulk of your documentation, but don't miss out on the opportunity to just customize it a little bit. What for that specific patient on that particular data service did you do and did you spend your time doing? Okay, and then our very last question for today is we certainly do wanna be punctual. For home-based PC practices that have an IDT, can we be billed for the IDT time discussing the patients, or would that fall under CCM? It depends on what you would be doing in your practices because there are, so there are like team conferences. If you're billing for that, you wouldn't be able to bill for that and chronic care management together. So you would just need to check what you're billing. You typically can't do everything, but decide what are you spending the bulk of your time doing? What makes the most sense for you as far as is it chronic care management? Even with patients that are enrolled in chronic care management, you might not be meeting that 20 minutes every calendar month. So maybe that extensive time you build prolonged services for that particular visit. If I didn't answer your question fully, please reach out to me on the help email that's on the screen or by phone. I'm happy to talk further with you, but just make sure that whatever you're billing there isn't, you're not double counting your time. That's the important thing. If you're billing for your non-face-to-face time or that care coordination, it needs to be attributed to the same service. So you're not counting time for care plan oversight, for example, and chronic care management. Any final closing thoughts from our subject matter experts before we let everybody go for the remainder of their day? Well, just as the CEO of HCCI, your success is our success. Our goal is to spread home-based primary care programs and the workforce nationally. This was our first webinar in this format in terms of webinar and office hours, the first of many monthly ones to come. And so just thank you so much for taking the time to be with us. And we look forward to more of them and more of your excellent questions. Yeah, just thank you everyone so much and thank you for the work that you're doing. HCCI is here to create access to home-based primary care and spread this model of care nationally. So just thank you all for doing what you're doing to support these complex patients in their home. Well, we wish everyone a wonderful rest of your day. We will make the archive recording of this available to our attendees as well as provide copies of the handouts. If you do have any questions, again, you can reach out to us at the HCC Intelligence Hotline, 630-283-9222 or via email at help at hcciinstitute.org. On behalf of everyone, we wish you all a wonderful rest of your day. Thank you.

webinar

billing and coding

medical services

codes and guidelines

advanced care planning

prolonged services

anticoagulation management

home health certifications

reimbursement