Welcome to the AUG's urogynecology webinar series. I'm Dr. Pamela Coleman, the moderator for today's webinar. Today's webinar is titled, The Business Side of Female Pelvic Medicine Reconstructive Surgery Practice, Basics of Billing, Coding, and Such. But we don't teach house officers. Our speaker today is Dr. Tanaz Farzandi. She serves as Service Line Chief of Obstetrics and Gynecology at Keck Hospital. She is also the Director, Division of Urogynecology and Pelvic Reconstructive Surgery, and Associate Professor of Obstetrics and Gynecology and the Associate Fellowship, Director for FPMRS, University of Southern California and LA County Hospital. Additionally, she has her MBA from Heller School for Social Policy and Management at Brandeis University. Let me just give you a couple of last minute reminders. The presentation will run around 45 minutes. We'll take the last 15 minutes of the webinar will be dedicated to Q&A. Now before we begin, just a few housekeeping items to review. This webinar is being recorded and live streamed. 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 tech issues. All staff will be monitoring the chat and can assist. Well let's begin. Thank you, Dr. Coleman. I am going to do my switch around and get my slides going here. Please, Dr. Coleman, if you can tell me when you see my slides in presentation view. Your slides are up. Great. Thank you so much. And thank you everyone for joining us. We were just talking. This is very awkward because I can't even see a single person. I have no idea who's on the other side of the screen, but it's good to be here. I am very passionate about this subject. And I changed the subject around like 16 times, including the objectives, because I think there's a lot to talk about. So I just want to kind of preface this by saying we probably will go the entire time. And the reason that there's a lot here is because we can't talk about one issue, which is billing and coding, without talking about the other issues that impact our daily lives as surgeons and clinicians. And so what I want to do here is kind of create a primer for you going into this so that while we may not hit every single thing in granular detail, it sparks an interest for you to go back and look at some of the resources that I will continue to highlight. And so without further ado, I don't have any financial disclosures related to this talk. I am a consultant for various companies. I have a really deep-seated interest in the business side of medicine and healthcare policy. And as such, I have been a member on the coding committee, the APM committee, and the finance committee for OGS. And I am also active in the American College of Surgeons Advocacy Committee. Obviously, we've been on a hiatus with the pandemic, but even that rolls into how we practice medicine and the ability of us to take care of our patients. So the objectives, there's going to be a time factor here. But again, I talk fast, I apologize, but hopefully we'll hit all of these pain points along the way. You know, so what are we doing here? Well, I've been in academics my entire career, and I got a real, real, real splash of cold water on my face when I first started. So the goal here is to give you some pointers on how to educate yourself before you graduate. Start reading, learning, talking to people, then some contract and practice pearls, things that you should have on a checklist, perhaps, things to look at and read up about. Then we'll dive into the basics of diagnostic coding and procedural coding rules and regulations, and how to manage your revenue cycle when you are out there and practicing. You know, this talk really was initially requested and geared towards fellows and our young faculty. Then how to manage your financial platform, and ultimately, ultimately, you have to invest in yourself. No one else is going to do so. So it behooves you to take this very seriously as you embark on your journey for this career. So why should you care? So I bring this up because my very first roundtable, it was at Augs, when I was like a fellow or a young attending, I don't remember. And someone said, why are you here tonight? You're an academic. And I was like, wow, I'm here because I need things. And then it really opened my eyes, and I actually got involved in the coding committee way back then. So maybe you are an academic, you are a salaried employee, you're a researcher, that's like your shtick, and you get salary support through grant funding, hospital-based practice, multidisciplinary, solo, military. Maybe you just got lots of money and you don't care. So if you're the last bullet, good for you, I wish I was there. But regardless of where you fall in any of these categories, the skies are pretty dark. It is a looming, looming horizon. And so here are some facts to ground us and keep our feet on the ground here in reality. We're talking about money. In 1970, in the United States, $100 billion of the B dollars was spent on health care delivery, which was about 7% of the gross domestic product. In 1990, that jumped six-fold to $666 billion, which is about 12% of GDP. Fast forward to 2018, we went into the trillions, $3.5 trillion. And this hovered at about 17% of GDP, and people were starting to freak out. The sky was falling. And then we know what happened in the last couple of years. We started looking at even higher numbers, 4.1. There's an asterisk here, because there was a lot of money that got funneled into health care that probably is skewing these numbers as to how much it actually costs, because the feds were printing money and giving it to hospitals to stay afloat and to practices. The other thing I wanted to bring to your attention, there was some data on the $3.5 trillion that was spent on health care in 2018. Only about 18% even trickled its way down to the physicians. So we're talking huge numbers here, but where are we in this big pyramid of chaos? So the top graph here, we're just talking about the GDP, just kind of highlights what I've run through. This one, the bottom graph, is where a lot of economists pay a lot of attention to. This is where the government looks at. They're talking about, why is the United States so high up there amongst most of the industrialized countries? So even back in business school, I had a beef with some of this data. The United States does spend a lot of money on health care. But if you look at all of these other countries that we are compared to, only one of them falls in the top 20 most populous countries in the world. We are third behind China and India. And then you've got a ton of other countries that are not even in here for us to be compared to. Some of these countries are smaller than some of our bigger cities. So it's very hard for us to talk about apples and apples, but that is the reality of who's making the decisions and the policies in this country. So we know what's happening on the national front. What's happening with us as doctors and physicians? Well, when I was younger and I saw my friends and their parents, or mainly dads at the time, there were a lot of them in private practices, and they were killing it. They were working hard, playing hard, making the money. They got what they felt they deserved. Well, what's happened in the last 20, 30 years is that we see that the private practice community is shrinking, shrinking, and shrinking. And you can see this here in the green, and that hospital-based practices and bigger enterprises are going up. Sorry about that. And so, you know, the thing here is that we're seeing kind of this skewed relationship between what's going on with physicians and practices. And we have our own survey data on that from OGS. But what's of interest to someone like myself is there's another player in this field, and it's private equity. I don't even know how that's going to roll out. What I do know is we're not immune to it. While I have friends in urology and ophthalmology that are getting better versed in what's happening with private equity, and they can give me their pros and cons anecdotally, we know that private equity is also stepping into the space for REI, which is our home base, right, OBGYNs. So this is that kind of quirky entity that we don't understand, and we probably won't for a little while. So how does this all relate to you? We talked about the badness that's going on on the national front, possibly even on the local front with how hospitals are growing in size and gobbling up practices, private equity is coming in. So this is your world and my world. My husband and I graduated. We had debt. We had debt to manage. We needed to figure it out, and we needed to figure it out well. Otherwise all the hard work that we did, we were just going to squander. Then you look at compensation. Compensation is not going up. It is only going to continue to go down, and sadly, you know, regardless of which graph you look at, and there are a lot of different groups out there that put these numbers out, and they're all basically similar. One thing is common, OBGYNs as a specialty are always at the bottom of the surgical specialties. I have yet to find a graph where we're anywhere close to some of our surgical counterparts, and in this one, our cognitive specialists are actually higher than us in some respects. So this is the reality, and then there's more reality. I mean, listen to the news on the way to work. Watch the news at home. We know that things are getting worse and worse with the economy. We're talking inflation. The feds are having to discuss why they have to stop printing money now, and the costs are rising up everywhere. Our salaries are going down. Costs are rising. You know that there's the great resignation that's going on. All of this is going to impact how you practice and how well you can deliver care, and then as you're trying to figure out where you're going to go with all of this, how much are you going to actually bring home to take care of yourself, your family, and even in your business life? You know, how are you going to provide care? You have to think about location, and this is something that you have to give a really hard look at. This isn't just location, location, location as in real estate. This is about where you practice. Where you practice actually matters. If you're in an urban versus rural setting, north, south, east, west, the patient population and demographic you're going to take care of, the hospital environment that you're going to deal with, all of this will actually factor into how you are able to then create a career for yourself and also some financial stability. First step, no matter where we go, you have to ask yourself, take a step back and say, what is important to me? So I can throw all of this out at you, but it's not a broad brush for everybody. It's not a broad stroke. You have to have a lot of self-reflection. What is it that matters to you? Because then that can drive how you address all of these things, time, money, and titles. Do you care about the space, academic prowess, global medicine, are you more into altruism? Do you care about the call coverage, what kind of a practice you're going to be in, and what is your work-life balance ideas? The first thing I would say after you have that self-reflection, manage your student debt. I can't impress upon any of my young faculty members or even my mentees. This is really important. There are different ways to manage your debt repayment, whether it's standard, extended, graduated. What I will ask you to do is consolidate things, but look at the bottom line. Look at how much you paid for your medical school education. You deferred that during training. And then look at how you want to repay that, because you have to look at the interest that's going to get compounded over the course of that timeframe that you're deciding, 10 years, 20 years, whatever you decide, right? So then you take a step back and you say, okay, I'm just picking on something. I bought this glass for $10, but I'm going to pay it off over 10 years, 20 years. At the end of that, was that glass worth $15 or was it worth $30? That's only something you can answer, but it's important for you to do this. And so I just have some pearls that I learned and I dispense, which is that no matter what your situation is, get organized, map out your loans, consolidate your federal loans. That's one simple thing to do. If you have private loans, get a broker. A lot of times I didn't have private loans, but I had government loans, but it allows you to use someone else that can help you navigate that. Repay your loans. A lot of the gurus will say seven to eight years. I will say, buckle down, see if you can get it done sooner, okay? Your paycheck will go up quite a bit from anything you're getting in training. So do something simple for yourself. This was my father-in-law's advice to us. Live at the standard that you're accustomed to. Don't go out and buy a brand new car. Don't go out and buy a brand new house. Don't add more debt to what you're already trying to whittle away at. You're okay. You can live comfortably in the manner that you have been. Hell, we've been doing it for so many years. Just do it for a couple of more if you can. Sock away the money. But you know what? Take a vacation. Like, do those little things for your wellness that is important, but try and manage your finances separately. Now let's move into contracts and stipulated compensation. One of the biggest mistakes I hear people say, myself included, when I started, was I looked at what am I getting paid? What are they going to write me in my check every single month so I feel like, wow, I finally got it in delayed gratification, be damned? Well, it isn't just about that. So I've kind of broken it up into these different categories. These are all the things that you should consider and think about as you're talking to your prospective employers. Educate yourself on these things. Ask these questions. Get everything in writing. No one is your friend. I'm sorry. I'm such a cynic now. No one is your friend. But what I mean by that is, you know, the next day, John Doe, who was sitting across from you and making all these promises to you, he's gone. You know, John Smith just came in and he says, I don't know what you're talking about. Get everything in writing. We as physicians tend to be very trusting. We do curbside consults. We talk to our buddies. Get everything in writing. I don't know why I'm saying that so many times, but it's important. First bulk, first set of bullets is your salary, incentives, bonuses. Understand what your base salary is. Understand if there is an incentive program. Understand if there's a bonus program. How do they arrive at those metrics? If this is a job, are you going to get a signing bonus? Are you going to get a relocation bonus? Is there a loan repayments plan in place? How are those incentives decided? Are we going to talk about RVUs, which we'll talk about, charges, how much you charge per month versus collections, how much they actually got back? And this is important because you can only control the RVUs to a certain degree as well, but you can't control the other things, and we'll talk about that. Grant funding. Let's say you are someone who loves research and you're hired to do research. Well, how is that going to play into your bonus salary and how is that going to be equitable with your colleagues in the department? Is there going to be a grant task? Are there going to be administrative fees? And then the other player out there along with private equity is bundle payments that are coming not from CMS, but for third party. How does that actually play into this as well? Now let's take that part, which is very tangible, and then go into benefits. This is the stuff that people forget is actually very important. This may actually be worth more than your salary sometimes because so much of this is pre-tax money. When you get out of training, you get into a different tax bracket automatically. And then all of a sudden that money that you thought you had is actually 40% less or 30% less because Uncle Sam just took a chunk of it. And then after that, if you're then going to go in and pay for your CME and all of these things, you're really going to be in a deficit. So talk about your CME. How does it affect your time, money, vacation, maternity, paternity leave? Do you get sick leave? I've never had sick leave. I came to this institution out in California and they actually have sick leave policies or they have sick days. I've never heard of that before. State licenses, all of the stuff that I call cost of doing business. Without these things, I can't perform my job. I can't deliver my care. So that is something you want to negotiate as part of your contract and it comes out of your pre-tax dollars. It's going to come out of your cost center. No one's going to give it to you, but at least it's not coming out of your own paycheck. Dental and health insurance, figure that out. Figure out how much that is going to save you and your family per month. That's important. The savings accounts they give you for benefits, healthcare versus dependent care, max those out. Do it carefully. Do it thoughtfully because a lot of it is use it or lose it. You don't want to be losing it. So do your math, spend some time and figure that out. And if you are a board examiner on a speaker's bureau, find out and make sure you have in writing how that will affect all of the above. Your incentive plans, your bonuses, your salaries, are they going to take a cut of it? You need to understand that. The next bullet, retirement plans. I have yet to find a financial advisor that will not tell you this. You have to max this out. This is in a lot of ways, free money. You've earned it, but it's free money, meaning that you're not going to get taxed on it. This is deferred. And then even more importantly, a lot of institutions or health systems may give you matching funds. That is really free money. If you put in $5 and they put in $5, take that. So maximize it. So you can do this carefully because the more you do early on, the better off you are later and you're not thinking that you have to keep working until you're 80 years old. The other things I just kind of threw in here, industry relationships, intellectual property, and even non-compete clauses, that's important. Because if you, for whatever reason, have to leave your job and you've got a very restrictive clause in there, you're hosed. Anecdotally, a friend of mine, neurosurgeon in the Midwest, had a very restrictive non-compete clause. And that institution did not work for a year because he couldn't. So understand those things because that does hit your bottom line. So the other additional asks in contract negotiations, I had a great talk with Dr. Ray Foster a little while ago. And he'd given a workshop a while back on all of this, and he had like an eight-page document. That's how detailed he got in trying to make sure that everything was covered. And so these are the things that I've dealt with as well, and so I just kind of put them up in categories. These are the things, while you're even talking to your new employers or revisiting things, OR equipment, understand what's happening in the operating room. That can make or break you. That can make or break your RBU cycle when you're dealing with cases. Talk to your OR lead, sit down, get your prep cards done, get your trays done, efficiency. So that's what I'm getting at there. In your office, all of this affects your workflow. All of this affects the ability for you to build and code for your patients. Don't make assumptions. I'm telling you, all of this stuff, I've made my mistakes. I made assumptions. Well, I'm walking into a certain type of a practice. Of course, they must have this, this, this, this, this. Well, they didn't. Or they had the wrong equipment, or it was broken. And then once you step through that door and you need to ask for things, trust me, the honeymoon's over. It is very difficult. So all of these things that I have listed on here, really important for you to look at and ask questions. Tell them you want to see the stuff, make sure it is what you need. And then you can negotiate that into your contract. Something as simple as your exam rooms and procedure rooms. Your workflow is completely dependent on that. If you are a, you know, enthusiastic, you know, you're a guy and they give you one room, by the time you turn that room over, you're going to see three patients and then that's it. Figure those things out. Ask people with a few gray hairs to help you see how they've navigated their own practices because all practices are different and you can learn from that staff. This is really important. And then I'm going to get to the really important mini grid here. Ask about the front desk staff. These patients, I mean, patients are coming, they either love you or hate you based on the person who said hello to them. And then by the time they get to you, you're doing a lot of recovery, figure out if they're going through a call center, go talk to the call center, tell them, hi, I'm a Euro guy. You don't know what a Euro guy is. Let me tell you who I am, what I do. And by the way, I'm different than urology because these are the people that are referring patients when they come through an 800 number, perhaps, right? And all of a sudden, all the patients that should be coming to you might be going to your urologic colleagues. You're trying to build a practice. You're trying to generate revenue. Surgical scheduler. I just talked to someone and he's getting tortured by the fact that he doesn't have a surgical scheduler that has the time to manage his patients. You can't go to the OR and have things canceled because someone didn't make it to the pre-op visit. You just wasted an entire half day, potentially. That's important. It's really important. Then RN versus LPN versus MA, can you get a scribe? All of these things work into your workflow. Ask about the scope of practice. At my previous job, my MA at one of my sites could do everything, including your dynamics, but at the other site, within the same hospital system, all she was allowed to do was room patients. It's important for you to understand this because that one person you have employed or the two people you have employed may have one hand tied behind their back, not being able to do what they need to do. And then finally, your advanced practice provider, APP, whether this is a nurse practitioner or physician assistant. I talked to Matt Barker. He's done a lot of work on this. He's created all these fantastic workshops we'll talk about as well. He's very simplistic in his view about this. Your bottleneck is your OR. Your APP can be that driver for that. That APP can help you see more new consults because that's what's going to get you to the operating room. We don't need to do things that we don't need to do. Your APP is your secret weapon. You have to decide for yourself the demographic that you're serving, the environment you're in, whether nurse practitioner unionized and PAs or not. You have to sort that out to see who will best serve your needs. And there are nuances there as well, but this allows you to work at the top of your license. And then you have to carve out, my particular practice was I would see all my own new patients. I needed to see them because very quickly I could decide, is this a surgical patient or a non-surgical patient? Because in my back pocket, I have all of my tools. I know what I can offer the patient. An APP may not have that. So what do you offer patients? What you can offer patients. You shy away from things that you may not feel comfortable with. So I just kind of feel strongly, but some other people actually use APPs to triage even their news. You have to sort that out for yourself. Post-op patients, I would have my APP see all my two weeks. We wanted to make sure they were doing well, pain was controlled, they weren't in retention, dot, dot, dot. So it was great because then it stopped all the numerous phone calls. We laid hands on the patient, they appreciate it. And then when I saw them at six weeks, I knew if there were any problems and I could either fix them, solve them or say, are they done? They can do your procedures again, scope of practice, but why would you spend an hour doing your, your dynamic testing? If you have someone clinically savvy that you've trained, send them to the courses and they can do that for you. You practice and you keep seeing new patients and in the operating room, depending on the environment you're in you can use them as an assistant or not. That is something that you tease out. So just want to put a plug in for the, the advanced on the APP courses, a lot of information, even on the website. I would ask all of you to take your time and look into it. Do not forget about operations waste, not want, not when we talk about cost, we have to look at our efficiency and our operations. Get creative, understand that your equipment costs a lot, share equipment, talk to your reps, make trade-ins, refurbish, look at your disposables versus your reusable. So I put this, I threw this up here because I was like my, I was like a gas when I saw this, this I found in an article, it was a large military group and they were looking at different types of speculums that they can use in their own clinics. And they did a cost analysis based on their workflow and their equipment use. Their yearly cost for a metal speculum was $209,000 and plastic was $319,000. They factored in everything else. So if you think this isn't going to hit your bottom line, it absolutely will, because this hits your cost center and what they're spending on you to do your job is going to come out of your cost center. So pay attention to these details. We don't have the luxury anymore of saying, you know, I'm just here to be a really nice doctor and take care of my patients. You've got to mind your own shop. All right, we'll take a deep breath, maybe I need to, and we're going to move on to building and coding. Okay. So we, we've done a lot of the pre-work as I like to say it, you're trying to set yourself up for success. We know you're well-trained. We know you're going to do a good job, but how are you going to get paid for doing such a fantastic job? Like I said, this was a primer and this is really geared towards our younger faculty and fellows. And so I'm going to throw a lot of stuff out. I don't know who's in the audience. Some of you can just take a nap perhaps, but this is to really get you to start thinking on these terms. Next week, there's a fantastic entire workshop on this from the coding committee, and they do a really good job and dig deep into the weeds about how to really build and code for all of these things. I'm just going to throw a few things out here to kind of wet your appetite. So I used to have this and I really feel sad. So this was my fantasy. I used to have this on my door. It was out of New Yorker and I found it online, so I put it in here. And it says, sorry, boys, but we're cutting back on bean counters until we have more beans. You know, you would think if money is drying up, they would get rid of, no. This is probably the reality of what I live with and probably you do too. The math often doesn't add up. And so again, I'm kind of deep skewering it in. You've got to be vigilant. You've got to be careful. Mind your own shop when you're doing your work because someone else is going to be looking over it and saying, oh, you're not doing enough. So billing and coding, it all starts with a very basic skeleton. I'm going to run through these because you know this, but it gives you the framework. You see a patient and you start doing the work. Then you document very accurately what you did. You convert that work into a numeric code. And then that code allows you to charge for the work. And then eventually you get reimbursed for that. It's really that simple and streamlined. So what you do is a CPT code and why you did it is an ICD-10 code. So you code what you documented. The basic terminology that we use routinely day in and day out, ICD-10, this is the diagnosis. Why did you provide the services that that patient is sitting in front of you? HCC is a little bit of a nuanced part of the coding. It deals more with the greater risks and complexity. It's more on the hospital side. CPT, these are the services provided. This is the what. What did you do? And then RVUs, this is what we all go for, it's the numeric value assigned to each and every CPT code that translates into work and money. This is the talk in itself because it is the most intricate process and the most convoluted process as to how CMS arrives at this value. And if we have time, we can talk about that as well. So ICD-10 codes, international classification of disease is the 10th edition. We were kind of late in the game getting the 10th edition now. We were on ICD-10 for a long time, but the funny part, not funny, but the interesting part was we went from a few thousand to 68,000 individual codes. And the reason for this was that they were really trying to better the ability to measure healthcare services, surveillance, and also kind of factor in some of the more advances that we had made since the last rollout of ICD-9. And E&M is evaluation and management, and these are also codes. So this is services in the diagnosis and treatment of illness, disease, symptoms. This is what's going on with that person. They're broad categories, right? There's an office visit, a hospital visit, or a consultation. And then you also have it subcategorized, and that's how I kind of put it in my brain. Is it a new patient, established patient? And if you do inpatient consults, is it a subsequent visit or initial? We don't do as many of those in our field. So when I first see a patient, the first thing I think of is, is it new or is it established? There's a three-year mark here. So let's talk about the new, and this is, again, another talk, but we are your gynecologists. We are subspecialists. However, we are not considered any differently than our OBGYN colleagues, which is very different than our gynecologist colleagues because they have a two-digit code and we do not. We are working on that. Why does this mean something to us? Because as like probably most of you, I work amongst other OBGYNs. Now if Dr. Smith found the hall, saw a patient, did her well woman exam, and Dr. Smith says, oh, go see Frisandi, you've got really bad prolapse, that patient comes and sees me. I have never laid eyes on that patient. She's never been seen in Uruguay, but because she came to me from Dr. Smith and we're all under one big tax ID, I can't say she's a new patient. So automatically I lose my revenue on that. This is different than Gynonc. I could send my patient because she has a pelvic mass to Dr. Jones who's Gynonc down the hall, but because Gynonc has a two-digit code, she can bill as a new patient. Those are challenges, support odds, we're working on it. Three years. So we know the difference between an established and a new patient, it's someone in your practice versus not. So let's say someone comes to you five years down the road. She was doing great, she had her surgery, but she comes back to you because she's got a recurrence of her prolapse or she's got a new condition that you need to see. If it has been greater than three years, she becomes a new patient for you. So you do have that ability. What I used to do is have the, when the MA used to get someone in, I used to say, last seen when, especially with someone that was seen by my predecessor, because when I took over a new practice here, I had no idea who was seeing me and why. And so they would put that in there. So I knew if she'd been seen by my predecessor more than three years prior, I could actually say that she was a new patient. Consultations. We don't do as many, at least in most of our settings, outpatient and inpatient. The criteria are very simple here. You need to have a request that has been documented by someone for an opinion. And then in turn, you have to give your consultant report as a written opinion back to the requesting physician. Consultations are touchy. Talk to your compliance people and your own billing and coding people as to how this works at your institution and or in your state and or with your payers. Outpatient versus inpatient. This is kind of a busy slide. What I'm getting at here is there are some really intricate rules about what an observation is inpatient, outpatient, talk to your case managers, find out who's working with you specifically on the OR side. We came up with a system where we made everybody off or an outpatient. If something changed, then case management would talk to us to change them to an inpatient because what we did is we worked with them and we found out because initially I would say everybody's an inpatient and then you can decide what to do because we didn't want to lose that revenue. The difference between an outpatient and inpatient can be tens of thousands of dollars. We worked it out with them, which was more efficient for the process and that communication was constantly going back and forth. Coding strategy, pretty simple. You code to the highest level of specificity. Only code the confirmed diagnosis or diagnoses, but you can code for signs and symptoms if you don't have a confirmed diagnosis. Code everything that you have even touched or managed because the more you code, the higher risk is. We'll talk about that. If someone comes in and I see that she's on a diuretic for her hypertension and that's affecting her OAB, but she's also a diabetic, she's uncontrolled, I will list all of those things down because they have affected my care of this patient, even though she came in with, quote unquote, just OAB. How do we get to all of this? It's mind boggling. I'm learning every single day. I'm going to the coding course next Tuesday because I keep learning, learning, learning. The only way I stay ahead is to keep myself armed with this information. I put this up here to kind of see how things have changed. My predecessors will tell you when the 90s hit them, it was awful because the documentation that they imposed on us was overwhelming. So in 95 and 97, they came up with these different metrics that we had to check out all of these boxes and you had to meet and I'll show you a grid to kind of impress that upon you. Fast forward to now, we're in a better place, a much better place. So let's see what we were dealing with. This is a very simple grid that I had made up for a previous talk back then about all the things that we had to know and do and document in order to meet the different levels of care. On the far left, you have your E&M level, one, two, three, and four, five, and in order to build for any one of those, you had to meet all of these criteria. Luckily, we've finally gotten past that and 2021 was the golden year. So what CMS decided, thankfully, was that it really should be patients over paper. We need to get beyond the fact that physicians and nurses are sitting at their computers with their backs to the patient. And so we can do it in one of two ways. One is medical decision making, medical necessity. You only have to do things that are appropriate and necessary. I don't need to ask about her bunion to check off a box anymore. That's not why she's coming to see me. Or we can do total time of day of the day of the encounter. And I think this serves us actually even better because while we may be seeing just one or two conditions, we have pretty complex patients. And by the time someone even gets to me, they've seen three or four other people and they brought, you know, the truckload of information for me to review. So the 2021 changes only affected the outpatient office visit codes. And these are the codes inpatients were not necessarily. There is no distinction now between two, three, and four levels, okay, on that far left column, same flat rate, level five desk will give you a higher column, but I would suggest that in our world, it's very difficult to get 11, five level five. We have to be careful. You don't want to get audited. Medical necessity is the single most driver. So the key provisions for the changes. So they've reduced the new patient codes to four levels. They've retained five levels of the established patient codes, medical necessary exam, and physical should only be performed, but that does not decide that code selection. Like that first grid that looked like my brain was going to blow up and time and medical decision-making definitions and criteria have changed somewhat. So again, lots of graphs, but everything will be available to you and I'll give you all the websites, but this is something that you have to see over and over and over again in order to really get a depth of doing this. And I would just suggest doing this and having these posted on your wall and eventually it will become easier, but I still review these things over and over again. So on one side, you're looking at three different elements and two out of the three need to be met for the level of medical decision-making. And then with complexity, there are four levels, it's either straightforward, which I would argue we should not ever be at that point, low, moderate, and high. So most of our patients should be hitting that moderate complexity. So time-based billing. This is something that I do want to touch on a little bit because it's very different than what we used to do. Basically they're now saying you can count the total time on the date of the encounter. So that one day that the patient came to see you, that may or may not even include counseling and care coordination. So it says the elevator of time contains the face-to-face and non-face-to-face time that the physician personally spends before, during, and after the visit on the same day. So to drive home that point, we now get credit for all the work that we were doing that we never got credit for. So when that patient brings in that truckload of papers from the 6,000 places she's seen and the 400 cases or procedures she's had, and all she ever knows is she had a bladder lift. And I'm like, I don't know what that means. That time means something now. So I can document it as long as you very clearly specify what it is you were doing. So the review of tests, the review of your documents, getting a separately obtained history, ordering medications, test procedures, putting all of this in the EHR, even communicating with the family patient. And a lot of us communicate with caregivers because we have elderly patients. So I created this little grid to make it easy. So we go to that old grid, which was like, blah, here we go. Much easier, cleaner. You don't have to have my grid. There are some nice, nice grids. I believe this one is still on the OGS website, if you go into that section. This is a nice, clean one from the AMA. I've seen others that really were a little too much for, you know, way too much information. This one breaks it down nicely. And then I also, having worked with the ACS on some stuff, they also have a website. And I thought this was almost a little cleaner once you get used to seeing the different things that you want to tick off. But I like this particularly because this was the risk. And this was helpful for me. Just touching on telemedicine, we all know enough about it. I'm just going to breeze through this. The reason I brought this up is because telemedicine is now coming out of the pandemic health emergency guidelines where CMS relaxed a lot. Check with your compliance people and your billing and coding people. We are still getting paid to do phone visits and telehealth, but they've changed some of the guidelines regarding the fact that, you know, during the pandemic, we were able to go across state lines, talk to people in different areas. Our state licenses weren't being held to that. Revisit that stuff. Because I literally had a conversation a month ago because we do transfusion-free procedures at our institution and we get people from Nevada and Alaska, et cetera. And so that's thrown a wrench in some of this. So just talk to your people. They know more than I do, but they also know what's going on on their home front. Synchronous versus asynchronous. I'm going to blow by this. Because basically we do real-time. We're not cardiologists who are interrogating machinery, et cetera. There is a guideline, but I would suggest that, you know, most of you probably have this embedded into your EMR. Just be very thoughtful about documenting how much time you've used and make sure you document whether it's a phone visit or telehealth. All right. This is the stuff we love. We're surgeons and we like to do procedures, okay? We are going to work at the top of our license. We didn't spend all these years, some of the most formative years of your life, getting trained to do this and not actually get the benefits from it. We love what we do, but it doesn't mean that we work for free. How do we figure this out? We've got to know the system. The CPT code. This is a five-digit code that describes the services. It's that what. What did we do? We have a CPT code for just about everything you can think of. An EMB in the office to the basic systole, a sling, colopexy, abdominal hysterectomy and a BSO. That has a one code if you do plus or minus, right? What if you do a VACHIST? Well, there are a few of those, okay? So VACHIST is not a VACHIST is not a VACHIST. It can be coded differently based on the size. It can be coded based on whether or not you remove the tubes and ovaries. It can be based on whether or not you did an NRC repair, learn these, put them in a Superbill, just put them in a Superbill of some sort, have a cheat sheet. So you don't have to go looking this up on Google every single time. RVUs. This is the Holy Grail in so many ways. Relative value units. So Medicare established an RVU for every single CPT code to determine reimbursement. Third party payers, the Blues and the Uniteds and whoever else, they tend to follow Medicare's lead. There are three components. I'm going to give you a slide on this because I look at it because you just have to like learn it. There are three components to this. There's the work, there's the practice expense and the liability. There are other features where adjustment for cost of location. And the goal here is that they want to drive us to doing more in the office space than in the really expensive spaces of like the hospital and maybe lesser to that degree outpatient centers. So they're trying to drive the patients into the office space because guess what? It's less overhead and less expense. So when we look at this as a whole, how do we get paid? Well we get paid based on the RVUs and then there's this nice little thing called a conversion factor. So we look at the relative time and intensity of the work RVU. What is the cost of maintaining your practice, which is your practice expense? And then there's this mishmash of throwing in where your geography is and relating that to your malpractice and your practice expense and your work RVU. So all of this gets lobbed into your parentheses and then you've got a nice multiplication table with something called a conversion factor. The conversion factor changes annually. And I can promise you this, I'm not going to give up my first born, but I'm pretty sure it's never going up anytime soon. So in 2021, I looked it up the other day, your conversion factor was $34.89. And in 2022, it went down by $1.30 to $33.59. This hits you hard when you start looking at this across the spectrum, because all that work you did, your conversion factor is going to bring it down from the previous year you did the same work. So little things matter. And when you scratch your head, start thinking about it based on this slide. So let's look at something very simple. Dr. Smith does an endometrial biopsy in his home state of Wyoming. And in the physician's office, he got paid $111. But then in the surgery center, he got paid $89.74. Well, he did the same procedure, the same work, the liabilities the same. So why is it different? It's because of the practice expense. He got paid less to do it in the surgery center than in the physician office. You have to think beyond the five digits. So we know that you have a CPD code that is directly related to RVUs, but then you've got all this other stuff that you've got to work on. You've got global periods. A lot of you are very familiar with this. There's bundling. You can't just go a la carte. This isn't cafeteria style. I want this, and I want this, and I want that. They're like, no, no, no, no, no. It's all going on one tray at the end. Modifiers, multiple codes. We do a lot of multiple procedures. I love telling my billing and coding people, I'm like, find me a few cases where I've only got one CPT code in there. That must have been an interesting day. And then other variables that affect your reimbursement. Global periods are broken down into minor and major procedures. There's a zero day global, 10 day, and 90 days. Basically I kind of say this is like a bubble. So a global period is anything happens related to that procedure is captured in the bubble. You're not getting paid any more for it. You did it. They already paid you, figure it out. So you do a sling, because I know that the sling is about a 90 day. You do a sling, the patient comes back two months later because she thinks she's leaking urine with cough and sneeze. You assess her for it. You're not getting paid differently because they're saying this is all part of the global package. E&Ms are not paid unless they are reported with a separate diagnosis and you need a modifier. So there is a way to manage that, especially if you are in a practice and you're taking care of a lot of different things, but be aware of it and be very clear about how you document and we'll see that happen in a couple of examples. How do you find your global packages? This came off of an ACOG website. I'll also give you a couple of guides that are really handy for having in your office. It's worth the money that you pay for it because this is how you will get paid. Understand your global packages. So I created this, I wish I had my old one, but I created this. These are the things that we do routinely. So I kind of know this, but you know what? I had this in my previous practice on the office wall because our nurse practitioner who's fabulous would see a lot of the Botox patients. We just wanted to make sure we never accidentally didn't get paid for it because if they come back and it's a zero global fee, I'm in global period. So if she comes back in two weeks, we can get paid for that visit and we actually get paid for the work that we did, which is different than the 90 day. And be very careful. I give you anecdotes because this has all happened. Be very careful that you audit your stuff because you may do the right coding, but someone on the other end that might be scrubbing your edits, sees that you did a procedure and sees that that patient with the FIN number comes in and they saw you within three months, they'll say, oh no, it's a post-op global. No, it may not have been. So this is really important. And I think I've said it a couple of times already. Become friends with your coding and billing people. Modifiers that we kind of alluded to. So CPT says that you have this inherent amount of counseling and the E&M code, so you can't build the GOES unless it's distinct and you have to put a modifier. So what can you use modifiers for like unusual services, something that was provided more than once, something was prolonged and really difficult. It's not related to the surgery or the procedure you actually did. Sometimes it's mandated by a third party. And then it also has a professional and a technical component. So again, a lot of information, but learn your modifiers. Make a cheat sheet. Understand when you can put these on. Some of these we use routinely. In clinics, 25 modifiers are going on so many different things. In our surgeries, we're putting a lot of 59 modifiers on. And then the one that I really want to bring to your attention is the 22 modifier. How many times have you gone in and you're like, oh my God, it took me as long to get the license of adhesions done than to actually do the procedure? Well, you're not getting paid to do hard work. There's no code for license of adhesions that you can tack on to your procedure. However, if you tack on a 22 with very clear information in your op note, whether you're talking about the complexity, the changes in the anatomy, how much longer it took you than average, you can potentially get paid. And when I looked back on some of mine, sometimes it's two, $300 more, which isn't for the work and the hair loss you had during the case, fine, but it's still something. But you have to be very clear about the documentation. The 25 modifier, busy slide, but here's the gist of it. Someone comes in with one condition, but you uncovered they have something else going on that needs your attention and maybe a procedure. Usually you're not allowed to do this unless you put a 25 modifier on it, okay? So let's look in our world. Ms. Jones comes in for an evaluation of her stress incontinence. She's post-menopausal, but on her intake, she says, yes, she's having vaginal bleeding. You're like, no good, let's do an EMV. So what you do is you tack a modifier onto your E&M. Say your E&M managed to get you a level four. So you get a level four E&M, tack on a 25 modifier, and then put your CPT code down for an EMV. So you get paid for all of the work you did. This hits us a fair amount, and I would say it hits our general colleagues a lot more. Multiple procedures, oh yeah, this hits us below the belt. Unfortunately, we don't get paid for everything we do even if we do all of it for the right reasons. You know, there's this tug and pull of like, we wanna do all the procedures and not bring people back, but you're not gonna get paid for it, but we still do the right thing. We want that patient under anesthesia only once. You need to know your RVUs. You wanna put the highest RVU first because you're gonna get paid for that, and everything below it is 50% or perhaps less. Example, you did a batch test, an RSO, NRCO repair, and a sling. I didn't even put the cystoscopy on the top because I'm like, you know, it's not gonna get paid. It's bundled. So is it the top one or the bottom one that's gonna suit your purpose? The top one, I just listed all the CPT codes. The bottom one, I paid attention that because it's a multiple code, I have to put these 51 modifiers on it. But this still isn't right because your cystoscopy is bundled into the sling. They don't care you did it. They're like, good for you, pat you on the back. You didn't injure the bladder. You're paid for the TVH, utero-sacral interseal, and then you'll get paid some for the sling. You've gotta make sure your modifiers are on there. Multiple procedures and the reimbursement, I just kind of threw this up here based on a case that had gone a while back. So we did a robotic supra-cervical hyst and a BSO, and then we did a robotic copepaxi. Well, you look at the RVUs and you look at the reimbursement. Well, your supra-cervical hyst was 800 and some dollars. Your copepaxi was a thousand something. Your total was gonna be about 1800, okay? However, you have to put your higher RVU first. That's it. And the reason we did that is because the secondary code is only getting paid 50%, sometimes less. That's a big difference between what you think you did and what you're gonna get paid. I also threw this example in because it surprises a lot of people starting practice. They don't care you use the robot. Good for you, you look fancy. There are no robotic codes. There are only laparoscopic codes. So this code, 57425, is a laparoscopic copepaxi. It is the same code for the robot. The hospital side, however, depending on the payers and where they are, might get a little extra money for the robotic using an S code. Unilateral versus bilateral, not much to see here. It really doesn't affect us, but there are codes for that. Again, it's on that grid. Co-surgeon versus assistant. You have to be mindful of this. If it's a co-surgeon, it's someone from a different specialty. If it's someone from the same specialty, it's only an assistant, and there's a huge difference in the amount that person will get paid. How do you know if an assistant is allowed? Go back to your grids, understand that, talk to your billing and coding people. If you work in a teaching institution, you will not get paid for the assistant. CMS is like, uh-uh, we pay your institution for having trainees. However, there are times, if they have protected time, they're unavailable, and you ask one of your partners, you put an 82 modifier on it with very clear language that someone qualified was not available. Procedure-only visit, this hits us a lot in the office with your dynamics. Everything else is built in. So if you spend an hour talking to them about the UDS, you're not gonna get paid for it. So why didn't you get paid? Poor documentation, didn't justify the procedure, didn't support the level, you didn't use the right code, you didn't file the claim, or someone didn't file the claim in a timely manner, missing documentation, please don't have this, even on the claim form, or it's not a covered service. How do you recoup it? Get to it quickly. Just bounce it back as quickly as you can, fix the problems, get a letter for reconsideration, but ultimately do it right the first time. I really would encourage all of you to get to the coding sites on the OGS website. There's a lot of information here. These fact sheets are the holy grail. Like I use them, I'm gonna use them for some of the cases I'm gonna show you if we have time, but we also have a Q&A section here where you can use this to send questions in and the coding members actually man these and vet these and get you an answer. Really important. It's a great resource. Eurodynamic coding is on there. Again, I'll run through these because these came off of the code sheets and I don't wanna waste time doing it, but really understand how to code this with the RVUs, which ones need a modifier. And certainly if you need to use a modifier 25 for a separate billing visit. Pest recoding, you can code for a pest refitting, but you can also code for irrigation. If you did it, you did beta dine irrigation, but make sure you document whether or not there was some vaginitis, et cetera, and put that in your E&M as well. PICS-PICS codes, important for you to talk to your billers and coders because these, you can actually get paid for the supplies you use. PTNS, another one that we do. We know that Medicare has certain guidelines as to how many visits that they will in fact reimburse for. Most payers now are in fact also covering PTNS. I know years ago, they said it wouldn't, even though it was published data, they said it was experimental. And finally, I think the AUA actually beat them down to it. Sacral neuromodulation. A lot of us do this. Stage one, stage two. Make sure you know your global periods on this. Very important. If you're doing a stage procedure to add your modifier for stage two as a 58, this is a stage procedure. You want to make sure you get paid for it. And the websites, I got these off of the two websites, the Medtronic and the Exonix website. They have information there. They also have good codes that you can create a cheat sheet for, for what's happening in your clinic. So I think I'm going to breeze through just a couple of cases that I want to highlight. And then I want to close out with some of the scarier stuff that is going on, because I'm just looking at the time. I know we started a little about five after. So I'm going to skip through this one actually. And I want to go jump through to this because this is a procedure that we do a lot. And I wanted to highlight something that is available to all of you. It's the OX coding today tool that you can get. And this is why it's a beautiful thing. I went through a lot. And like I said, I mean, we need more time and we need a couple of sessions, but I wanted to just kind of scare you into also making sure that you understood no one's going to look out for this except you. So I go to the OR and I do a DNC, a LAFORT, a posterior repair, a perineoplasty, a mid-uricle slaying, and a CYSTO. I don't know. I've forgotten everything I just learned in my coding workshop at the last OX. You can plug in all of these codes into this bundling matrix and it beautifully shows you this grid. It tells you what you can bill and what you can't. And even better, it tells you what is never allowed and what you need modifiers for. Another example, you did a super cervical HYST, BSO, PEXI, slaying, and a CYSTO. Again, throw it into your bundling matrix. I know that that CYSTO was never allowed because they say, uh-uh, that goes along with your slaying. But guess what? Her PCP called me just last night and said, oh my God, I totally forgot. She's had hematuria on two urinalyses I did. Well, luckily I'm taking her to the OR tomorrow or whenever, and I know I'm going to do a CYSTO. Because I am doing her CYSTO, even though it's bundled in my 57288, because I know I'm doing it for another reason, I put a modifier on it, which is 59, and I link it to the diagnosis code for asymptomatic microscopic hematuria. I will get paid for that CYSTOSCOPY. But you've got to be mindful, you know, cross your T's and dot your I's. Another case, just kind of demonstrating this beautiful bundling matrix. You did a vagus, uterus, sacral, MUS, and CYSTO. Here you go. It tells you where you need the modifiers. And I wanted to highlight this, because we went a long time where CMS was saying, mm-mm, that uterus sacral that you guys spend a lot of time doing and worrying about the urinal injury, that's bundled into the vagus, because, you know, general OBGYNs do this all the time. And OBs really fought to get that modifier back on. Because we had to prove that as specialists, we were doing a slightly different uterus sacral, and it carried a lot of risk with it. And we were managing that risk. So now that we can put a 59 modifier, you'll actually get paid for doing that hard work. So let's put it all together. This is the stuff that we've been talking about. It's about doing the work, accurately recording, converting, and charging, and receiving reimbursement. Your reimbursements are changing. This is the part that's going to be yucky. Fee-for-service is a dying, dying horse. It's going away. We just don't know how. There are a lot of different things in the mix. What we know is there are going to be value-based payment models out there. What does that mean? They want high quality. They want low cost. You may not be able to control cost in your tiny little microsphere of the world, but you can control your waste. You know, people talk to me about lean and all that. Control your waste. Control your efficiency. How does this look? People argue all the time. Well, we need a single payer. We need mandatory. No, listen. All of these are done in countries, like I said earlier, you know my bias, that are smaller than most of our states. What we have is the value-based programs that have been moving and chugging along this path. We're looking at payment models. We're looking at how to bundle things. We haven't sorted it all out, but it's happening. The genie's not going to go back in the bottle because ultimately CMS is clear. We need to take better care of individuals, better health for our population, and lower cost. It's not going to be per tick. It's going to be bundled payments for episodic care. Kind of think of that bubble again. It's all going to be captured. And if you decide you want to order 6,000 tests and get three ultrasounds, two MBs, and get a chlamydia test on your 90-year-old, go crazy. They're just not going to pay you any more for it. They're going to say, you guys figure it out. So you and your anesthesiologist and your hospital and whoever else even touched that patient, this is all you're getting. We want quality for the money we're getting. So we have to start being very careful about doing what we do. Maximize your revenue, study your workflow, billings, make super bills, reconcile, self-audit, self-audit, self-audit. This is the scary part. It's not going away. This is just recent. The chickens are coming home to roost. The money has dried up. The pandemic is quote unquote over and hospitals are seeing huge, huge deficits. And I can assure you, you're not getting the pay raises while they're getting the deficits. And you're not going to get the resources as they're seeing the deficits. And this is what it feels like on most days. Be vigilant. These are my takeaways. We can make a difference. We have to do the work. Take a breather, stop, manage your finances, manage your own backyard, manage your office, manage your awards. Before you start the first half of the talk, get a contract lawyer, get an accountant, get a financial advisor, understand what you're getting into, get it all in writing, protect yourself. Once you get started, operations, waste and efficiency, personnel, charges and receipts, your RBUs, accounts receivable. Why is it taking so long for you to get your money? Figure that stuff out. Don't allow them to throw out denials. It's easier for them to deny it. You know, say, we're just going to write these things off. And this is the slide that I started talking about when I was in business school. I was like, the ivory towers are crumbling and the only people that don't know that are the ones in the ivory towers. We can't practice medicine the way we've always practiced. It has changed and we have to change with it in order to survive and continue to do what we decided to do, right? Take care of our patients. So this is that moment of take a pause, stop saying you're too busy, look at your resources. There are a lot of resources out there, but if you keep doing what you're doing in an inefficient way, you're not going to succeed. Tons of resources. This is probably going to cause a seizure. Tons of resources. Find something. I don't care that you're in academics and you're a salaried employee. Your bottom line is still going to hit you hard. If you're in private practice, you know most of this. You're living and breathing it. Look to your colleagues. I talk to my colleagues on a regular basis. We bat around ideas. We vet our issues. We do all of that. I want to thank all of these guys because over the years I've learned so much from them and I continue to learn. I want to thank the Oggs Coding Committee and Ms. Rathburn because they really have educated a lot of us and they continue to do so much work behind the scenes and my business compadres who I keep in touch with all the time. I thank you for your attention. My email is up there. I really want to encourage you to go to the coding workshops that we provide. ACOG also has a very good coding workshop. The OBGYN coding manual is really good. It's really good. And I'll stop there, but I'm really passionate about this. I thank you for your time and I know that we are right at the limit. So I will stop sharing my screen at this point, Dr. Coleman. Thank you so much, Dr. Fasandeh. I mean, you deserve all the A's. I mean, really it was, I have so many questions and chats and not some of them are questions but some are just really applauding you. Oh, thank you. Everybody can take a deep breath. I talk fast and I told you I cut out so many slides but there's just so much that I just want to make sure people get and we have to take care of ourselves. You were amazing. You were awesome. I think you have made all of us accountable tonight. A few questions. I mean, one, I guess, overall question. Is your presentation or your slides, will they be available at some point? Yeah, I can absolutely make them available, sure. And you know what I might do and not to like, not to overload it. I will give kind of my more original slides. A lot of them I actually hid because I knew that I would run out of time. So I will include all of that in a format and I will make sure that the August education group has it. Thank you. There were a couple of questions. I know they're like a little bit specific but maybe you can just sort of touch on them. The 22 modifier, there was one participant that was concerned, how often do you use it? And they heard that sometimes it delays reimbursement and you know, how do you go about that? First question is, you use it very carefully. They're not stupid, right? They know that you're trying to get as much money. You use it very sparingly, but you know, I mean, this is the way I look at it. You know, we all do difficult cases. We didn't go through all of this to do the, you know, the chip shop cases, right? So my husband actually said it best, he's awesome. And he said, you know, every now and then in that case you have that moment of despair where you're like, oh my God, am I ever going to get out of this? You know, that that level of a complexity case is much more than your average. And I use something like that to say this really was above and beyond what I do. Other times when I know I'm getting into deep doo-doo, I look at the time and I get in there and I'm like, God I don't even know where to put my next trow car. I look at the time and I'm like, all right I'm going to document how long it took me to get all these adhesions down. And then I look at the time again and I document how long it took me to actually do my Colopex C. And I put that in there. You're 20, so it's really important to be very judicious about this. You cannot use this willingly. It's like the boy who cried wolf, you know you're going to get caught up in it. Now, that being said, a lot of payers knee jerk, knee jerk will bounce right back to you, right back to you. You've got to be armed and ready with a cover letter and your documentation should already been done the first time, right? You put it all in there. And I would say a discreet paragraph at the bottom of your op note, very clearly saying this case took this much time, blah, blah, blah, blah, blah. So it's not buried in your note. You can do all of the descriptors, but make it discreet and then have a cover letter that automatically goes back. But be very careful, these denials come back and I have caught way too many people saying the hospital would rather write things off than fight for some of these things. But guess what? It's going to come into your, it's going to come into your Excel spreadsheet if they don't collect that reimbursement for you. So good question on that, yeah. Thank you. So I keep hearing the word documentation, documentation, documentation. You know, even from medical legal, like those of us who do expert, you know, I've been in a position where I know a couple of the colleagues that have been in a kerfuffle. I know how good they are, but if it's not written down, you can't do anything about it. So thankfully, I think most of us are really good at documentation and be careful with your EMRs and dot phrases. Always put something in that distinguishes this patient from the other four people with prolapse you saw that day. It's just little things like that, yeah. Right, I think it's really important. I mean, some of the fellowships coming out may tend to undercode. Can you speak to that, undercoding? So interestingly, CMS considers undercoding fraud just like it considers overcoding fraud, right? It's kind of a weird thing to wrap your head around, but fraud is very... Can I give you my one anecdote? I remember self-auditing. I was barely like four years into practice and I remember thinking, you know, I did a few TLHs. Why are none of them on my sheet? And I had to dig into it and I had to get all this information. This is what I realized. The people who had been scrubbing, even though I had put TLHs down, they had been scrubbing it on that end. They looked at my op node and because I had delivered the uterus to the vagina, they said, oh, she did a laparoscopic assisted batch hits. That's called fraud. Because if I ever got audited, I had done something, I had built for something, and then it went out to CMS as a completely different charge. So you've got to be very careful. Work with your compliance people. I mean, they are so happy to talk to you. Physicians never bother to go down into the bowels of the hospital and talk to them. Go down, take a cup of coffee, meet with them. They need to see you face-to-face. Then all of a sudden there's a person behind that op node, not just some, quote, greedy doctor who's trying to make money. You get what I'm saying. You know, it's like, it's really important to develop that relationship. And I guess I know we're, this is so, this is just awesome. And a lot of the audience would like for you to give this talk again at the general meeting. And certainly like you said, I mean, another thing is codes and things are changing all the time. So you really have to keep up with it. They're always changing. But there was a question with respect to telephone visits. Now that we're in these days of Zoom calling, telephone visits, telephone calling, if you call the patient about test results, how do you code for that? I think you do it based on time. Yeah, because the luxury we have with telephone visits and telemed is that it's primarily based on time. As much of the complexity and everything you can talk about, if someone's coming in for test results, in your node you'll be able to do your assessment and plan and very nicely categorize all of this. Talk about the complexity, talk about the test results, talk about the next plan, the next steps. In one of those grids, I talked about the risks. It's one of those bullet points, talking about the next step. Does she need surgery? Is she gonna have conservative management? And then you code it with your time-based factor on it. Well, again, this was just great. I mean, I started off in pirate practice and then went into academia. And I wish I had heard you like so many years ago. I think it would have been really great. I don't wanna scare everybody because I scare myself every day. Well, this was very thorough and extremely resourceful. I think you gave a lot of wonderful information and I thank you for the time that you put into this because I know it's a lot of time involved. So thank you. Honestly, I kept learning every time I dug into my rabbit holes of like, wait a second, I don't understand this. So yeah, I'm happy to give you the kind of the larger talk, but at least they'll have that information in front of them. Well, I'd like to say on behalf of AUGS, I'd like to thank you sincerely, Dr. Farzandi and everyone for joining us today for this webinar. And I just, someone just said, please share this with us. Be sure to register. We have some upcoming webinars in July and August. I wanna tell you all about. We will have racial and gender disparities. This will be in July 20th. There'll also be vulvar dermatosis on July 26th. How Physiology and Uruguay Interconnect on August 17th. And the ULITRA, what we know and how much we don't know on August 23rd. Thank you very much and good day to everyone. Thank you. Thank you, Dr. Coleman.

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