For those joining, we're just going to give a few minutes for people to join and we'll get started. Thank you. Thank you. Thank you everybody for joining today. This is the first in the series of Springs OGS Workshops at Home, Medical Decision Making and Selection of the Appropriate Evaluation and Management E-M-C-P-T Codes. And we're going to start off with a previously recorded presentation by Emily Hill, who's the president of Hill and associates and an expert in coding and reimbursement. That presentation will be about an hour and five minutes. So once the presentation is completed, we'll stop. And then we have members of the coding committee here with us that can help facilitate question and answers after you view the session. Hey, thanks, Dr. Pullman. And thanks to everyone for joining us today. I'm making my slides, sorry, my slides advance here. I just want to say I have no conflicts of interest to declare. I've been trying for years to figure out where the conflict is in coding, but haven't done that yet. I also want to mention that we've made every effort to make sure that the information is accurate as to the date of this presentation. Just remind you that we're talking about something that's new for 2021. And we were just talking before all of you joined us about the fact that we're expecting to have some clarifications as we start to use this new code set and code structure from the AMA and perhaps even from payers. So we're going to talk about how to use these codes for new and established patients because they've been revised in 2021. We'll look at medical decision-making component. And we're going to be talking about a new concept for time, which is total time. And of course, we always, as was mentioned, want to be sure we're documenting and coding correctly so that you get the appropriate reimbursement. So why did we have this change? Well, it really started back, believe it or not, in 2018 when the Centers for Medicare and Medicaid Services, CMS, put out what they call their proposed rule, which is their plans for changes for the following year. And they indicated that they thought that it was time to revise the E&M documentation guidelines because they wanted to reduce the burden on physicians. I'm sure that's true, but I'm sure we all assume there are some other reasons behind all of that, not to mention the fact that we all know that the medical record over time has just become clogged up with information that was necessary to code properly, but not necessarily valuable clinical information. So as CMS said, we want to have this change and basically kind of promised a change. They said they believe that medical decision-making and time were the most important factors in picking a level of service. So rather than have CMS drive the bus here, the American Medical Association established an E&M workgroup. And that was from a variety of specialties and providers and also included a very large group of people who participated in Q&As and comments and responses back on proposed changes. So as a result of that workgroup, the CPT editorial panel made changes to the office-based new and established patient codes, and they were finalized and accepted both in terms of their definition and their proposed RBU values to be implemented January 1st. So it's important, and I'll say it again, it's important to realize that these changes only apply to office-based new and established patients. So the changes look very much like CMS's proposal, which is that we're going to select codes based on medical decision-making or time. So the key provisions of this is that it retained five levels of established codes but reduced new patient codes to four levels, essentially deleting 99201 because it was really almost indistinguishable from 99202 based on medical decision-making. The CPT manual and their guidelines say that a medically necessary history and exam should be done, and of course documented, but it will not influence code selection at all. And in the process of this new structure, both time and medical decision-making definitions and criteria were changed. Many of them, I think, probably for the better, and in fact, most of them probably for the better. They also added a new prolonged service code that I'll review later in the presentation, and then again, these changes don't impact hospital admissions, consultations, subsequent hospital care, observation, and all of those stay the same under the current system. I can tell you that this E&M workgroup continues to meet and to consider whether this new structure should be carried forth to other families of E&M services. I think that is kind of the plan, but at this point, there's no big rush on that because folks are kind of pretty well occupied with dealing with COVID these days, and to get new code changes, it requires surveys by physicians and a lot of work. Now, the common descriptor for all the codes reads office or other outpatient visit, which requires a medically appropriate history or exam. After that, codes are differentiated by either a new or established designation, the type of medical decision-making that's associated with that, and then the time associated with that level. So this is how the new codes kind of look. You can see we've just got four levels of new patients, still have five levels of established, but let me mention now that 99211 continues to be what we have often termed a nurse visit code in that it is when you're supervising another clinical person in your office. But you can see already that the times look different than what we're used to. So instead of having a single time that's defined as a typical time, we now have a range of times. The type of medical decision-making, straightforward, low, moderate, and high are things that we're familiar with and have used in the past. So I'd like to start off with looking at the medical decision-making. We'll look at some of the definitions. We'll look at the criteria and how to use this table of medical decision-making, which now will appear in our CPT book. After that, we'll take a look at how to use time, and then we have a few clinical examples that the panels put together for you. So we have four levels of complexity that I mentioned. Those are familiar with us, and we have three elements. They are also familiar because they are derived with some revisions from that table of risk that we've had for years now. It's the number and complexity of problems addressed, the amount and or complexity of data to be reviewed and analyzed, and the risk of complications and or morbidity, mortality of patient management. So there are a few additional words here. Problems addressed, to be reviewed and analyzed, and patient management. And just like our table of risk in the past, two of the three elements need to be met or exceeded to meet a certain level of complexity, but certainly never all of those. So let's start with number and complexity of problems addressed. So it says that there could be multiple new or existing problems that may be addressed at the same time and might affect medical decision-making overall. It also points out that symptoms that cluster around a specific diagnosis don't necessarily represent a unique condition. So common to all of you, a burning frequency and urgency typically means a UTI, which is one problem, not three individual problems. It also talks about comorbidities and underlying diseases. And this is a bit of a difference, I think, in how we've thought in the past. And they said, basically, those conditions aren't considered in your level of E&M service unless they are addressed and their present increases either the amount and complexity of data involved or the risk of complications of patient management. As we all know, the final diagnosis per condition doesn't necessarily determine complexity or risk. So you could have a patient kind of move into a GYN world coming in with pelvic pain that could be a number of significant issues may turn out to be pretty minimal, a middle spurt, for example. Or a patient could come in with very few symptoms and turn out to have a high-risk condition after addressing those. And multiple problems might create a higher risk just because of the interaction of those problems one to another. Now I mentioned that a change to this was adding the term problems addressed. And they define what that means. And CPT says that a problem that is addressed is one that is evaluated or treated by the professional reporting the E&M service and includes consideration of further testing or treatment even if not elected. So as long as you evaluated, considered perhaps a treatment plan but decided not to do that in conjunction with conversation with the patient, it is still a problem that's addressed. They say something that is not addressed is not considered addressed. If it's simply a notation made that someone else is managing the problem without any additional assessment or care coordination on behalf of the provider seeing that patient. Or it's not addressed if you simply made a referral without evaluation or consideration of treatment. They come in and say, you know, oh, by the way, I also think I have an ear infection. And you say, well, I don't do ears. But let me send you to your primary care or to an ENT or what have you. That would not be a problem that you addressed. You just simply referred them on. Now I mentioned that there's some new definitions. And actually, these are not really new definitions. They're just definitions for the most part that are coming to our attention. Most of these, with the exception I think of one, have been present in the E&M guidelines. We just never really referred to it. So they have different types of problem. A minimal problem is defined as one that may not require the presence of the physician or QHP. QHP is qualified health care professional, which means advanced practice nurses and PAs, for example. So when you're just supervising them, that's the 99211. They also define something as a self-limited or minor problem. And that is one that runs a definite and prescribed course, is transient in nature, and not likely to permanently alter health. For a stable chronic illness, first of all, a chronic illness is something that has an expected duration of at least a year or the death of the patient. And stable is defined as meeting the specific treatment goals for that individual patient. If they're not meeting their individual goals, they are not stable, even if you're not changing what you're doing to handle that patient. Now I just should mention that the examples that you will see coming up on these slides of the types of problems are taken directly out of the CPT manual with their examples. I didn't try to make some judgments on anything else. I thought we should review what's in the CPT book. And we'll look at these things more when we look at our clinical examples. So examples are well-controlled hypertension and non-insulin-dependent diabetes. I'm assuming that being one that's well-managed as well. They talk about acute uncomplicated illness. And this is something where it's a recent or a short-term problem with low risk of morbidity for which treatment is considered. And you expect full recovery without any functional impairment. And it would also include any self-limited or minor problems that weren't resolving as you expected. Examples in CPT, cystitis, rhinitis, simple sprain. Now they divide chronic illness into two types. One with exacerbation and one with severe exacerbation. So exacerbation is something that's acutely worsening, poorly controlled, requiring additional care of treatment, but no consideration of hospitalization. The severe exacerbation or side effects or progression is a significant risk of morbidity where hospitalization might be required. They also talk about an undiagnosed new problem with an uncertain prognosis. And this is a problem maybe in the differential diagnosis that's likely to result in a high risk of morbidity without treatment. They gave one single example of that, and that was lump in the breast. Then they have acute illness with systemic symptoms. And this is systemic symptoms with a high risk of morbidity without treatment, and it may involve a single system. The examples are polynephritis, pneumonitis, colitis. It does clarify that general symptoms such as fevers, body aches that are part of a minor illness are not considered systemic symptoms, even if you chose to treat them with an anti-inflammatory or something else to alleviate that discomfort. Then there's the acute or chronic illness that poses a threat to life or bodily function. And these are systemic symptoms with exacerbation or progression that pose a threat in turn without treatment. So many of these things are based on treatment plans or what would happen without treatment. And of course, there's severe respiratory distress, peritonitis, renal failure, changes in neurological status, pulmonary embolus, MI, some of those we've seen in relationship to high levels of service in the past. So basically, it seems like a lot of definitions that we have to go through, but as we look at this table of medical decision making in a few moments, we'll see how that progresses and where that might place your patient. Remember that this is only one of three components of our medical decision making. So it could be that the other two components are going to drive your level as opposed to the problem. So we'll see as we go through and as you practice with your patients. So the middle category is the complexity of data to be reviewed or analyzed. And there are three general categories for this. The first includes test, documents, orders, and independent historian. And this is where we start to count things in this data piece. And so every test, order, or document can be counted to meet the threshold. And that'll be clearer, I think, when we look at our examples. The other category is an independent interpretation of test, which I will define. And then the discussion of management or test interpretation with an external physician, qualified healthcare professional, or other appropriate source. And that other appropriate source can be a facility, an institution, it can be a lawyer, but it cannot be a patient and their family. And an external physician is also defined as someone outside your group or if they're in your group of a different specialty or subspecialty. So what's included here is information that has to be obtained, ordered, reviewed, and analyzed for the encounter, such as medical records, tests, and other information. It can be obtained from multiple sources or interprofessional communication, as long as you're not billing one of the codes for interprofessional communication. Information can be interpreted, but not reported separately. And I'll come back to that a little more for more clarification on that. So when they talk about reporting diagnostic tests, the actual performance and interpretation of those diagnostic tests during the patient encounter are not included in the E&M time when they are reported separately. So in other words, if you are performing the test, you can't count your time of performing the test towards your E&M time, because you're already been paid for the time in the code that's the performance of the test. So your aerodynamic studies, for example, you can't count actually doing those as part of the time of your E&M. This study and test can be reported separately when there is a CPT code available. And you have done all the requirements for that, such as distinct separately identifiable signed and written report that can be done separately. But any study that is used for the management of the patient that is not separately reported on that day is part of medical decision making. So basically, they're trying to avoid people from double dipping and either counting the time of doing the service or considering that test as one of your data elements if you're already billing for that test elsewhere and getting reimbursed. So let's kind of look at our tables here. First thing to notice, which is actually quite interesting for me, is that level two new patient and established patient have the same criteria. And that's true for levels three, four, and five. So as you recall, currently, if you're billing a new patient, you had to meet higher standards to meet that level of new patient code. That's not going to be true in 2021. So if you understand that this meets the criteria for level three, then it's going to be a level three, whether it's a new patient or an established patient. So let's look first at the number of diagnoses management options. So for our straightforward, then it's minimal, might be one self-limited or minor problem. Remember those that are expected to sort of resolve without worry. Data is minimal or none. And then the risk is the risk of morbidity or mortality from additional diagnostic testing or treatment. So that's really an important concept as we consider risk. It's not risk of the disease itself necessarily, but the risk of what you are going to do for or to the patient. So if you are doing an invasive treatment such as surgery, you're going to see that's going to be included in the higher levels of service. But this is about what you're planning to do with the patient. Now level three, we've always loved the level three code the best, that one in the middle, it seemed nice and safe. And I hope that for some of you who've loved level three, you'll find that you have some level fours that you might not have been aware of. So in looking at the low complexity and going again at the table of diagnosis or management options, again, two or more self-limited or minor problems, or it could be one stable chronic illness or an acute uncomplicated illness. When we move to data, now you notice you see it says limited one of two. That means either test and documents or number two, assessment requiring an independent historian. So if we're going to use the number one as part of our data, we have to do two of the following, either review of prior external notes from each unique source. So that means if the patient had seen two providers prior to you and brought notes from each one of those, that counts as two and you would have met your requirement. Would include the reviewing the results of each unique test. So if you look at two different tests, you've met the requirement. If you reviewed one test that had been done prior to the visit and you order something at that visit, now you've also met two of the following. But understand that you can't count if you're ordering, let's say your analysis in your office, you can't count that as both a review and an order. It would be considered a review of the test results. If you had ordered a test at her last visit, and then, or if you reviewed a test from her last visit and ordered a new test, then that's a review in an order. But basically, once again, you can't get two things for one test that's being managed at the same encounter. Talk a minute about an independent historian. So an independent historian is, according to the CPT, is when you need to get additional information because the patient's not able to provide that. It might also be a situation where there's conflicting information. Let's say patient and family discussion. It could be the inclusion of someone outside the patient's family. It could be communication, perhaps with the nursing home about the patient. So an independent historian is not going to always be used when you've got another family member chiming in, I don't think, but when they are providing a substantial viewpoint and information for the patient. Viewpoint and information that the patient is not adequately sharing. And of course, the risk is low risk, again, from any treatment or testing that's going to be done. Now level four. Suddenly our slide becomes much more busy. Let's again start with diagnoses or management options. So first of all, it's one or more chronic illnesses with exacerbation, progression, or side effects of treatment. Remember, this is not significant, but with some change, either not currently being managed towards treatment goals or having something that's truly progressing. It could also be two or more stable chronic illnesses, or it could be one undiagnosed new problem with an uncertain prognosis or an acute illness with systemic symptoms. Remember, that's a single organ, or we don't have to worry about injury so much. So any of those would make the diagnosis or management option criteria for moderate complexity. When we go to data, now it's still one area, but it's one of three different options. And so now under test and documents, we still have notes, we still have reviewing results, we still have ordering, but now the assessment requiring the independent historian has moved into category number one. The second one is independent interpretation of test. So let me comment on that independent interpretation of test a little bit more. You would never do this if you are actually the person who is reporting the interpretation of that test. So if you're going to report the interpretation of the urodynamic testing, you cannot consider that independent interpretation of the test. If you were getting the test from an outside person and you actually looked at all of those and did your own interpretation, that would be an independent interpretation. And then of course, the third one is discussion of management or test interpretation with that other source, somebody again outside your group or with a different specialty. And of course, moderate complexity looks at the individual's ability to respond to leads to moderate risk. For those of you who were familiar with the table of risk, you will recognize some of the things that fall there. Prescription drug management. They're talking about decisions regarding minor surgery with identified patient or procedure risk factors. A major surgery without identified patient or procedure risk factors. And let me just kind of comment on that. As we all know, every procedure has a risk. And I guess every patient has some risk. But what we're really talking about with identified risk factors are certainly patients underlying medical conditions. BMI, for example, can make that. You can have certain procedures that are clearly inherently more risky than other things. And so that would be identified risk factors. The thing with risk, CPT said that these are examples only, by the way. So there could be many more things that would fall under moderate risk. But CPT failed to do a lot of definitions of risk because they said risk is something that physicians understand. And it is the risk compared, your assessment of the risk compared to someone who is in your same specialty. So your plan to do a surgery would be the risk that's associated with other urogynecologists or gynecologists, not what a family doctor would feel about taking a patient for surgery. And of course, that makes sense. There is also a new factor under risk. That is a diagnosis which is impacted by, significantly limited by social determinations of health. Food shortage, housing shortage could be other things. I would think failure to have adequate help at home, any of those kinds of things would impact that social determinant. It doesn't come into play, though, until we get to that moderate complexity level. And finally, for our risk, we get to high risk. And so high risk, as it has always kind of been, our level five visits, are those that are not our most common codes that we report. And they are really your most ill or most difficult patient to manage that's in your practice. Now, remember, we can also have patients that we spend a lot of time with that could turn out to be a level five, and we will talk about that. So a number of diagnosis or management options. This is our chronic illness with severe exacerbation or an acute illness that poses a threat to life or bodily function. Once again, in the near future, as CPT discusses it. So for level five, instead of one of three areas, we now have two of three areas. And so for tests and documents, it's three of those things. Plus, we would also need to have either independent interpretation of tests or discussion of management or test interpretation. So remember, though, and I failed to mention this before, again, we can reach our level of medical decision making by two out of the three areas. So if your patient met the criteria based on the type of problem or situation you're dealing with, and she was also at high risk because you're doing a major surgery with identified risk factors or an elective surgery or an emergency major surgery, all of those things would now put her at high risk. And it wouldn't matter whether you had met all the criteria for the data or not, because it's two out of those three areas. But for the data, it is a quantitative piece, and we have to be able to mark those things and take them off your list, so to speak. So this sounds, perhaps it sounds complicated and overwhelming. Perhaps it makes more sense to you and less complex. I've done this presentation before. I learn something every time I do this about what new questions we might have or how I might present it. But, you know, some of the physicians say, oh, this makes a lot more sense. I can handle this. It was much easier than our old medical decision making, where we had all kinds of things to consider, plus then a table of risk. So we'll see. I think it will take some practice. I think it will probably take a little thinking through your most common presenting problems and patients and trying to figure out what you usually do for those folks and where that puts them. And so the panel has helped put some of those examples together towards the end. Before we get there, let's talk about using time to select our level of service. So first of all, the times have been revised for all the codes to change from face-to-face time to total time spent on the day of the encounter. And this was something that physicians who participated either on the panel or who participated in providing feedback were very adamant about that time concept being changed. And what they reflected is that things are not like they used to be and that there are many patients where it's not only the time you spend with them, but the time you spend there after them, maybe chasing down test results or calling someone else or calling them back with their test results. So the other thing that this time also includes is both face-to-face and non-face-to-face times, but those provided by the reporting provider. Reporting provider, not time spent by clinical staff. And the time can be whether you're counseling or coordinating care or not. It's just straight time. So speaking of time, and before we look at that a little more closely, this is another change that I think many folks were happy to see. For those of you who work with nurse practitioners or PAs in your practice and you often share patients, so to speak, or talk about patients or you both see the patient, in 2021 for office new and established, now we can include both the work of the physician and the qualified health care provision to report the total time for the visit. You can sum that time. So let's say that your nurse practitioner went in and spent 20 minutes with that patient, comes out, talks to you for 10 minutes about that patient. That's 30 minutes. But we can only count distinct time. So if you go in and you both spend 20 minutes talking to the patient together, then you can only report a total 20 minutes. And that would be code 99213, which is 20 to 29 minutes, not 20 minutes plus 20 minutes for each of you because you were there at the same time. So it couldn't be the level five visit. So I think it's important also to talk about what they've said can be included in time. First of all, preparing to see the patient, because remember, you wouldn't be face to face again. Obtaining or reviewing separately obtained history. So that patient, you might have them complete history form. You might have some of your staff get history and you review that. That's counted towards time. If you're doing a medically appropriate exam or evaluation or history, that's also part of the total time, as is counseling and educating patient and the family. The time it takes for you to order medications, test or procedures also counts towards total time. Good news, documenting clinical information in the record is now considered time that you can count because remember, we never really could count recording clinical information if you weren't doing it in front of the patient. Now that that time gets to be considered. Any communicating of test results to the patient or family, referring and communicating with referring and communicating with other health care professionals, as long as it's not something that is being separately reported with a code. We talked about independently interpreting results. Again, if you're not billing for that and care coordination, if you're also not reporting any of the codes for care coordination. In other words, you can't double dip. Now, one of the, because it's total time on a full day. You cannot report prolonged service codes on the same day as office E&M codes, I should be a little bit clearer about that. So, 99354 to 99357 is direct patient face to face contact. So we'll no longer use these prolonged service codes. These prolonged service codes, they've given us a unique code, you could still use these codes for hospital observation, etc. The 99358 and 99359 is without direct patient contact. So that was the one that we used for looking at extensive records prior to seeing the patient. CPT believes that you should be able to build this the day prior to the encounter, but not on the date of the office E&M. Because again, we've got time and we've got different codes to use. I just learned yesterday that CMS is not wanting to allow any of these prolonged service codes in association with an E&M visit. But just the AMA is getting ready to address that. And it's one of those things that we'll work through and see what happens. But just kind of be aware of that may be happening for your Medicare patients. So here's our new prolonged service code. And it is really long. And I could read it to you, but I think better yet, I'm gonna tell you what it really says on the next slide. I will mention and note here, it addresses only level five visits. So basically it means you can only use this new prolonged service code with a 99205 and a 99215. The prolonged service code can be added beginning with the minimum time in the range for each code. So you remember that instead of one exact typical time, we now have a range of times. So for example, 99205 has a range of 60 to 74 minutes. You can report the add-on code beginning at 60 minutes. So you don't have to meet the end time. So 60 plus 15 is 75. For the established patient, the range is now 40 to 54 minutes. And if you've spent 55 minutes, you can report that one unit of each additional 15 minutes. Now this table you see kind of helps us understand when we've got one unit or two units of prolonged service. They have done that in the past. And this appears in the CPT book as a guidance so that you can know how to units for prolonged service. This is probably a good time to talk about how do we document time in the record? I did some audits over the summer where a physician was doing telemedicine and had understood that we could use the new approach to time for picking his level of service. And so he tended to say, I spent X minutes face-to-face with the patient and then X minutes non-face-to-face reviewing records and looking at tests. I think that was, frankly, it was a little confusing when I read it. I think that it's probably gonna make more sense for you to have a single statement at the bottom of your record that says something like total time on the date of the patient, you know, with counter with the patient was X minutes, including both face-to-face and non-face-to-face activities or something like that. That would be at the end of the note. Some of this of how we document this depends on how you do your notes. So in some of the medical record audits I do, folks will come back into that patient encounter, that day's patient encounter and update that they have reviewed the records and it appears in that progress note for that patient for that day. And if you do that, that's reasonable because you're updating your record at the end of the day and then you can update and document your total time. If it doesn't occur that way, we're gonna have to figure out how it gets, you know, figure out how best to get that in the medical record somewhere. It does not do any good to put it in billing notes or anything like that. That does not count as part of the clinical record. So you can't just, you know, it's like saying I circled that on my charge, my old super bill and that counted as clinical documentation. So it would not. So we'd have to specifically state that. I suspect that we will rapidly start seeing some recommendations from perhaps AMA, but certainly specialty societies, payers, et cetera, about what they expect to see in terms of time. To me, the biggest challenge here is going to be figuring out the non-face-to-face time. If you had a big bunch of records and you know, you spent 30 minutes reviewing those records before seeing that patient or afterwards when she brought them in her hand, then you know, you've got 30 minutes. But if there's a lot of back and forth with about testing, with calling the patient back. And again, you would have to be doing the calling. I can see that those are gonna be a little hard to keep track of, but I'm sure we'll adjust as we go along and figure out some schemes to make this all better for us. So my assumption is that for most E&M services looking at all physicians and all specialties, most of them will be based on the level of medical decision-making. Because sometimes patients come in and they're like doing okay and everything's great. Time's gonna be beneficial when you've got a lot of work before or after the face-to-face encounter, or you spend extensive time talking with that patient. Just like we use time now. Just remember, you can count not just that time, but also the time after the patient. So with that, let's practice a little bit. And again, I've gone through and done some interpretation here. And our panel has helped with that interpretation. You might have in your questions or your thoughts, some indifferent interpretations or questions, and we're gonna look forward to hearing those. And at this point, if Dr. Pullman and Dr. Schuster want to pop in at any point in chat, they are welcome to do that as I go through these cases. So let's take a look at Debbie. Debbie is a 48-year-old who's been treated for urge incontinence with UDS demonstrated OAB. She's happy with her current treatment and notices that her incontinence episodes have decreased by about 80% on her current regimen from baseline. She does note some dry mouth, but no other anticholinergic effects. She's read about increased cognitive issues that should be decreased. I'm assuming cognitive issues with long-term anticholinergic use and wonders if there would be value in trying a different medication. I guess I was hoping for an increased cognitive performance for myself. So under assessment, she's got stable urge incontinence on medication. She is concerned about long-term therapy. The plan was that reviewed with her differences between the various medications and B3 agonist talked about these issues related to cognitive issues, and she wants to switch. Her prescription was given. She was counseled on risk benefits and differences with her new medication. And she's going to follow up in six to eight weeks to determine the efficacy of her new medicine. So let's look at this from a medical decision-making standpoint. But let me also say, we really don't know how long this discussion was. So it could be that if time had been documented, it could have resulted in a different level for her. We'll, time will tell for that, right? So let's look at it from a medical decision-making standpoint. So first of all, I saw this as a stable chronic illness. She's doing well. She's happy with her treatment. She has a little side effects from treatment, but not anything really significant. We had really no data here. So even if we had just one test, it would have still been under the minimal category. When we move up, and so right now, excuse me, right now she is at level three for diagnoses, level two for mountain complexity of data. But when we move now to risk, we've got prescription drug management. So she turns out to be 99213. I'm going to go backwards. Because we are going to meet or exceed two levels. This patient actually originally also had diabetes, which was not being very well controlled. And it was discussed with her about maintaining good blood sugar. When we did that, we realized that put her at, really turned out to make her at a 99204. And which was kind of an interesting thought that we had. So we kind of made her a very straightforward and simple. She turned out to be a level three visit. And she would have been a level three new patient or a level three established patient. Abigail is an 82 year old with worsening dementia. She's requiring a LASIK. She's got poorly controlled diabetes. She's got prolapse. After her TBH about 20 years ago, she was fitted with a pessary for the issue and maintained it herself initially. But as cognitive function has declined and she's required relocation to assisted living, she's not removed it. Neither she nor her family recall when it was last maintained. And she was last seen in the office 18 months ago. So for this one, even before we get to our table, we would say that we had an independent historian here because clearly Abigail's probably not able to tell us everything we need to know. It could also have been that you had gotten information from somebody at assisted living as well. So over the past two to three months, she's noticed worsening vaginal discharge, vaginal bleeding. Her exam reveals the pessary in place with copious malodorous discharge. And when removed, there was about a five centimeter or greater than a five centimeter vaginal erosion and a small amount of bleeding, but no granulation tissue. So the assessment is a neglected pessary, a vaginal erosion and dementia. The plan is to remove that, start her on vaginal estrogen and discuss with the patient and family surgical options and to permanently treat her prolapse. So we didn't have any data for her. So she fell at a 99202, but that's okay because the other two categories can drive the level of complexity. We have an undiagnosed new problem with an uncertain prognosis. So this is something that she's not been treated for herself. We're not sure where it's gonna lead. We're also not sure what we're gonna do with her. And then when we go and think about the risk, that's our last place. We now have a decision for elective surgery, a major surgery with identified patient or procedure risk factors. And of course, she's got her diabetes. She's got her dementia and she's got some congestion. And she's got some congestive heart failure that I didn't even mention along with chronic kidney disease. So she's clearly at risk. However, she's gonna turn out to be a level four because for her to be a level five, we would also have to meet the data, either the data component, which we don't have here or our high complexity type of problem that we didn't feel like we had quite met that criteria for her. Now, Betsy is a 63 year old who had a TH late in the 1990s for endometriosis, subsequently developed prolapse and SUI. She underwent anterior posterior porophy, safer spine as ligament fixation and TBD placement in 2003. She did well for several years, but over the past five to seven years, she's noticed an increasing bulge in her vagina along with increasing symptoms. She underwent cystoscopy, which was negative and your dynamics, which demonstrate her SUI with their measurements, et cetera, et cetera. And now she comes in today for discussion of testing results and therapy for her prolapse and SUI. So she is stage three, prolapse with recurring issues. The plan was a prolonged discussion of the results of her testing and the implications of this testing for her urinary function, talked about all kinds of options, discuss those in details with benefits and limitations. And then also had a prolonged discussion about her prolapse and ways for treating that, including pessary use and surgical therapy. So talked with all this and she ultimately opted to have a surgical approach. So again, no data, that's okay. So that's a level two. So we're going to rely on her other two areas. She has got a chronic illness with exacerbation progression or side effects of treatment. So she's a great example for that. In terms of risk, she doesn't have the same type of risk factors that our last patient did for surgery. Again, everybody has a risk and every surgery has risk, but she was a solid 99214 based on diagnosis and management options. Both of those happened to fall in the level four place. But what about time? And what I failed to do here was to put back in our ranges for our time. So she's an established patient. So a level two would have been 10 to 19 minutes, but I don't think anyone describes that as prolonged. A 213 would be 20 to 24 and the 214 is 30 to 39 minutes. So for time to move us to the higher level for this example, would had to have spent at least 40 minutes with that patient. So in this case, if you spent a significant time with her, then time would be helpful to move it up to a level of service. But if you spent anything less, 39 minutes or less, time is not a help. I would suggest that everybody make themselves a little chart and I'm sure there will be some of them coming out from everybody all over the place that has these ranges of times for your levels of service. Remember, you can use it just for face-to-face counseling time like with this patient, or you can also use it for the time before and after for that patient that you might have looked at records or dealt with their testing results. We also have now Meredith, who is a 58 year old who presents with urinary incontinence, which is primarily insensate, but occurs with SUI and UUI. She also has a vaginal bulge, which has been present for two to three months. She has intermittent episodes of gross hematuria. She's had a radical hysterectomy for cervical cancer a few years ago and had radiation therapy, but she's been without evidence of disease since that time. She is hypertensive, continues to smoke. She's got a BMI of 42. We've got her exam that helps. Notice I haven't put exams and stuff in there, but we have some exams that helps us to identify other things for her, such as extensive atrophic changes and scarring probably from her radiation. And so she's got a stage two prolapse. She also has retention. She's got hematuria. She still uses tobacco and she is status post radiation for her cervical cancer. So talked with her about the needs for testing to further evaluate this. Rule out any recurrence of cancer in her bladder or any de novo bladder cancer. Talked again about the risk of smoking. Discussed options for her treatment of prolapse in detail. So once again, lots of discussion here. This could have been based on time or let's see how it would look with medical decision making. So this one we get to count low complexity for data. So let's start there because it's the order of each unique test and we've ordered two for urodynamics and or cystoscopy. And that's met that criteria for one of two and only two tests need to be there. And just let me say to get to a level four under testing, we would have had to have like three tests or independent interpretation or discussion. With external positions. But for complexity of diagnosis, we put an undiagnosed new problem with an uncertain prognosis. We really don't know what's going on with her. It's kind of like akin to the one with the lump in the breast, for example. So we are at a four for diagnosis, a three for data. And actually put her as high complexity for her surgery. But she's going to turn out to be a level four because we don't have two categories met under her high complexity. But we have one under four and we have one under five and that puts us down at a level four. This patient two might have been better or easily reported. But again, we would have had to spend greater than 39 minutes total with her. Our total on that day in order to move that up to the level five. So kind of in summary, the way we do things and for office new and established patients in 2021 is we're going to select a code either based on time or a medical decision making one or the other. We're going to document the history and physical, but it's not going to have any impact on selecting the level of service. So when I put your case examples up there, I just simply left out all of that stuff that had to do with review of systems, exams, all of those kind of things because they weren't going to contribute to the level of medical decision making. Obviously, some of those things contributed to what you knew about the patient and how you managed her. But we're not counting any bullets or not counting any numbers of review assistance. The time is going to be the total time on the date of service, and that's going to be of a real benefit when you're dealing with very complicated patients. And all of our other E&M services at this time are going to be key components or face-to-face time only. And this brings up a conversation about consultations, I think, and something for you to think about in your practice. If you are billing a consultation code, we know we have to meet the requirements for a consultation, but that level of service will have to be based on key components or face-to-face time only. The new patient codes, we get to count the total face-to-face time with that patient or medical decision making, and we don't have to worry about checking off the right boxes. So as the values for these codes come out and you assess the situation in your practice, some of you may determine that consultation codes in the office are not particularly as useful as they once were. We all know, too, that Medicare does not pay for consultation codes, and that's not going to change. And there are a couple of major payers around the country who've also stopped paying for consultation codes. So this is a good opportunity to take a look and see where it's going to work out best for you and to be able to report the code that's going to be made for the best medical record, as well as the best reimbursement so that it matches the work that you were doing with the patient. So with that, we're going to open up for questions, and I think that I'm going to get a little help with reading through those questions since it's hard for me to think and read. Okay, with that, we're open for questions, and we have members of the coding committee here. You can ask questions either via the chat or the Q&A button. Okay. It doesn't look like we have any questions, so we have a few to kind of get things started here. So do folks on the roundtable have thoughts on this question that we got previously on E&M since changes? Did someone read the question? For those of us who are on the phone, we can't see it. Sure, I can read it. If I see a patient and request prior records which show up three days later, how do I code for time spent reviewing the records, test results, et cetera, if it takes a long time on a separate day from the visit? Well, if nobody wants to take a stab at it, I think I'll take a stab at it. There are kind of two ways to approach it, and it sort of depends, from my thinking, it sort of depends on the nature of what you're reviewing and why you're reviewing it. So for example, a patient has a previous surgical procedure, and what that procedure was is going to affect either our testing or our future therapy. Usually what I tell people if we need those kind of records, I say, let's get those records and come on back and we'll sit down and talk about it. So I usually just put those records aside and review them with the patient or review them and then review them with the patient. Again, at the time of a follow-on visit, and I just code that into that visit. So that would be one way to approach it would be to just say, okay, I will put these aside and deal with them when I have a patient encounter. The other alternative, if it's something that's more pressing or something that needs to be dealt with more urgently, there is the code for time spent doing review of records. It's a separate code. Emily alluded to it. I forget the code number and I'm not at a place where I can look up that number right now. But there is a code that you can use for that purpose. And that would be the way to build that would be to build that under that code. I believe that code is time-based, but I'm not 100% sure of that. Joe, am I completely off the mark? No, I don't think you're off the mark. I think that's right. I think that the three-day window issue is the problem in this question is that in doing time, you still have to be within the date of service, I believe. So I think that's when you're counting time, you have to really understand the window of time for the code. Right. Because I think when they were thinking about time and particularly now moving into non-face-to-face patient time, that you would be reviewing test results and things prior to the patient coming into your office that day. Right. I think it's pretty clear that the modern times associated with that are really times on the day of service. Yeah. Okay. So let's go to another one here that we have on our little slide deck. If I discuss surgery with a patient with multiple risk factors and the patient decides to have conservative management, would that qualify would that qualify as high risk of complications? Because it was an option that was considered regardless of what was chosen. Yes. Well, and this also might be a situation where you would also want to clock your time. That you were in the discussion with the patient as well as all of their different test results, risk factors, et cetera for MDM and then compare which is the better system to use to pick your level. Yeah, absolutely. That's exactly the right way to approach it. Depending on how complicated and how many risk factors this patient had. I mean, if you talk to them all that time about having surgery and then because of their other medical health issues, they decided not to have surgery because of the risk of the surgery. That could be a very long conversation. And so I would want to compare both methods, at least in this first year until we get a sense of how these total times count up vis-a-vis what a face-to-face time number was in the old system. Because even though the times are larger for the different levels, in the new system, because you would be counting up all of the time that you worked on that patient and all their information that day, it could be a lot more time than you think fairly quickly, so to speak. Agree completely. Okay, let's look at the next one. Ah, is the global fee schedule still in place? Well, it is. Global fees still apply to surgical services both zero-day, 10-day, 90-day. The issue that we are still addressing in the entire House of Surgery, this is not specific to GYN surgical procedures or even OGS, FPRMS surgical procedures, is that the increased RVU value for work that was added to this standalone E&M code, so 9920, 99212 to 99215, did not get also included in the global surgical package E&Ms that are included in the 10 or 90-day package, and so that is something that all surgery is still working on this year with the new administration to try to fix that because technically under the Medicare law, same services are supposed to be paid the same amount, and so even though the office visits are included in the global package, they're still office visits, and they're still being performed as E&M office visits, and therefore they are supposed to be paid at the same rate as a regular E&M by law. CMS is making the argument that the services you provide during the global period are not as robust, in their mind, I'll use that word, as a standalone E&M. We would argue, I would argue, maybe you would argue clinically they sometimes are more robust because the patient has issues going on post-surgery, but anyway, the global fee schedule is still in place. The E&Ms are still included in global surgical packages, and you cannot bill separately during that 10 or 90-day depending on what the service's global surgical package is for office visits. So, yes. Is an HPI review of family history and a physical still needed to meet medical necessity? Well, you need to document what's medically relevant because that's not part of the, that's not part of the MDM process. So, you need to document whatever there is, whatever in the history or family history or ROS is relevant to you. But beyond that, I think, beyond what's clinically relevant, it's not required. Right. And this is actually an interesting question because this was a discussion point when the E&M codes were being reworked, is that the E&M code selection and information is coding, right, CPT coding. Medical necessity is really coverage. Right. And then there's also medical liability, right, when we look at documentation. So, even though the new system and moving to MDM or total time gets rid of the old 12 systems, you know, having to redo the family history and all of the characteristics every single time the patient came in. But still, if the insurance company wants to see some sort of medical documentation for coverage, which is really medical necessity or medical reasonableness, and or also you want to make sure you have everything documented if there was ever a medical liability need. As Scott just said, you need to understand for your own practice, what do you feel comfortable as your level of documentation in these areas of family history and present illness and other factors, H&P type factors. So, that's something, given that the body system way we used to do E&M is no longer required, you'll want to probably in your own practice, think up your own system of these elements that you feel comfortable would be good documentation for medical necessity and medical liability. If a patient decides on surgery during the visit, does the time required to write up their ORATP also count in the time component of non-face-to-face time? If I understand the rules correctly, and again, Jill, tell me if I'm wrong or somebody else tell me if I'm wrong. The time you spend documenting stuff in the EMR, it doesn't matter what note title it's under, it doesn't matter what section of the EMR you put it in. That documentation is a component of the total time you spent reviewing, considering, evaluating, examining, discussing or documenting with the patient. It's all part of the total time. I am looking in the book. It's always good to look it up. If you purchase or have access to at your institution, the professional edition CPT coding manual, there is a nice section in the front of the book that the pages are green. That's all about E&M coding, but it says time, the inclusion of time and the definition of levels of E&M services has been implicit in prior editions of CPT book. The inclusion of time as an explicit factor began in 92. Time alone may, beginning with CPT 2021, except for 99211, time alone may be used to select the appropriate level for the office or outpatient E&M service. Different categories of service use time differently is important to review the instructions for each category. Time may be used to select a code level in office or other outpatient services, whether or not counseling and or coordination of care dominates the service. Time may only be used in selecting the level of the other E&M service. Oh, so that's nothing. When time is used for reporting E&M service codes, the time defined in the service descriptor is used for selecting the appropriate level, that's the amount of time. The time personally spent by the physician or other qualified healthcare professional assessing and managing the patient on the date of encounter is summed to define total time. So if you're assessing and managing the patient, filling out all of their OR information would be part of managing their care, I would say. Yeah, preparing to see the patient, obtaining or reviewing separately obtained history, performing medically appropriate examination under evaluation, counseling and education, ordering medication tests and procedures, referring and communicating with other healthcare professionals, documenting clinical information in the electronic or other health record, and interpreting results and care coordination not separately reported. Yeah, a surgery is a procedure and we're putting information in the electronic or other health record. Yep, yep, yep. Thank you, Jill. If there's any other questions for the committee, please go ahead and ask now. Otherwise, we can wrap up unless the committee has any other questions that they want to bring up or discuss. Thank you. Thank you very much for joining us today. This has been recorded and will be available, I would say, probably by Tuesday online. You can access it there as well. Thank you very much. Thank you. Thank you.

E&M coding system

2021 changes

office visits

time-based coding

medical decision-making

level of service

total time

coding system examples

criteria for level of service

reviewing prior records

surgery discussions

global fee schedule