So, I'm Vice Chair of Coding for Augs. I work with Mark Togley, who's the chair, and I'm also managing partner of a private group. There's eight generalists. I do Eurogun. Then we have three nurse practitioners out of two practices. We're in North Alabama, and so most of my responses to things will be from the private practice perspective. I have no financial disclosures, however, I do serve with ACOG on the Coding Health Economics Committee, as well as the practice expense portion of RUC, and we'll talk about that in a few minutes. Anything that we talk about in terms of specific money is always, as everyone's already mentioned already, is always going to be related only to CMS. Anything beyond that would be an antitrust violation. So quickly for agenda, going through pearls of coding, and I personally think these first couple slides are the most important. We'll go through some basic scenarios of things in the practice setting, or in facility and non-facility. Surgically, we'll be doing it, looking at a few surgical modifiers, and then some post-op modifiers, and all these actually really pertain to people, and I don't think they quite understand like the post-op stuff, and we'll get there in just a minute. So the pearls. I personally think these are the most important things. Correct coding suggests the most accurate description of what you did and why you did it. If you'll always just answer those questions when you're writing it down. So that means when you've seen the patient, you've done all this before the patient leaves. You've already got it all in the chart. The note is finished, and so I heard earlier someone saying, yeah, at the end of the day we do all this kind of stuff, and I'm thinking, whoa, whoa, whoa, how can you do that at the end of the day? The patient's gone. You've already put in a code somewhere in terms of what you've built, or a 99213, or a 4, or whatever you've done, and you haven't written a single note. That's backwards. You should be doing the note, and then you code based on what you've written down in the note, and that's the hardest thing that we struggle with to get people to understand in terms of E&M coding. And then coding is different than coverage, and we see this a lot, I think, in the redneck state. The physicians think, well, this is all our insurance is going to cover, so this is what we're going to do. That's not why we're there as physicians. Coding is based on what is documented. It's not based on what their insurance is going to cover. So here's the one take-home point for everything, this next thing. Physicians will always do better financially if they're selecting their own codes, if they understand the coding process, and if they involve themselves in the reimbursement cycle. If you do those things, you're going to be maximizing your revenues for sure. ACOG teaches this when they do their ACOG courses across the country. I've seen it in our own practice. I see it when I'm talking with other physicians across the country. I got a phone call not too long ago from a girl who was changing practice from private practice into an employment model. And her opening statement is, yeah, I'm pretty frustrated because I'm only making $600,000, and I'm sitting here listening to this, and I said, well, you're probably in the top 1% right now. Yeah, but they're wanting to do it on RVUs, and that means I'm only going to make five something. And I'm thinking, whoa, whoa, whoa, yeah, we're missing the picture here. And so you've got to get involved in all that so that you know what's going on. If you are employed, here's some things, the little things that just from talking with other physicians and helping them out that you've got to watch for. When you're trying to figure out your contracts and how you're getting paid, what year RVUs are they utilizing in your contract negotiations? How frequently do they update those RVUs? What your conversion factor is for both your procedurally based things and non-procedurally based things? And then this is the little tricky one, what does everyone use as their global period? Is it the same CMS global period, or is it a global period where if you've operated on someone you've got to see them for six months before you can start charging the next RVU? So those are the little things that you've got to watch out for. And then I put this last sentence in on this slide again, just to really drill it home. Physicians are the ones responsible. You've got to select your own codes. You've got to understand how it works. And you've got to get in there and talk to your coders. You need to be able to talk to your people who's managing your receivables, who's looking at your EOBs. You've got to know what you're getting paid for. And if you do that, that's the very best thing you can do. So with that being said, all we've been talking about through the day mostly is how to get quality. And there's a difference between quality and quantity. We've all seen notes from physicians where it's eight pages, and all you know is they're 58 years old and they're leaking urine. I mean, it drives you crazy. And so the thing that the AMA looks at in terms of the quality is the medical necessity of the service. That is the reason the patient's coming in. That's what they want to pay for. It's not the volume of the documentation. And then the AMA's definition is what is a prudent physician going to do to take care of the typical patient? And typical is the key word in terms of dealing with CMS and with all of our governmental agencies regarding payment. So let's go to some examples. This is the one that everyone kind of gets bored by, but it's really interesting because we're actually having to fight through this right now. 72-year-old comes in complaining of vaginal bulge. On exam, she's got an anterior compartment defect, leveled the hymen. You counsel her regarding treatment options. She decides she wants a pessary. She drove in. You do a full new patient evaluation, and then you go ahead and do a pessary fitting on her that day because she's decided she wants to do that. So how are you guys going to bill it? So he says a new patient with a 25 modifier for the pessary. That's probably what I would do also. A lot of times in urogyne practice, these patients, for me, it's nothing for a patient to drive 70, 80 miles to come in. I just don't feel like it's right to send your 60, 72-year-old lady home to drive back over for a pessary fitting. Here it is. So here's the pessary fitting. So it's a 57160, that's the CPT code, the initial fitting. And then if you actually provide the pessary that day, you can use an A code, which is the 4562. But what CMS says is an EM code is not billed unless it's a completely different problem. I'm personally going to do what you said. If she's driven in that long a way, I'm going to do it. However, what I do from documentation is I'll do a full E&M code, or full E&M evaluation, and at the end, when you get to your N81.2, your diagnosis code, then I will have a full pessary fitting note. If you've got a procedure note that is different from the E&M, you're probably going to be covered okay. However, a lot of times in doing chart reviews, we'll see where people are putting the 25 modifier down, and what they do is, like for a straight cath, you go in, they get to the GU exam, straight cath was done. Well, there it is right there. That's the procedure. No, that's not a procedure note. That's probably going to be listed as part of the E&M. So, that's a good answer. So, she comes back for a check, feels like her prolapse is well-supported, take the pessary out, exam looks good, no irritation, no abnormal discharge. You wash and replace the pessary. She has a few questions. You answer those. You spend 10 minutes with her, most of it regarding pessary counseling. So how are you guys going to build this one? Okay, so the gentleman says you could build it as a time, or you could build it as replacing the pessary. Is that what you said? An E&M visit? A level three visit. Okay. Yeah, I think in this instance, you've got to report the appropriate E&M that was documented. So, it's really going to go back to how did you do your note. If you did it at the end of the day, and you're like me at the end of the day, and I'm trying to get finished and get home, it was probably a pretty brief note. Patient in for pessary, doing great. No problems. See her back in two months, or whatever. And so you've got, it's going to be dependent upon how you do the note. This exact question came in through the question and answer portion of the OGS website. My personal opinion, and this is personal, I'm not a professional coder, but just working with the guys at ACOG, we use, or they tell me to try to use your time coding, or your time valuation when you're having particular problems that just require a lot of counseling time. For me, I see more, this more as an E&M visit, not really a struggling with my husband left me, you know, just kind of counseling kind of stuff, you know, does that make sense? And I've had to talk with the fellows too, because some of the fellows at some of the areas in our community, they were coding, because it was so easy to remember, yeah, that was 18 minutes, so we'll code it this way. They were coding every visit as a time code, and not realizing that probably is not the smartest way to do that, and would get you in trouble with an audit. So I think if you can, always try to do the E&M with the appropriate components. And so the question is, what are the components? And these are the things that's hard for us as physicians to remember. So here's the easy, this is the quick and dirty easy way to remember this. 2-1-2 is going to be pretty quick, I don't even think about time. I actually go down to that very last thing, medical decision making. That's kind of the overreaching thing. I mean, it's hard to turn a yeast infection into a 9-9-2-1-4. But some people can do it somehow. So for this kind of thing, pretty quick, in and out, not having any problems. For me with pessaries, I'm usually asking about constipation, bowel disturbances from the pessary, asking how their incontinence is doing, asking about discharge, and so I'm meeting a lot of different elements in terms of review of systems. And so I tend to code these as 9-9-2-1-3, but every once in a while I have someone coming in saying, yeah, it's looking great, have no problem, you pull it out, looks great, slide it back in and they're gone. That's going to be a 2-1-2. I mean, it's just because that's the way you would make that note. But again, it's how the note was made, because that's what's going to be what's out there in front of the auditors. So she comes back, it's not working quite as good, and so you've got to refit her. You would be able to refit again. You can build that fitting pessary code charge, that CPT. And so what I've done right there is I've put down the two RVUs and payments for the 1-6-0, which is the pessary fitting, versus the 2-1-3, and you can see there's really not that much difference. The thing that's getting us in trouble, and that we are struggling with right now, I mean literally this past week and the week, in fact, most of you all probably just received surveys about pessaries, is we have a lot of people who's going to build that pessary fitting, the 5-7-1-6-0, with the 9-9-2-1-3, doing them both. So feels her prolapse well supported, denies any pain, speculum exam's normal, oh yeah, this one here, you irrigate the vagina using a 60cc catheter tip syringe. So a lot of you all do vaginal irrigations at the time of pessaries. When you're just doing a pessary check, your nurse practitioner might be doing it or something like that. Well, here's the thing, we're also, you probably got this same, in fact both of them went out, yeah, the vaginal irrigation questionnaire from the AMA last week also. Here's the thing, the long descriptor, so this is in the RUC database, and we'll talk about RUC in a second. Long descriptor is irrigation of vagina and or application of medicament, which that's a new word for me, for treatment of bacterial, parasitic, or fungoid disease. In other words, that is what Medicare thinks they're paying for. So this is like driving through the drive-through at the Mickey D's. You pay your money for your, what is it, Big Mac, fries, and a drink, and you get your food and you pull out and you get halfway down the road and you realize you didn't get your fries. And you're upset, and so then you've got to decide, I'll go back and get my fries or I'm just never going to go there again. We're kind of, the CMS is the Mickey D's, no, we would be the CMS, how would that work? We've paid for something, CMS has paid for something, and they're expecting it, and what they've paid for is that this washing out for a treatment of the bacterial, parasitic, or fungoid disease, are they getting what they've paid for? That's kind of the position that they're taking. And I would think, if you're just doing a pessary, I would say no, I mean, I would be frustrated with it. And so I think that's how most of the auditors are looking at that too. The vignette for this is this 31-year-old, the vignette though, this is how Medicare thinks that the typical patient is. In fact, that's the first question they ask you on the survey, is this your typical patient? In fact, this is the exact, this is what just went out last week. Yeah, treatment of resistant monelial vaginitis, who's used Genshin Violet in the last 10 years? Okay. So the time that Medicare thinks they're paying for with this is 10 minutes of pre-service time, 10 minutes of intra-service time, and 5 minutes of post-service time. That's what they think that they're paying for when we build this code. So basically, it's 25 minutes. Does it take 25 minutes to do, I don't, I can't imagine what I would do for 25 minutes. So that's the answer on that. So final thing is, that's why we had to do all the surveys. We got caught on this one. For the final rule 2017, over 50% of the time on the same day of service, E&M code was getting billed as well as those things. So that's what our colleagues are doing. I mean, that's their Medicare data. And so, that's why we have to spend a lot of time going through the surveys, trying to revalue these things. That's why we have to have a lot of time just going through education so people understand, hey, when you're billing an E&M visit, this is what Medicare thinks you're getting. So here it is. So this is the final thing on pest recoding. Initial fitting or refitting, use a 57160. You're typically not going to do it at the same time as another visit. Now some people, though, like this 82-year-old or whatever she was lady coming in, I mean, I'm not going to make those people come back. As long as you're saying, patient's driven a long period of time to get to this appointment, this seems appropriate for the best care of the patient, you're going to be fine with that. Any typical or subsequent follow-up care, use typical E&M visit coding. That just means you might need a little cheat sheet with just the quick bullet points sitting on your, wherever your workspace is, just laminate it, stick it right there to help you remind yourself how to code it. Yes, sir. Yeah, the A code is the actual pessary itself. That's a good question. So his question was, for our virtual people, is the 4562, is that the actual pessary itself? And the answer is yes. And then irrigation, I personally avoid use of that code, mainly because I just don't think that what CMS feels like they're paying for, I'm doing, and I don't want to cheat them. Just to comment on that, some insurance companies, I never really tracked and paid attention, but you'd bill the 57160 fitting, and then you'd bill the pessary code, and they would reduce the payment for the pessary code. I've seen it with IUDs, too, and I don't know if it's just a quirk with their billing system, but they should not be reducing the reimbursement. Jill, do they consider that a DME? That's kind of what I was- Yes, so the pessary code is actually paid through the DME benefit. It is not included as a supply in the 57160. So it should be paid the price that is on the DME supplier fee schedule. It does vary by state and region sometimes. So just like Bob, you were doing earlier this morning, it does vary by state and region. So it's not included as a supply in the 57160. So it should be paid the price that is on the DME supplier fee schedule. It does vary by state and region sometimes. So just like Bob, you were doing earlier this morning, it does vary by state and region. So it's not included as a supply in the 57160. So it should be paid the price that is on the DME supplier fee schedule. DME payments can be geographically adjusted as well, but there is a ceiling and a floor, national ceiling, national floor for each thing. So we can- A4562 is in the DME fee schedule supplier database, and we definitely can show you what the variation in payment is. And then you have to have a DME license as a practice. If you- Well, that's the issue. That's the issue. Right. If you're sending them out on a script, they get it right back. Yeah, there was a big, long string in terms of the private practice SIG, what, about four months ago regarding this. So I actually have been checking into it. We're working on that now since we're working through this family of codes. And yes, ma'am. Yeah. In Georgia, it actually says on our billing sheet, 57160 includes pessary supply. So I don't know if because of where we are, and that was different than when I was in Philadelphia where it didn't say that. And we often wrote scripts, and the patient- Is CAHABA? Y'all's- Well, no. CAHABA is there. Is there- Your subcontractor? Yeah. But the practice expense for the code, and Mitch knows this extremely well since he's looking at all of them right now, the practice expense for 57160 does not include a reimbursed amount- does not include a price of a pessary. Now that's something we've thought about when this family of codes came up for resurvey, particularly because of the DME supplier requirements, is should we just put the pessary in as a supply into the code and call it a day, right? So that makes me wonder if some payers have done it, which technically is incorrect. I mean, because it's not- there is no money in the code. Yeah, in those kind of situations, I would definitely send a letter to your- and I think it is CAHABA in Georgia, isn't it? CAHABA is your subcontractor. It's Medicare. It's CAHABA. And then when I was in Philadelphia, we weren't- for Medicare patients only, we weren't even allowed to put the 845-4562 code down. You can now. Oh, you can now. I know the preliminary stuff you did went in and that looked like the governor and some other folks, so- Okay. Yeah, this is a- In all honesty, those are the kind of things that the AUGS Coding Committee need to know about, because we can then, as a group nationally, have the power to say, hey, this is not correct. You're not interpreting this well. Those are the things we need to know about. So, yeah, if that kind of stuff is happening, we need to know for sure. Any other questions? Yes, sir. I guess just- so just in addition to that, maybe, if not specifically, I was a CMO for a Medicaid- managed Medicaid plan. And so the thing is, when you look at some of the- what they reimbursed, too, it's not necessarily based on any database. And so in certain situations, we found that we were losing money when they had the shipping and all that stuff. And so you can actually approach the payer and say, hey, you know, and show them that you're actually losing money. And we have gotten at least them to cover the shipping charge. So it's- so those are the kind of things- So, yeah, yesterday, actually, I was on the phone with Cooper Surgical, getting them to send our last grouping of pessary fitting kit charges with the shipping, without any time- I mean, all that kind of stuff. Because when we submit these, we've got to do that in about three weeks. We literally have to show them the invoices. So, yeah, that's a great thing to do. Yeah, and it gets that specific, and it's amazing. All right. Laparoscopic apical support procedures. We're seeing them more commonly now, especially with the advent of robotics. They're being done a lot of times preventatively at the time of laparoscopic hysterectomy. Graphs are getting used quite a bit. Revisions are more common. A lot of retrospective studies regarding the use of the meshes in this space done laparoscopically. And then I want to take a second to talk about this code right here. Vaginal vault prolapse after surgery. So, our apical suspensions on someone who's had a prior hysterectomy, and basically it's just vaginal vault prolapse. The correct diagnosis code for that is N99.3. So, the new ICD-10. That would be the International Classification of Diseases. Version 10-CM, which stands for Clinical Modifications. Intra-op, post-op, this is how they describe this code. Intra-op and post-op procedural complications and disorders of the genital urinary system, not elsewhere classified. How many of you think vault prolapse is a complication of surgery? I don't. And so, and our coding committee took that position as well. And so, we had four phone calls with the CDC, and we got nowhere. And they were very nice, so I'm not trying to malign them, but getting a code changed like that was almost, I mean, it's almost impossible. So, with that thought in mind, what their recommendation was, better educate your hospitals that this is not going to be a post-op procedural complication. So, every ASC you're doing, they need, the hospital needs to know when they're looking at quality measures, this is not a post-op complication. It just happens to fall in this N99.3 class. And Augs is having to, we just really got to educate the membership better. Yes, ma'am. When do you suggest using it? So, vault prolapse? Vault prolapse after surgery versus vault prolapse. So, if someone comes in with a POPQ stage 3 vault prolapse anterior apical issue, N99.3 would be the diagnosis code. So, what would you use for that code? Cystocele? Midline? Well, isn't there just vault prolapse? This is a vault prolapse. N99.3 is vault prolapse. That's the only one. Yeah, I think so. There is something called a vaginal enteroseal that I've seen people use before, but this is... I guess I've never seen it. I've only seen vault prolapse, not the vault prolapse after surgery. Yeah, well with the... That's the intention, is that if they've had a hysterectomy and they have vault prolapse, it's going to be the N99.3. Yeah. And some of that is a change from 9 to 10. Right. That's kind of the issue that we've been struggling with for the last year. So, yeah, that's why I'm saying this is really, really kind of important stuff you have to kind of know. Not only in terms of correct coding, but in terms of this could be a quality measure that your hospital is picking up as a post-op complication because it says post-operative complication. And so you're going to have to talk with your quality people. Is that fair to say that, Jill? Okay. And she's nodding yes. Okay. So these are the different procedures that we see. CPT codes for apical support. 57425, which is our sacrocopalpexy. There's your WRVU of 17. Abdominal sacrocopalpexy, work RVU 1672. The next one, the 57283, is actually your uterocircular ligament suspension, and levator myorrhophy. There's the RVUs for that. 57282 is going to be your sacrospinal suspension. And then the 426 down there at the end is revisions of any of the meshes or anything like that that you're having to do with sutures or anything like that. So I put those down because we're fixing to – oh, my bad. I forgot this slide. So all of these codes are 90-day globals, and if you have to go back within that global period, you need to be using a 78 modifier to let them know that this is related to the initial surgery. And then if you are having to do a revision, you can bill that 57425 as well as whatever you had to do to correct the defect again. You just got to bill them together. All right, so here's the thing that we see. 54-year-old, para 3, worsening prolapse, stress incontinence, BMI is 32, daily smoker, POPQ stage 2 prolapse, most of it being an anterior apical defect. She's desiring continued ability for vaginal intercourse and does not want to mess with a pessary. She's scheduled by her OBGYN for a total laparoscopic hysterectomy. The op note reports that the TLH was done with cuff closure and incorporation of the utero-sacral ligaments bilaterally into the apical portion of the vagina. Used a delayed absorbable suture, and you see the rest of that. So this came out just a week ago. This is in the Gold Journal. And so reading the bold part there, the K technique. It's a novel modification of the utero-sacral ligament suspension using a knotless barbed suture technology, rendering suturing easier and quicker to perform. And then they go on to describe how they do it. And it looks like they're running it through the utero-sacral ligaments and attaching it to the fascia there at the apex of the vagina. So how are we going to code that? I'm sorry? There is no code for laparoscopic utero-sacral ligament suspension. What he said was there's no code for laparoscopic utero-sacral ligament suspension. Are you all buying on that? Okay. So here are all our different options of how we can do it. Total laparoscopic hysterectomy 58570 with a 57425, which would be a sacral culpo. You can do that same TLH with a 57283, which is the vaginal utero-sacral ligament. Do the same TLH with the 280, which would be an abdominal sacral culpo pexi. TLH with a 58999, which is an unlisted GYN code, or you can do it with a 425 and use a 52 modifier, which means a reduced services. In other words, you didn't do everything that you would normally do. Or you can do it with a 22 modifier, saying you did just the TLH, but we did a lot more than what we'd normally do with just the typical laparoscopic HYST. So, those are all our different options that we can code. Who wants to venture out on that one? Which way would you go? Okay, so what he said was he would stay away from the 52 modifier and the 22 modifier because it's gonna change your revenue cycle. Oh, and the unlisted, all three of those codes, okay? And be honest with you, this question has come in, what, five or six times? So, this is the descriptor that Medicare looks at for the 57425, which is what I would call a sacral copopexy. Y-graft, laparoscopic entry, vaginal probe, peritoneum incised over the vagina, develop the vesicovaginal space, rectovaginal space. You have to develop the sacral promontory, attach it up there, that kind of stuff. We're gonna do a coldoplasty, watch your pre-sacral vessels, size your graft, get it all put in, close her up. Here is the 283, this is what Medicare thinks you're gonna get, that you're paying, this is what they think they're paying for. Open the vaginal mucosa, dissect anterior-posterior, retract your bowel away, identify the utero-sacral ligaments, grasp them, place our permanent sutures up high on the utero-sacral ligament. The typical utero-sacral ligament suspension that we all know, fully catheter, pack the vagina. Here's our 280, basically it's a sacral copopexy done through an abdominal incision, edges of the sling. Now these, I didn't make these up, this is straight out of the Medicare book, this is what they think they're paying for. Here's the 58999, and this one is interesting, and I'm gonna read this. You can claim unlisted procedure codes only if an existing code does not describe the procedure that you wish to report. And this is from NCCI, Correct Coding Institute, or I'm sorry, Correct Coding Initiative Policy. A physician should not report a CPT code for a specific procedure if it does not accurately describe the service performed. So all those that we just went through real quick, did any of those describe what was done in the case? I would say no. So it's inappropriate to report the best fit, which is what I highlighted there, unless it's accurately describing what we did. So this, in my mind, is the correct code. Believe it or not, you would list it with an unlisted procedure code. Now, to facilitate payment, you're gonna have to include your op report, and that's why I'm putting that down there before, and provide Medicare with what you think you ought to get paid for it and why. And believe it or not, they actually do really well with this. Now, I'm agreeing with you completely. It's gonna alter your revenue cycle, but this is the correct way to do it. So the question is, should we correct this or not? Because there's obviously, I mean, we got papers coming, we just put this out in the gold journal, that this is a better way to do it, it's quicker. I haven't seen any long-term data on it yet, but we're putting it out in the gold journal, we should do it. So should we maybe go and see if we can get a code that actually is describing what we're doing when we do laparoscopic apical suspension procedures? What would y'all say? Yeah? That's kind of why I say maybe, maybe not. And here's why. First off, it's gonna require a new CPT code, and that is a multi-month process, multi-year process. The last, is it two years? Two years. I can tell you the last CCA code change application I did took me about two weeks, it was 16 pages long, and all the data that you have to provide. Proposal, got to support this for widespread use, efficacy and need for the procedure, got to document it's different than anything else that's being done, which I think we could do that. However, here's the, and this is the big maybe not. It opens the door for review of every single code that was just listed up there. The whole family's gonna get reviewed, because they've got to figure out, well, if we're gonna do this, where does it fall in that family of payment? So, when you're sitting at the CPT editorial panel, and it's a table, it's shaped just like this, and a couple tables longer, everyone's sitting there watching you as you present this as to why it needs to be there. And you're probably the only gynecologist up there even knows what's going on, and they grill you. I mean, they want to know why we need another code. And it doesn't just happen. And then they're gonna say, well, if we're gonna put that code in that family, we don't think it's worth that much. In fact, that one might be overpaid anyway. And so suddenly, instead of getting a code that might describe what's happening in terms of our management of patients, we're actually losing money overall because all the other codes are getting revalued. And so that's kinda, that's why the last line, if CPT says, yeah, I think you're right, we need a new code, all they say is, here's the code. Then they send it to RUC. And RUC is the one that makes the decision on how much the code is worth. And that is, that'll make your sphincter tighten up pretty good. It's not just limited to looking at the codes for prolapse. They can actually go to other specialties and pull, okay, if we know this increase is gonna cost this much, they may pull urology or personal therapy. There's one pot of money in Medicare. And so if we want something, either for a new procedure or something, that means someone else is losing money. And ophthalmology doesn't like losing money, and orthopods obviously don't like losing money. So that's where the fight comes in. And in all honesty, they're all very nice. It's a great, it's been a kind way of fighting. I've never seen anyone scream or yell, I mean, there's some snide remarks every once in a while. And it's a very relationship-based kind of negotiation. So we have to be really, really careful every time we do that. So the RUC, as we were kind of talking through all this macro today, all I can think is what goes around comes around. Because back in 92, RUC was developed. And RUC was developed because before 1992, a doctor would submit a bill and Medicare would pay for it. Fee for service, you just write how much it was worth and you'd submit the bill and they'd pay it. And then they said, no, no, no, we're paying way too much money, we've got to figure this out. And so they came up with the way we're paid now. Now all we're doing is changing the payment system again. It's like we're just doing history all over. And so that's all I could think. Anyway, so the RUC bases the payment on three areas. The work component was what everyone knows about, that's the work RVU, which is about 50.9% of the value. The practice expense component's 44.8. The rest of it is related to insurance, your liability insurance. And really there's no change in that, that's a set fee. All of these values are then further adjusted by something called a GIPC factor. G-P-C-I, which is a geographic practice cost index. I can treat people a whole lot less expensively in Alabama than people can in California or in New York. And my nurses don't cost as much, so they adjust my factors up and down. In fact, the county that I live in in Alabama is the worst reimbursed county in the continental United States. That's why I'm on the practice expense portion for ACOG. Because I had to figure out, okay, what can I do to help myself here? And I couldn't gripe about it if I wasn't willing to jump in and help. Your malpractice premiums are reasonable also? Yes, sir. Yeah, we don't have that much trouble. But we also have a very strong legal system that doesn't allow for a whole lot of frivolous suits. It's not a tort reform state, but everyone knows that you gotta have a good case. Those malpractice reviews are headed by CMS. Are they? It's a methodology that CMS creates that attributes... Malpractice is attributed to each code based on the number of minutes that are in that code for the physician work. CMS updates the malpractice on a five-year schedule based on malpractice premium insurance that they get from state insurance commissioners. And so they take that and then they rate by specialty versus, say, a primary care. I know then, so OBGYNs, of course, have major factor adjustment because we have the OBs with us there. Urology has their own factor of adjustment. And so then they use that in the allocation methodology, your factor adjustment and your minutes, and then they give a little bit to each code. But the malpractice is only worth about 5% of the RVUs to a code. So it's very small, but if you've got a procedure with a lot of minutes and you've got a good factor, like some of the big, old-time, open OBGYN procedures, you might have a couple RVUs of malpractice. But most malpractice is under one RVU, maybe two. But your big numbers are in your work and your practice expense. Practice expense will be way higher. Mitch, you probably have this on your next slide. Way higher for office-based stuff if you have a lot of supplies and equipment. It's quite a bit lower for surgical codes because it's your practice expense in the global period, because your practice expense during the procedure is paid to the hospital. So just looking at our apical support codes, I went through the database real quick when I did the slides and pulled up the 57425, which would be our laparoscopic sacrocopalpexy. In the post-operative period, there's 72 minutes. So these are post-op visits, four. We got credit for four 99213 visits in our post-op period. And we have in that, as part of the practice expense, a light and a table that cost $8,000. So my question would be is if we got resurveyed now, how many of us are seeing our robotic sacrocopos back four times in the post-op period? Yeah, most of those people are going home the very next morning. So yeah, it'd be one and then three post-op. But it's still not 99213 visits, I don't think. It's not gonna be three visits. It's not gonna be three visits. And we're not gonna get a 213 visit from RUC for every one of those visits. They might say, yeah, I can see that that's a more intense visit post-op day five, but three weeks out from surgery, why is that as intense as someone who's three days after surgery? And so that's just gonna be a 212 visit. That's kinda how they think. So just in that one code, we would probably take a hit on that one code just because of the post-op period. So how do y'all wanna code this same exact procedure that we just did where we tied it into the utero-circle ligaments? Any of those ways? Any of that? That's the way I think it oughta go. Here's the one we were talking about with the 52 modifier, reduce services, 22 modifier for additional services. Yeah. Let me ask you a question, and maybe this is more, again, antitrust or anything, but with that description, if we added an unlisted GYN code, is that something that we could share as a society? It's not really saying how much to bill. It's saying how to describe it. In other words, you're saying if people were doing an unlisted procedure and it was this particular procedure, what would our comparator codes be? No, could we as AUGS write the descriptor since it sounds like we're all kinda doing the same thing? So would us sharing the way to describe 858-999 be antitrust or? No, that's a good question. We're not paying how much a charge. Yeah, so Mitch, what's the real answer? Okay, so yeah, I would do the 589-999. That's the real answer. And the reason you would not do the 52 modifier is because Medicare really, in fact, when they talk about this reduce thing, the ACOG course people teach this as if someone's trying to do one of the tubal, what do they call those that go, escher. Yeah, and they can only get it in one side. For those kind of types of things, and they're gonna cut it 50% if you do a reduced services thing. That's what CMS thinks is happening with that modifier. And then with the 22, we all have these patients whose BMI is 40 and we're struggling for hours just because obesity, that doesn't fly with Medicare. They say that's part of the typical patient. So the only thing, it's gotta be something extraordinary to get a 22 modifier in there. So yeah, the answer is, you're gonna cut it with a 99 modifier. So, yeah. So we just did a nice fact sheet on this issue that's now on the OGS website under the coding section. But I think we could also do a little packet to help people with their letter to their payer. That's a great idea. To put together, to then attach their op note. And also in that letter, give some ideas of crosswalks to existing codes in regards to RVUs that are probably good comparators to the work of this procedure. And people could then change that out if they don't agree, but at least get people started on a letter. Give them a template, so to speak, with areas that could be put in and out. And then we could also possibly do some sample documentation. We can do that, generic documentation. So let us take that back to the coding committee. That'll be a good project for the folks who worked on the fact sheet. Yeah, that's a great idea. Yeah, the 58999. So yeah, the big thing is, you just gotta watch your reimbursement cycle on that. You gotta be sure you know what you're getting paid. So how about someone who does a simple VAG test for prolapse. The op note describes clamping the uterostatic ligament, tacking it with a suture. Suture's incorporated in the anterior and posterior. It leaves a vaginal mucosa. So you're gonna code that as a vagus uterus sacral. And I have a confession. One of my partners asked me to help him with a case right before I left, and it was this exact case. And she was a stage three prolapse. I mean, it's like, okay. And so when it was finished, you know, I feel really uncomfortable in the OR saying anything in front of nurses. And so I'm just helping, and we got through the case fine. And afterwards, I said, John, I said, you just killed that little old uterus. I said, and that guy wasn't even causing any of the problem. You know, just trying to explain to him, this was a problem with the pelvic floor and kind of go through all that. And so I went and talked to our coders later. I said, hey, how did he code that? He said, with a uterostatic sacral. I said, uh-uh. I said, just change that. That's not what we did. And so even in my own practice, I'm seeing this kind of stuff. Now, the bad news about this is Medicare is seeing this too. People have figured out that, hey, I can build an apical suspension procedure and get paid quite a bit of money. And this was what got us into trouble with our codes that we didn't quite catch all of them when they went through the NCCI edits, what, 18 months ago, two years ago? And that's why, when NCCI sends, NCCI, just really quickly, the correct coding initiative is an organ, it's a, they're subcontracted by Medicare. And they send you a list. And it might be 40 sheets of nothing but numbers in rows. Row one, row two, column one and column two. And you literally have to go through each numbered pair and figure out what they're talking about. And when you get 40 sheets like that, literally, sometimes you're gonna miss one. And that's what happened. That particular code for the vagissus with the apical suspensions was in a completely different section on like 12 pages later from all the other codes we were looking at, thinking that was all that was involving us. And that's how we missed it. It wasn't on purpose, I assure you. But that's how these kind of things happen. Here's the definition for a 283, two non-absorbables up high. Those are the diagnosis codes. So really quickly, post-op modifiers. And this is, I kind of threw this in real quick just because of people. Yes, sir. I coded it as a vagiss. Yeah, in fact, it's funny. That exact question also came in through the coding committee last week. ACOG, in their description of the book of the procedure, and we're all having to do this for quality measures, talks about trying to do something in terms of support. But that is not a high uterocircular ligament suspension when you do what that op note described. And in all honesty, this is all one of those things where it's on the honor system. You know, we're trusting, or Medicare's trusting that we're doing the honorable thing. And I think as physicians, we need to for sure do that, but unfortunately, not all our colleagues do. So that's what gets us in trouble with people wanting to go in and say, well, why are so many of these procedures being done? And the first assumption is it's for money, and in particular with these kind of cases. So for people in academic medicine, your assistance fees, these are things you gotta worry about at Emory. AD modifier for assistant surgeon. 81, I'd never heard of that one. Have y'all heard of that one before? I just found that one this week. 82, if you're in an institution that typically will not use residents, or you have a surgeon who won't use a resident, you can bill an 82 modifier. 62 for two surgeons. And I didn't realize that you can, in our state, you cannot bill for physician's assistance, but most states, you can. And so if you just need to check with what your state laws are, and possibly check with your Medicare provider to see on that. So VACHES, anterior repair, assistant surgeon, typically is gonna get paid 16 to 20% of the allowed reimbursement. If the resident helps with the case, should the 80 modifier be coded? Yeah, you can't code, because Medicare is a federal plan, also pays fees to the teaching institutions, and they assume that this is part of teaching. So they feel like it's a double dip situation. So yeah, CMS will not reimburse for an assistant surgeon. They will reimburse, though, if there's not a resident available, and that's what this modifier is, the 82. Or if you've got an attending who universally will not allow a resident to operate with them, then that person can do that. You've got to submit a letter with that, and it affects your revenue cycle again. And then this is, yeah, so when a primary operating physician's doing a case, suddenly needs help just for a little bit. You can actually, and you just happen to be walking down the hall, I guess, you can walk in, help him, and walk out. Relatively short period of assistant, and they will reimburse for the 81 modifier, which was, I'd never heard of that until I was getting ready for this talk. Two surgeons working together, we see this a lot in Eurogun. The generalist wants to do part, and you do part. What do you think, can y'all do that? You can do it, but we're not getting paid for it yet very well. Some places are, and some, but the answer is we're probably not yet to that point. And this goes back to what Jill's talking about in terms of liability insurance. It goes back in terms of cost, in terms of practice expense costs. Whether we want to have this whole separate identifier in FPMRS, it affects these kind of things significantly. So it's not just a simple decision. Well, yeah, we could get paid for that. Yeah, we might get paid, but the whole cost evaluation at the end of it actually might end up costing us more. Aug's leadership, and that's well above my pay grade, is having to work with the urologists and everybody else on this, and it's a quagmire of decisions. Okay. Can I just ask a question? Yes, sir. You may not, since you guys don't have it in your state. So when I was a program director, I had to write a letter. It was kind of a form letter. Residents not available, so the attending would take that. But what happens when you don't have a resident available, but then you use the AES code for physician assistant? Do they still have to have, if they're going to bill for the physician assistant's time, do they still have to have that letter since you're a teaching program? I don't know specifically, but my gut feel would be it's not going to hurt to send it. It never hurts to send it? Yeah. Okay. That's a good question, though, yeah. I don't know how many people in our profession are going to use that AES model. I mean, I know that some other surgical professions use a lot of surgical nurses with them, thoracic surgeons bring them in. You know, I think we mostly, you know, would use an assistant surgeon or use a resident. I don't think we use a lot of nurse practitioners, PAs in the ORs. What's changing is we used to just hire them in the hospital, but now we're putting them in our employee practices. I think an easy way to handle that is, you know, just determine who your primary vendors are in terms of insurance. If it's CMS and maybe Blue Cross and just give them a call and you'll find out real quick whether that's going to be something you want to invest in. If it's going to be a new policy for the institution, then yes, work with each payer individually and get an agreement up front so you don't have to send a letter every time. Yeah. So the Modifier 24, these are services that are medical services that occur in the global period. So if a lady's got blood pressure problems and you change her, she comes in because she's got a headache and her blood pressure's elevated, that would not qualify for this because those kinds of medical problems they see as being part of taking care of the patient. Now, let them come in in a thyroid storm, that's going to be different. That's going to be something that's totally unexpected and not equivalent to your regular medical problems of sugar or high blood or something like that. So you've got to watch the 24 Modifier. The same thing in terms of 79 Modifiers. If it's related to the case you've done, you're having to go back to the OR, that's going to be a 78 Modifier. If it's an appendicitis that's incidental, that would be the 79 Modifier. These are the fact sheets. Jill was mentioning those. So pessary, slings, the taxonomy code that we were just kind of briefly talking about. There's great fact sheets on all of those things on the OGS website. And I tell you, something that is really good is that one that's at the very top, OGS Coding Today. We can get a free trial of that. Just call, ask for Mitra. Either Mitra or Colleen could do that. And you can get it 30 days for free and it's really a great service. I don't know what it is after that in terms of expense. I don't think it was that pricey. It's a couple hundred dollars after that. A year. Yeah. It's basically a repurposing service. So if you don't want to search through all the NCCI edits on CMS's website or you don't want to look up your fee schedules on CMS's website or you don't want to look up Modifier examples like Mitch has on his slides, it's a good sort of place that, it's a good subscription service that will, that basically has sorted through all that information for you. And so if you've already done that, then it's not as good a value. But if you don't want to spend the time to do that, then it is a good value. So it's all information that's in the public domain. It just pre-sorts it all for you. And if you're just trying to kind of audit what's going on, which I would recommend you do, if you got a coder that's in a different part of a building and you don't really ever see them, you're not sure what your EOBs are looking like, part of getting involved in your own revenue cycle is to audit what's happening. And if you just want to spend it for one year to be sure that your coder's doing what they're supposed to do, it'd probably be worth the 200 bucks even if you had to pay it, because you might be losing thousands and not realize it. So I would highly recommend it. And then Augs also has a section in that same portion on the website for questions and answers. Mark Toglia and myself pretty much handle all those questions. Coding committee members work through them initially and come up with what they think the answer is. Then we work with them to go through it. For full disclosure, none of us are certified coders. We've just done it a lot. And if we ever have questions, we go to certified coders. We are working on more of a easier way of getting those questions in with a template. I think Colleen's working right now with Steve Metz on that, isn't that right, Colleen? So hopefully here in the next couple months, we'll have that up and going and it'll be easy to get those questions inputted. Typically it takes about three to five days to get the result back. And I think that's about it. I put this slide in. I live in the country in Alabama. And for me, it's all about balance. I could work from five in the morning till seven and eight at night every day and make more money. But I have to kind of back up and say, you know, why am I here? And for me, a lot of times it's just the simple things in life. And so for us at our house, the dogs are the things that are real simple. Our kids are grown and gone. And so as y'all kind of go through your decision-making process for MACRA and how much do we want to invest in this and that, I would just encourage you, figure out what the most important thing is in life and then make your decisions based on that. That's all I got. Thank you.

coding issues

apical support procedures

accurate coding

reimbursement

laparoscopic apical suspension procedures

modifiers

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fact sheets

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