coding webinars series. I'm Dr. Jameka Price, Vice Chair of the OX Coding Committee and the moderator for today's webinar. Today's webinar is titled 2024 NUCOs for Urogynecology Clinical Correlation. I would like to introduce our speaker today is Dr. Charles Thompson. Dr. Charles Thompson did the residency in OB-GYN at Parkland Memorial Hospital in Dallas, finishing in 1992. He was then in private practice of General OB-GYN for 23 years, first in the United States Air Force and then in the civilian world. In 2015, he became board certified in urogynecology and joined the faculty of Texas Tech University Health Science Center in Lubbock, Texas, and is currently the Residency Program Director at the Department of OB-GYN. Dr. Thompson has been on the OX Coding and Reimbursement Committee for eight years and now serves as the Chairman of our committee as well as a member of the ACOG Coding and Health Economics Committee. Just as a reminder, the presentation will run around 45 minutes. The last 15 minutes of the webinar will be dedicated to questions and answers. Before we begin, I'd like to review some housekeeping items. This webinar is being recorded and live streamed. A recording of the webinar will be available in the OX e-learning portal. Please use the Q&A feature of the Zoom webinar to ask any of the speakers questions. We will answer them at the end of the presentation. Use the chat feature if you have any technical issues and the OX staff will be monitoring the chat and can assist. Dr. Thompson, you may begin. Thank you very much. I appreciate everybody being here tonight and I know it's spring break in some parts of the world here and I can't imagine any more fun on spring break than talking about urogynecology coding. So, I hope you are ready for a great time. Anyway, this is actually the second of a two-part series on new codes for urogynecology and last time we got a really good broad overview of what the new codes are and I want to review a lot of those with you today and give you some clinical correlations during which we can see when we can use these codes and when we can't. So, let's dig right into it. Our disclosures are here. Unfortunately, we don't have anything to disclose. So, the objectives, again, reviewing the relevant new codes that urogynecologists will have the opportunity to use and cite clinical correlations by using case reports to show the proper use of the codes and then we want to take a few minutes to answer questions that you may have about some of these new codes at the end of the presentation. So, 2024, we did see that there are some changes in the conversion factor. On January 1, the conversion factor decreased by over 3%, in fact, almost 3.4% as a result of budget neutrality and so that went from about $33.887 per RV unit and then down to $32.7442. Now, just a couple of days ago, a bill was passed in Congress that actually decreased the decrease by about half and so now we are going to have two conversion factors, one from January 1 through March 8 and then for the date of service, that is, and then the second one is for claims for the date of service, March 9 through December 31 and you can see that it is somewhat higher, $33.2875. So, that gives us a little bit of relief but you will notice that it is still below what we were able to charge last year. So, here is a very busy slide showing examples of the 2024 Medicare national average payments and you can see that when you look at, say, a low visit complexity visit, that with the conversion factor, a non-facility payment, in other words, an office payment, is going to be about $89.39 which is slightly low what it was last year. When we look at the new conversion code, that comes up to $90.87 with the new bill. So, hopefully, this will give us a little bit of relief. It is not a lot of relief but, again, a little bit is better than nothing. So, below you can see the website at which you can go to find out about the actual fee schedule. And here, again, is the fee schedule lookup. So, you can search this position fee schedule and this has data accurate as of the end of December and you can use this search to view adjusted pricing amounts. So, you can download this by Excel file or even a text file. So, make sure that you select the 2024 year when you are looking at this information. So, issues with some claims processing due to the recent cyber attack on UnitedHealthcare. And on March the 9th, CMS made available a opt-in payment disruption, excuse me, change healthcare opt-in payment disruption accelerated payment to Part A providers and advance payments to Part B suppliers experiencing claim disruptions. So, the program is similar to Medicare loan practices during COVID and advance payments may be granted in amounts representative up to 30 days of claims. So, these payments will be repaid through automatic recoupment from Medicare claims for 90 days. So, hopefully that will give us a little bit of relief. So, let's get back into coding. So, these are some of the new codes that were authorized as of January the 1st. Now, specifically, these are the new codes for implanted percutaneous tibial nerve stimulators. Now, this is a relatively new technology and therefore, we don't have what we call category 1 codes. These are actually category 3 codes and you can see four of them before you, excuse me, 0, 8, 1, 6, T, 1, 7, T, and 0, 8, 1, 8, T, and 1, 9, T. And when you do these particular procedures, you will notice that you will not have RVU values based on these codes. And this is true for category 3 codes in general. So, therefore, if you're going to do this procedure, you're going to have to negotiate with third-party payers prior to the insertions being done so that you will know exactly how much you can expect for payment. So, we do have ideas for creating a packet for payers for these category 3 codes. Keep in mind that you'll want to have a cover letter for the packet summarizing the contents and information about your practice and about the procedure that you have. You'll also want to have a diagnosis that's relevant for the procedure, information on medical necessity, and you'll even want to quote some peer-reviewed journal articles. If you have any copies of practice statements that were by OGGS or by ACOG, that will always help. And then the requested physician payment amount. Now, for the payment amount that that you may want to request, we have a crosswalk here that Jill Rafferan, who works with our committee, has made. So, Jill, would you mind just explaining this particular table that you've made for us here? Sure. So, one of the open-source data files that the Medicare program publishes every year as part of the Medicare Physician Fee Schedule Proposed and Final Rules is a file on physician work times for each code. So, it gives you the opportunity to go into this very large file by code, and I just happened to pick the sling code, a simple repair code, and the two neurostimulation codes as examples. But for every code, it'll give you the intra-service time, which is the skin-to-skin time, and then whether it has office visits in the global period. So, if it's a 90-day global period, it probably has more than one post-op visit. If it's a 10-day, it probably has one. And then if it's a 90-day, it'll have a half visit for a 99238, which is a discharge E&M visit. So, this gives you the opportunity to look as you're thinking through or you've done some of the tibial nerve procedures as part of the research studies or you're aware of how long it takes you to do them and what your follow-up care plan will be for your patients. You can go into this file and look for other urogynecology or gynecology procedures that have similar amounts of time assigned to them. And then you can go back to the physician lookup or to Oggs Coding Today and look up their RVUs. And then you can put that in your letter to the payer that you'd like to be paid a similar RVU amount or similar dollar amount to the quote crosswalk code that is a Category 1 code for a urogynecology or a gynecology or urology procedure. So, that's what we mean when we say crosswalk. You want to identify existing codes that have payment assigned that are similar to these tibial nerve stimulation codes. And you can use this file in the public domain to justify your times and then also look on the physician lookup or Oggs Coding Today to get the RVU payment amounts and put that in your packet slash letter. Thank you, Jill. At this time, I'd like to ask Stephanie Molden, who is also on our committee, a question because I believe that Stephanie has done one or two of these procedures. Stephanie, have you been successful in putting in a claim and getting reimbursed for this procedure? Not yet. So, we are just starting to do that. The ones that I've done thus far were more on study, but I intend to crosswalk these more to probably the 64581, 64590 codes for sacral neurostimulators. And as we discussed actually earlier, one of the techniques uses ultrasounds. I'm also going to add that as a comparative code intraoperatively as well. That's great. Thanks, Stephanie, for your experience on that. So, it is yet to be seen how we are going to get reimbursed for this particular code here. So, all right, moving on. So, potential elements or areas to address in your cover letter include, well, I think I've already shared that particular slide, so we'll move on from there. So, most of the rest of this particular talk, I'd like to concentrate on two new codes that you're going to be using clinically just about every day. And the first of those codes is 99459, and this is called the pelvic exam on a female. And actually, that's really about the only descriptor in the CPT codebook. I want you to keep in mind that this is what we call a practice expense code. In other words, it is going to reimburse you for the expenses that you incur for your supplies and your chaperone when you're doing a pelvic exam with a speculum. So, you may use this code anytime you do a pelvic exam on a female with certain exceptions. Because it's an add-on code, you don't need to use a 25 modifier like you would if you were doing a procedure, because this is not a procedure, it's a pelvic exam. And anytime that you have an add-on code, you don't necessarily need to use a 25 modifier. Now, with regard to coverage of it, currently, Medicare, Aetna, and we've seen some Blue Cross Blue Shield companies accepting this. However, we know that Medicaid in Oklahoma, where Dr. Price is not accepting it right now, they're denying it. And some UnitedHealthcare is also denying. So, hopefully, we will see them come around with time. Now, I said that there are some exceptions when you use this code, and here they are. First of all, keep in mind that the 99459 is trying to reimburse you for your expenses. So, if you do a pelvic exam in a place that you do not own, in other words, not your practice, if it's in a hospital or an ambulatory surgery center, you do not incur an expense for that pelvic exam other than your time. And therefore, you cannot claim 99459 as an add-on code. Likewise, you may not use this code if you're doing a procedure for which the code is an integral part, or if it's in a global timeframe. For example, if you do a pelvic exam on somebody who you just did surgery on during the post-operative global timeframe, you are not able to use this code because it's considered part of the global service. Likewise, you're not going to be able to use this on obstetrical visits. And keep in mind that you need to use a chaperone. There is a certain number of minutes, and I believe that certain number of minutes is four, that is allowed for the use of a chaperone. You also need to consider documenting your use of the chaperone during your pelvic exam. Now, I think it's good practice to use a chaperone when you do a pelvic exam, but now it's advised that you go ahead and document the use of the chaperone in order to claim this code. You also may want to document your use of the pelvic pack. So what does a pelvic pack include? Well, anything that you use as far as supplies go. Not only your chaperone, but you're going to use the speculum. You're going to use your table, the paper covering your table, any gauze, any type of gauze, any kind of large proctoswabs or Q-tips that you might use, anything like that. These all are considered to have a value that can be reimbursed by using this pelvic exam add-on code. Currently, the RVU value is 0.68, and as of January 1st, that value would have been $22.27. Now, that may go up since the new bill was passed, but keep in mind that this particular code is going to be reevaluated, and it may decrease by as much as half next year. So that's just something to look forward to. So the rationale of the creation of the pelvic exam code is that, again, it was there to reimburse you for the additional resources that you put out for that particular code. So you'll see some of the codes that you can actually use with that particular code. These include the E&M codes, both new and established, and even some of the preventative codes. Remember that you cannot use this code if you're doing an E&M procedure for which the code is an integral part within global services. You also may not use this code if you're doing a procedure such as a colposcopy, during which the code is an integral part. That would include things like colposcopy, endometrial biopsies, cervical biopsies, possibly even vaginal biopsies. So you need to keep that in mind. So the other code that we want to concentrate our time on is G2211. Now, I have chosen to abbreviate it as complex longitudinal care, but the actual description of the code is in small font there. It says, visit complexity inherent to evaluation and management associated with medical care services that serve to be a continuing focal point in all needed health care services, et cetera, et cetera. This is why I chose to just abbreviate it complex longitudinal care. Now, keep in mind that inherent in this particular description is longitudinal care. So CMS really wants us to see that we are taking care of our patients long-term for this particular problem. So if you are the primary point person for somebody who has urinary incontinence, pelvic prolapse, which is our bread and butter, then you can use this G2211 in order to show that you are the person that is taking care of this on a long-term basis. Again, this is an add-on code. You may only use this with certain E&M codes, whether it's new or established. You cannot use this particular code with a 25 modifier. In other words, if you are doing a procedure, any kind of procedure, it doesn't matter what kind, this G211 code cannot be used with that, okay? So keep that in mind. It's also not to be used for a person that you are seeing for one time only. For instance, if you are doing a single consult or just giving a second opinion, it's important that we don't use that code because as of yet, we will not be performing that longitudinal care, nor is it to be used for a preventative visit. So the RVU values is just under 0.5, yielding us about a $16 benefit when we use this code. So let's go to some cases. And briefly, I'm just going to read some cases. And then with each of these cases, I would like for you to think of yourself, can I use the pelvic pack code 99459, or can I use a longitudinal code G22.11? And for some of these cases, you may be a little bit surprised. So let's go on and look at this. You have a 35-year-old lady who comes in to visit you for an annual well woman exam. Now, I know that urogynecologists normally don't do annual exams, but some of you still may. And so it's important to get this down. She denies problems and her general and pelvic exam are normal. You perform a pap smear and an HPV test. So the question is, are you going to use the pelvic exam code? And are you going to use the longitudinal care code? Well, you see the diagnosis there is just for a well woman exam. And in this case, the CPT codes that you can use are the 99396 for an established preventive exam for the particular age group involved. And you can also use a pelvic exam code because you are using your supplies for this, and it's not a procedure. However, it's not appropriate to use the G2211 here because it is a preventative exam. You're not treating a particular problem longitudinally. So this was a fairly simple case. Let's go on to the next one. So in this case, you have a 45-year-old lady who had an abnormal pap smear, and she's now in your office for colposcopy, and you perform a cervical biopsy and an endocervical curatage. So can you use either of these codes? First of all, you have the diagnosis R87612 for low-grade SIL of the cervix, and you are doing a CPT code 57454, colposcopy of the cervix with a biopsy and an ECC. So the question is, can you use a pelvic exam code? Well, in this case, you may not because it's already bundled into the colposcopy of the cervix and the biopsy. Likewise, can you use the G2211? Because certainly, the low-grade SIL is a problem. However, this is actually a procedure code, so you are not able to use this G2211 because it's not associated with an evaluation and management code. Next, you follow up on this lady's abnormal low-grade SIL, and you do a pelvic exam and pap smear. So your diagnosis is low-grade SIL. So can you do the pelvic exam and the G2211? Well, in this case, you can. You can use both, actually, because number one, you're using an established patient low-complexity code, which is an E&M code. And you are doing a pelvic exam. You're not doing a procedure. And you are actually following up this longitudinal possibly serious problem. Since no procedure was performed, you can actually use both. These are basically simple cases that I wanted to give you to show you how we are going to use a pelvic exam and the longitudinal care codes. So let's pretend you have the same patient in your office, but this time, you see a cervical polyp. You see the diagnosis codes for the low-grade SIL of the cervix and an endocervical polyp. So can you use the pap smear? I'm sorry, the pelvic exam code and the G2211. So in this particular case, you're going to use the 99213 with a 25 modifier because you are doing a procedure, which is the biopsy of the cervix. And since you are doing that, neither code is appropriate to use, neither the pelvic exam nor the longitudinal care code. So I hope that this makes sense to you. So let's do a urogyne case, finally. We have a 45-year-old lady referred by her general gynecologist in your group to get your opinion about her urinary retention after she had a SELENE procedure. The records show that she had a post-florida residual of 92 CCs by a scan. And you do a pelvic exam, and you give your opinion about the case in a document that you send to the gynecologist. And you give some encouragement to the patient. So what do you think? Do you think that you can use a pelvic exam code? And do you think that you can use the longitudinal care code? Well, you have the diagnosis of incomplete bladder emptying there. And this is what you code, 99214. This is the first time you've seen her in your group. However, because the gynecologist is in your group, she is technically an established patient. She also has a diagnosis of unknown severity. And so you actually have the support and the data to do a 99214. You can use a pelvic exam code. And keep in mind, if you choose to do the post-florida residual in your office, you need to add a 25 modifier to that E&M code. Without the post-florida residual procedure, can you use the G2211? Well, it all depends on if this is going to be your patient longitudinally. In this particular case, you have not established her as a long-term patient. So you cannot use that particular code. So hopefully, you're kind of getting how to use this 2211. In this next case, the same patient in number five returns to you in a couple of months and wants you to care for her bladder problems since she has de novo frequency and urgency. You examine her again and prescribe an anticholinergic drug. So you have your diagnosis of urinary urgency and the CPT codes. Again, moderate complexity. Your prescription supports a moderate complexity diagnosis. And so you charge a 99214. In this case, since you did a pelvic exam, you can go ahead and charge that particular code. And since this is going to be your long-term patient, again, the G2211 is appropriate to use. Oops, having a little difficulty. There we go. Case number seven. So at some point, this patient goes to the emergency department at your hospital because she had some vaginal bleeding. And you see that she has some granulation tissue at the previous surgery site. And you cauterize this granulation tissue. In this case, you have the ability to do another 214, and you can do another 215. You can do another 214 code. The patient being in the emergency room is still, you're still seeing her as an outpatient. And therefore, you have to use this particular code. You're using a 25 modifier because you are treating the patient with silver nitrate. And that's where the 57180 comes in. Application of a hemostatic medication for spontaneous non-obstetrical hemorrhage. In this case, neither the pelvic pack code nor the longitudinal code are going to be appropriate because you are at the hospital not using your supplies. Whereas, and since you are doing a procedure, again, the 2211 code does not apply. So I hope some of these cases make sense to you. Here's one more. Here is a case where a new patient comes in for evaluation of pelvic prolapse. The pelvic exam is done, and she has stage 3 uterovaginal prolapse, and you place a pessary. So once again, you can see that you use a new patient code, 9920X, because she is new to you. And then you can use the insertion and fitting of a pessary code and the HCPCS code, the A code for the pessary. However, neither one of the 2211 or the 99459 is appropriate, mainly because you're doing a procedure that includes the pelvic exam as an integral part. And since it is a procedure, you're not able to code the G2211. So I hope that that clears up a little bit about these particular codes, because I found them confusing at first until I worked with them. So we did get some submitted questions before our actual webinar. So these particular questions don't really have anything to do with those codes, so we'll go ahead and read these. So when adding a procedure code with an E&M code visit, for example, a level 4 new patient visit and a PVR via catheter, would it be 99204 and 51701 with no modifier versus a 99204 and the 99204 plus the modifier? So the way that this question is worded is a little bit confusing, but these were answered by two of our former chair people, Mitch Schuster and Mark Togley, and they both pretty much had similar things to say. So technically, you would code this particular code with a 99204, adding the 25 modifier on the E&M code and then coding for the post-forward residual separately. Now, keep in mind that the 51701 is a procedure code that is applied for a straight cath, not for a scan, and you need to have the diagnosis codes that are pertinent to that particular procedure. So keep that in mind. Mitch also said that he was aware of some offices that automatically obtain post-forward residuals on all patients as part of a workup for every encounter, and he thought that was an abuse of the system. So you really have to have the pertinent diagnosis code in order to code for that particular procedure. I'm going to add something, Charles, if it's okay. Go ahead. The other thing to remember is if you're billing a CPT with a new patient visit, many of the insurance is then half the reimbursement of that new patient visit. So it's often not worth billing the CPT in losing half of a new patient reimbursement code. Very good. Thank you, Stephanie. We'll go on to the next question here. So we've been told by our coders that if a uroflow and a straight cath are both performed, we're obligated to bill for the uroflow only because it includes the catheterization, despite this generating less RVUs. They state that it's inappropriate to code for the cath only in order to achieve the higher RVU. Is there any guidance on this? So we actually got divergent advice from Dr. Schuster and Dr. Toglia on this. And so let's just look at this. So Dr. Toglia says that technically you would bill the 51701 and the 51741. The 51 modifier goes on the least reimbursed code. So practically speaking, uroflometry is poorly reimbursed, especially when you consider the 51 reduction. It only has an RVU value of 0.62, and therefore the reimbursement in a multi-procedure situation drops it down to about $10. Regarding the uroflow and the 51701, whether it's simple or complex, the procedure codes are different. There is no obligation for billing the uroflow only. However, documentation integrity is required. There must be adequate documentation and clinical support for all procedures that are ordered and reported. So here is another question on aerodynamic testing. If an attempt to perform the pressure flow is made, it could be billed because it still requires the use of equipment. Now we have been informed that unless it's completed, it cannot be billed. So this is actually the one that had divergent answers to it. So this is the answer from Mitch Schuster. Regarding this scenario, we've discussed this in the past. Certainly a decreased surfaces modifier, which is decreased surfaces is 22, can be applied. However, he also has patients that struggle to avoid during the complex uroflow portion of the CMG and just continue the study with the urethral cath removed. The equipment still in use, the practice expense does not change. Nothing changes except the validity of the vesicle pressure portion and the urethral pressure portion and the flow rate helps with diagnosing voiding dysfunction. The study is being performed and the data is still analyzed. And so he chooses to report it as a completed study. So I really take the same philosophy. I figure that once we start that particular study, if we can get any information from that study, even if the patient is not able to avoid pass a catheter, I consider it a completed study. However, Mark had a different opinion. He said that he agreed with the coders in this situation because you can't bill for the voiding pressure study. He said the CMS rules are clear that when multiple procedures are planned and only some are completed, you can only bill for the completed procedures and that you cannot bill for the procedures that were planned and not completed. And he actually gives some references for that. You can discuss the use of certain modifiers to show that the study was not necessarily completed. So Stephanie or Jamaica, do you have any additions to any of those questions? I tend to agree. So the last question, I think, was the more under contention. I tend to bill the whole study, like you mentioned, in that, especially if they voided without the catheter, but they just couldn't with the catheter. I think if you still did avoiding systometry of sorts, you just didn't get those two data points. So I think it might be different if they didn't void it all, then perhaps maybe you should do the reduced modifier in an attempt to do the study but didn't complete it. But I think if they did void and you just couldn't do it with catheters, then I think that would be different. I think this comes up sometimes, too, when we do a Euroflow study and someone just can't go. So in that instance, I don't bill the Euroflow because I have no data. They didn't go at all. Other than having to wipe down the toilet seat that we use, I really didn't have to use any products or supplies. So I feel like in that case, I can't bill it. But I think in the aerodynamics case, there's those two scenarios that differ. Dr. Parker? I agree. I do the same thing. If my patient's not able to void for the Euroflow, then I usually do not charge it because it hasn't really added that much for the practice expense. But for the other ones, I do. If they're not able to void with the catheter in, then we remove it and have them still void. Just because the catheter has been opened, the nurse has still performed that part. And everything that we would do as far as an expense for the practice has been done. So. Yeah, I tend to agree. I think that when we actually have expenses to this procedure, we should be able to charge for that. So all right. And it takes the same amount of time, too. So I mean, all of those factors are the same. Yes, I agree. So now is the time for the listeners to ask questions. And Jill, it looks like we have some questions that are listed already. That's right. We already have a number of questions. So the first one is, when seeing a patient for UTI, do we charge the VISIT plus the straight cath procedure? Do we need a modifier 25 and diagnosis codes to support both the VISIT CPT code and the cath CPT code? Well, we talked about this a little bit earlier. I think that if you're going to do a straight cath, you need to have justification for it. UTI is not necessarily a justification unless you are wanting to have a straight cath urine culture. Maybe that patient has a post-fluid residual that you are concerned about. Maybe she's not emptying her bladder correctly. I think that in order to charge for the catheterization, you have to have your diagnosis that is consistent with that particular CPT code. If you are going to use that, then remember that you need to use a 25 modifier on your E&M code, even if it's a brand new patient. Because that tells the computer that there is a procedure being performed at the time of an evaluation and management. So keep that in mind. But again, know your payers. Because is it worth getting a couple bucks for a straight cath if your payer decreases your VISIT code by half? So that's where we're really getting stuck with a lot of our payers. UnitedHealthcare is definitely one. Blue Cross, a lot of our independent Blue Cross patients, all of those E&Ms get cut 50% if you add a CPT code. So I would encourage everybody to know how much your reimbursement is for these things and decide whether you really want to bill them or not, or just document them. OK. So kind of back to the earlier part of our presentation. Regarding Category 3 codes, do RVU amounts need to be negotiated with the third-party payers for each patient, each surgeon, each institution? I'm actually going to help you guys out with this one. So it depends is the answer. Usually, you will have to negotiate the first couple of patients. Because you're also going to be going through prior authorization on a Category 3 code, most likely. So after x number of patients go through, and if they're getting approved by the payer and they set a rate, at that point, then you no longer have to continue the negotiation because they've set a rate. If your payers, if you have a good working relationship with them, and they're willing to negotiate for the procedure regardless of the patient, they would do it per the institution or per the contracted entity, not for each individual clinician. So if you're a contracted entity is like Oklahoma Health or Stephanie, your practice's name, they would do it for the institution. But most likely, the first couple times through, because you're going to have to go through prior auth, it would be based on the patient. OK, so now back to a more traditional coding question. Can you use 99459 if you do a pelvic exam but do not use a speculum? That's a good question. The thing is that in the description, the things are not delineated as to what you're being paid for. In fact, there was some question in our first webinar whether or not we needed to actually have a chaperone there because it was not in the descriptor. But when we go back and we look at how these codes were actually given RVUs, yes, they are accounted for in the RVUs by the speculum, the chaperone, the paper supplies, et cetera. So you will still be using a chaperone, but not a speculum. And I think that's a real gray area. Personally, I think that you have the ability to do that. What do you think, Jill? Is this a particular instance where you would or would not use it? Well, I think one of the things to keep in mind is one of the things to keep in mind is one of the reasons, and sadly he's not with us tonight because he has a meeting at his institution, but one of the main arguments that Dr. Schuster made for having this code created was the cost of the speculum. And one of the differentiating factors between a pelvic pack and just a regular E&M pack is the speculum. So I think that given that the pelvic pack is $20 worth of the practice expense and the four minutes of staff time and the four minutes of equipment time are a couple of dollars at most, I think you're gonna need to use a speculum to build 99459. Okay, very good. Okay, so next question. Can you build a pelvic exam 99459 with a PVR by a ultrasound, CPT code 51798 when it's done during an office visit? And if so, would you add the dash 25 to the E&M code? Well, first of all, you will need to put the 25 code on the E&M code. And I think it's, again, we're in a gray area here. Did you do a pelvic exam and diagnose some other problem? I think that if you do a post-floid residual, even by scan, I think you're gonna have a hard time getting paid for the pelvic exam code. I'm gonna disagree and say yes. I've been billing these codes and I have done this scenario. So I'm gonna say you can get paid as long as you did the pelvic exam and you had them there, should you get queried on your records, that you had them there for a reason that's justifiable. Being that it's an add-on code, it doesn't matter if you're billing the PVR with it. So add-on code's kind of standalone. You don't need a modifier, as we mentioned in the presentation for a standalone add-on code. You just need a justification that you did it and a reason that you needed to do a pelvic exam. Okay, okay, so here's a good one, 99459. What if you do a pelvic exam as part of your clinic visit, but the clinic is owned by the hospital? Is it doing an exam in a hospital, thus you may not use the code? I think that if you are getting damaged for the expense in your clinic, I think that you should go ahead and claim 99459. It is possible, though, that you won't get paid for it. Yeah, I think so. Because imagine- Bill, isn't that true? Because she's a hospital. You're billing facility. She's a hospital. Yeah, they're billing as facility, so they're probably just gonna get it denied. Oh, if you're billing a facility, you can't use- You're not gonna get paid. So- If you're billing as a non-facility, you should be able to. So if your hospital is the billing entity, that has the tax ID number, and it's site of service, hospital outpatient, then 99459 is not going to get paid, because that's considered a facility under the physician fee schedule. So it has to be an office-based practice that is not owned by a hospital. And I would like to also agree with that. I mean, at OU Tulsa, we're a little bit different. Instead of OU Oklahoma City, which this made a big difference on how we do it, because in OU Oklahoma City, they are owned by the hospital. They have that tax ID. However, in Tulsa, it's actually, we're a non-facility. We are not owned by the hospital. We have this totally different tax ID from them. So we're able to use the code. So that made a big difference with us versus our Euroguide colleagues of the street. Yeah, and we are the same. At Texas Tech, we are owned by the state, but considered non-facility, whereas we do most of our procedures and at the hospital, which is private. So there's definitely a separation of tax ID codes there. So the answer is, ask your hospital if their tax ID number is as the hospital and that they're using that ID number as your billing entity. So you do wanna check that, because, Jameika, your example is very interesting. And so people need to check. And Doug, the fact that you have state involvement is interesting too. So again, check your billing entity. Is it considered a hospital if you're an employed physician or is it some sort of relationship like Jameika's where there's a nonprofit or like Doug, where there's the state involved? Okay. Oh, this is a good one. Can G-2211 be used for when you're doing multiple pessary checks? Well, now keep in mind that if the patient comes back for a pessary check and you're just gonna take it out, look and put it back in, there is no procedure code that you are actually claiming. So that is a viable use of the G-2211. Now, the problem is when you start using silver nitrate to cauterize vaginal lesions that the pessary causes, or if you have a vaginal infection and you decide to do vaginal irrigation, assuming that you have the correct diagnosis, you can use that procedure code. But if that's the case, G-2211 can't be used. Likewise, if you're going to, if the patient's pessary doesn't fit for some reason and you decide to use another pessary and you're going to do another pessary fitting, that is considered a procedure. So again, G-2211 would not be appropriate. If you're just doing a pessary check, the patient keeps the same pessary that she's using and you had no other procedures, then yes, you should be able to use the G-2211. Great, okay. So here's an interesting question, sort of like we've talked a little bit about is what's the best way to bill things. Given that we do an I slash O cath on most visits, we use the modifier 25 on the E and M. Is there a better way to bill to be able to use the G-2211? I'm not understanding this question. I'm not really understanding it either. So since you can't bill a G-2211 with a procedure code with it. Right. I mean, you could just bill the NM visit with the G-2211 instead of the I and O. Right. And honestly, it probably pays better to do it that way. You don't get paid much for an I and O cath. You'd have to look at your reimbursement, but it's not a bad idea to do it that way. So I'm not really understanding it either. You'd have to look at your reimbursement, but so this is where, again, knowing what your reimbursements are, at least in general, can be helpful to decide because you could really do it either way. And you're right either way in this situation, you have a choice. Yes, I agree. You would think, you know, the $16 maybe from the G-2211 versus the like $5 to $7 that would be from the straight tab. If you know that about your numbers and your practice, it definitely helps you saying it would be better just for me to do the G-2211. And again, if it's another private insurer, not CMS, you might lose half your E and M by billing that straight cath. So in that situation, it would definitely be better to bill the E and M with the G-2211. Yes, I agree with that. Okay. Okay, so this is an interesting, kind of in this same vein, in terms of losing compensation for new visits when a procedure is added, is that regarding both provider RVUs and monetary compensation? If I'm understanding correctly, it's generally best to only bill for the E and M code and not also adding the procedure rather than having to put on the Dash 25 modifier on the E and M code. I guess it depends on what the procedure is. So RVUs equal monetary compensation. I'm not sure if that was the first part of the question. So yes, provider RVUs and monetary compensation, right? Because if the compensation is new person. Yeah, I usually try to avoid doing procedures on it, especially with a new patient, because of that fact that oftentimes our reimbursement gets cut. So if a patient needs to have a procedure done, I usually try to bring them back for that particular procedure and then just bill the procedure and not the E and M code. Correct, I think that's similar to how I practice as well, when feasible. I would agree too. It's when you're doing that, you have to make sure that you have very clear documentation of doing both of those things. And many times people do not make very two very clear documentations of your E and M visit and your procedure. A classic example of that is if you do your dynamics on a patient that's a new patient that day, you might actually end up losing more than gaining just because of the lack of documentation and your reason of why you chose to do both. If you're thinking in your mind, well, I'm getting more RVUs because I get paid RVU wise. Yes, that would be understandable if that's how you get paid. But as far as for the practice, the practice and all would lose. Yeah, an exception to that for me is that if I believe that the patient has such severe prolapse that she's retaining urine, oftentimes I will do a, I'll go ahead and put a pessary in the first visit simply because it's better for the patient. And sometimes you have to do what's best for the patient and not just what is best to code with. And just keep in mind, anytime you use a procedure, you cannot use the G2211. But even on a new patient, if somebody refers that patient to you and she is a new patient to your practice and you intend to follow this particular problem longitudinally, you can build a G2211 even on the first visit. Okay, so now we're gonna take a total swerve here at the end onto something we taught at the coding course last fall. So this is around E&M coding. So does writing a script for the patient automatically allow you to build a level four established patient visit, even if the visit took only 30 minutes? Well, keep in mind that you have to have two of three elements in order to justify doing a level four visit. So your visit has to be moderate complexity in order to do a level four, okay? Now, if you have the diagnosis that supports that plus the prescription, then the prescription goes over to the amount of risk that you're taking, okay? And this was given as an example of moderate risk is writing a prescription. So yes, you can use that level four visit, but you have to have the supporting diagnosis, okay? If you have just a straightforward diagnosis like a yeast infection and you write a prescription, that doesn't entitle you to a level four visit. Straightforward, remember, is just a level two, even if you write a prescription. Okay. I agree with that. So we're gonna take two more questions here, even though we're a minute over. One about the pelvic exam code and one about G2211. So first G2211, it sounds like G2211 can be used for any chronic condition, even if stable. However, I thought G2211 was related to a serious or complex condition. Are there documentation requirements for this code? Well, that's a great question because even my coders at my institution had the same question. But when you get to the point where, let's just take an example. Diabetes is a very serious diagnosis, but if you are within treatment guidelines for diabetes, that's considered a stable chronic disease. Well, I'm sorry, but diabetes is a very serious diagnosis. You can still choose to use the G2211 for that. Just because it meets the definition of stability doesn't mean that it's still not a serious disease. So let's take an example. I mean, whether or not you want to consider stress urinary incontinence stable, it's usually, I'm sorry, serious. It's usually pretty serious for the person that has it. But people have differing takes on this particular diagnosis. Some patients will say it really bothers the heck out of me and I can't stand it. And other people will have the same amount of incontinence and it doesn't bother them so much. So I guess seriousness is in the eye of the beholder. Personally, if somebody comes to me and says that they have stress urinary incontinence that is bad enough to complain about, I consider that a serious diagnosis. Now, you don't necessarily have to, it doesn't have to reach the level of a level four or five visit. I think a level three visit is certainly a reasonable thing to use if you have a stable but serious problem. So yes, I think you can still use G2211 in that case. I'm interested in other opinions. Well, and the other thing, we'll put it up on the odds coding community. CMS has put out one MedLearn article on this. Hopefully they will put out more information on documentation requirements. But in that article, they really speak to the relationship between the doctor and the patient and the longevity of that relationship. So it's really, if you have a patient with incontinence and you and that patient are working together to address their condition and they've been your patient and you keep seeing them and working on it then you are their captain of the team, so to speak, for their stress urinary incontinence and you have this long-term relationship with them as you, the individual physician, and they, your individual patient. That's the example, although they didn't use stress urinary incontinence, they used some other diseases, but that personal relationship and the longevity of that relationship is what I think you wanna document at this juncture when you're billing G2211. Yeah, I think if, to this point, I think if it was only for serious, medical life-threatening issues, we would always have to bill it with a level four or five visit. And I don't think that's how this code was intended, right? So, otherwise everything would only be billed for very few things. So I would think of using this, for instance, for say a chronic cystitis patient who may or may not have issues with pyelonephritis and may or may not have been institutionalized or hospitalized for that. I've got plenty of those patients. That's the kind of person I see using this code on. It's somebody I'm chronically seeing. We're trying to make sure they're not getting infections and it can be very serious. So that, from my perspective, that's the typical patient I think we see in our population. Yeah. Yeah, I agree with Stephanie. We have used it a lot with our patients with recurrent UTI diagnosis, because we are constantly, maybe about 15 to 20% of our practice, we're the team captains for those patients. Patients refer them to us to manage their recurrent UTIs. And their PCPs usually are hands-off with this and they send them to us. And we're seeing them for years and years. So. Yeah. And as we all know, sadly, the very elderly or even the not that very elderly, a UTI can be very dangerous and even be a mortality event. Yeah, so keep in mind the definition of stable in this case, when we're talking about medical issues. The definition of stable is that you are reaching treatment goals, okay? So if a patient is not reaching treatment goals, but yet satisfied with where she is, your treatment goals, she's technically unstable, right? So it's a real question about how you rank the severity of her problem. So one last question about the pelvic exam add-on code. If a female doctor does the pelvic exam in the office without a chaperone, can we still build a pelvic exam code? One area says yes, and one area says nothing about a chaperone. So we're all still figuring that out too. Well, we did on the last ACOG coding committee, ACOG staff did mention that if you documented that you offered a chaperone and the patient declined it, that that would be okay. And you could still build the add-on code assuming you had the supplies in your pelvic exam, assuming you had the supplies in your pelvic pack and you had this extra time for the table and the light. But you at least sounded like ACOG's opinion was you at least had to offer the chaperone and have it declined. And I would think if it's a female physician, it's most likely going to be declined, but maybe not always. So that was their take on it. These are typical patients, not absolute patients. Typicality is 50% of the time. And I would also say, just understand your payers. They will actually give a document reason why they denied it. The majority for ours is that they just denied it out front. It wasn't because of lack of documentation. So that gives you a little understanding of what your region is doing with this code. Yeah, we haven't been audited on charts yet for this code. So time will tell what they're really looking for. We have been audited a lot for combining CPT and E&M codes of 25 modifiers. That seems to be on the firing block for all insurances lately. So I encourage you earlier, we probably didn't pound this in a little bit as much as we should, but to document why you're doing a visit code versus why you're doing a CPT code and they need to be different or else they will withdraw your E&M visit and only possibly pay the CPT for instance. And as CMS puts out more information, particularly on the G2211, we will put that up in the OGS coding community and we'll probably have it in our OGS coding committee health policy e-newsletter that we send out every other month. Hopefully you're reading those for the information about things like the conversion factor, other sorts of Medicare payment, coding issues, as well as research and development issues, as well as research funding issues, et cetera. So particularly for that one. And I think, please let the coding community know as you're working with your payers on this new public exam add-on code and so we can all learn from each other's experiences. That's very helpful. You're not signed up for the OGS coding community, please do because that's a way to ask coding questions, get our fact sheets, et cetera. Thank you. Okay. I am going to wrap up a couple of things since we are at 7.09 PM. Thank you for all your attention and sorry we went a little bit over. On behalf of the OGS, I would like to thank all of our faculty today for the excellent webinar. Follow OGS on Twitter and Instagram or check our website for information on all upcoming webinars. And thank you all for joining and have a great evening.

coding webinar

urogynecology codes

clinical practice

99459 code

G2211 code

reimbursement rates

insurance providers

billing procedures

speculum

documentation requirements