Good evening, everybody. My name is Steven Metz. I'm a doctor and an associate professor at Tufts Medical School. I work at Baystate Medical Center in Springfield, Massachusetts. I did my residency at the National Naval Medical Center in Bethesda, Maryland, and a fellowship at the University of Louisville. For the last 25 years, I've been in teaching faculty at Baystate and also serve as quality assurance and risk management on their committees. I want to welcome everybody to tonight's webinar. It's entitled, Your Gynecology, Coding, and the New Age. It's going to be presented by Ms. Jill Rathbun, who's managing director at the Galileo Consulting Group and has much experience in this area, and I know you're going to enjoy what she has to say. I'm going to open this conversation with discussion of coding, and she's going to pick up with the discussion of the new coding initiatives. A word from our sponsor. This program has been put together by the AUGS Coding and Reimbursement Committee. We exist to be a reference to the AUGS membership to help with problems in this area. However, and this is a big but, we can't guarantee that our interpretation of the issues you refer to us are the same that the third-party payers may come up with. I have to point out that just like the IRS, third parties, especially private payers, may have different ideas than we do. Ms. Rathbun and I are just working steps. We don't have any outside interests. At this point, I need to, these are your learning objectives which you saw in the advertisement for the course. I do need to admit to some limitations. There's no way that we could condense a two-day course on coding into just an hour. Our objective here is really to give you an outline of the coding process and to point out issues that you might want to research more fully. Believe me, if this sentence comes as a surprise to you, it's a good thing you're here with us tonight. These are basic rules for coding. Unfortunately, sometimes people forget these rules in both directions. If you undercode because you haven't done your homework, you're leaving money on the table. If you choose the wrong codes or don't document correctly, you'll get nothing. The note about unbundling is especially pertinent, and we'll be talking about that later on. I did want to point out, and this is a really important take-home message, as a member of AUGS, you have access to a wealth of information regarding coding. The fact sheets address common coding topics that have come from questions from you, and they're usually pretty popular and common kinds of issues. Coding Today has a lot of basic information on coding. It's a subscription service which is well worth the investment. Finally, if you have a specific coding question, you can ask us directly with the Coding Committee's request forms. Ms. Rathbun is going to talk in detail about the rule being proposed by CMS in a few minutes. However, you know that the federal government moves with all the speed of an advancing glacier, so that whatever they come up with won't go into effect for at least a year. I did want to mention that some other information that's very much useful to you is the ACOG Coding Manual. It's really the font of all knowledge for us as we try to figure out what we want to call or what we do. It contains general information about the evaluation and management coding, and more importantly, it provides a narrative describing the details of the procedure that's being coded. I have to tell you, CMS.gov is a blessing in disguise. It has all kinds of interesting tidbits. Because it's going to be a while before the new initiative is put into place, and as I said, it's probably not going to be for a year or two, it's worthwhile talking about the current world we live in. For our purposes, it's useful to think of the coding procedures as to fall into one of two camps. The evaluation and management activities, which they pertain mainly to the office or inpatient interactions. The other one is process codes, which address the stuff you do that involves physical activity or instrumentation. The CMS website that I mentioned before provides a lot of good details about what constitutes the element of the evaluation management codes. Now, a few comments about the NM codes before we get to the procedural side of the fence. Evaluation and management activities are evaluated by one of two pathways, either by the amount of effort required to accomplish this goal, the first three components listed inside, which are history, physical, and medical decision making, or time. This is the time spent with the patient face-to-face. Each of the pathways are marked by levels required to Each of the pathways are marked by levels requiring progressively more complex actions. One important consideration I want you to keep in mind is if time is a pathway, it has to refer to either or both coordination of care or counseling. If you follow this pathway, the activity has to be in the presence of the patient, face-to-face time, and has to involve more than 50% of the time you spend with the patient. Now, I'm going to go a little bit more into detail into the other pathway, the history, physical, and medical decision making. A quick comment about the history part of the interaction is probably the easiest one. Documentation must include the chief complaint. You've got to let them know what you're about to do. Beyond that, the amount of history required increases with the coding level from problem focused, which is level one, to comprehensive, level five. These are described in good detail in the ACOG coding manual, so I'm not going to bore you with the details. The physical examination component is a little bit more interesting. There are two protocols which are permissible. One issued in 1995, and the other in 1997. CMS being very innovative, they're referred to as the 1995 rule and the 1997 rule. This is a chart which describes the differences between the two protocols. I know, oh, geez, this is a busy slide. They don't even supposed to look at it in detail. It's just a compilation obtained from the CMS website. The basic difference between the two is that the 1995 rule is based on the number of body areas or systems evaluated. The 1997 rule is primarily based on the degree of evaluation performed on one organ system. Some of the details that the CMS wants are required by their rules, but the rest of it should be determined by the problem you're evaluating. I did want to spend some time on the medical decision-making. A lot of providers, and I'm not going to go into detail, a lot of providers have the mistaken impression that this refers to the amount of time spent figuring out what is going on with a patient. However, this is not true. There really are three distinct components of this section, which I'll discuss in more detail in a few minutes. These are then summarized to determine the final level that you report. If you're going to go with time, this just gives you a guide as to how many minutes are typically spent on each of these levels. As I mentioned before, the time is referred to either counseling or coordination of care. They have to be face-to-face, and they have to account for more than 50% of the face-to-face time they're having with the patient. The final evaluation management level that you determine, or report, depends on whether the patient is a new patient or an established patient. For new patients, the highest level is achieved by the lowest ranking component of all three components, whether it be history, physical, or medical decision-making. We luck out a little bit with the established patient, but the highest level is achieved by the lowest ranking component of all three components, whether it be history, physical, or medical decision-making. We luck out a little bit with the established patients, where you only have to look at two of the three to figure out which lowest ranking component. Let's get back to medical decision-making. The first component, there's three components, the number of diagnoses, the number of tests you have to evaluate or studies you have to do, and the risk of the whole evaluation management. Number of diagnoses consists of all the diagnoses, which are either known or in the differential, as well as diagnoses which may possibly impact on the diagnosis or its management. However, that latter part, the comorbidities, have to be ones that are actively involved during the management of the patient. If a person is coming in for some major surgery and has a bruise on her toe, that doesn't count. Probably one of the most difficult to assess is how do you count data points? This is just basically a sheet of bullet points as to how many laboratory tests you review, the imaging studies, which you have to be requested or reviewed, and other kinds of evaluation procedures, such as your dynamics and so forth. The more of those things, the more you can count. And finally, risk assessment refers to the degree of possibility of complications, such as morbidity or mortality, which is associated with the condition itself. If the evaluation that you have to do, the management of the problem, and the effect of the patient's comorbidities, you get a lot for your buck there. So, the total sum of the medical decision-making, then, is determined by the lowest of these two things. It's all three. There are some guidelines that you have to follow to make sure that you're doing the right thing. And I'm not going to go through all of them. I'm just going to give you a little bit of information. And again, we talked about time before, and I'm going to just reiterate that it's only face-to-face time in the office or other outpatient setting or hospital. And it's total length of the encounter is a face-to-face floor time, but it's documented appropriately, and the time you see is only works if it's more than half of the time you spend with the patient. Now, let's turn to the fun stuff. How do we code for the things we get to use equipment for? These are the procedural codes, which are listed nicely along with their descriptions in the ACOG coding manual. Keep in mind, though, that the procedure reimbursements covers three periods of time, the preoperative care from the day before this, the procedure to the procedure, the intraoperative management, and the postoperative care. This includes post-discharge management. Many of these procedures are governed by a global period, which is the time after the procedure is completed. These are included in the definition of the code. During the global period, you can't separately bill for any management actions which can be construed as being associated with the procedure. Now, for the bad news. Not everything you do is reimbursable. You basically do it because it's the right thing to do, or really that CMS thinks it's just another part of the procedure. We've already talked about the global period issue, or one of these reasons. Another main reason not all codes are reimbursable is because of the curse of something called bundling. This is a component of CMS called, and there is a component of CMS called the National Correct Coding Initiative, which is charged, among other things, with determining what procedures are used together often enough to be considered different parts of the same procedure. Modifiers are two-digit numerical codes to get around this and try to parse out outliers so it can be paid. This is what bundling is. NCCI updates new pairs quarterly with input from organizations such as OGS, ACOG, and others like the urologists. NCCI, with the input from these organizations, just determines whether or not separate codes should be combined, or sometimes taken apart. These changes are made after a comment period, so if you were asked about one, please don't blow it off. If you get a question about it, please send it in to give us some help. Now, I'd like to talk a little bit more about a couple of two or three scenarios that will help understand how this works. This is an uncommon scenario for us. Somebody comes in with a prolapse and needs it repaired. So, how do you code for it? Actually, we do pretty well on this one. You code the diastolic hysterectomy as the main procedure, and then you use a 51 modifier, a very common one for us, to tack on separate procedures that you do at the same time so that you get better results. CMS decides how much of a reimbursement you get. It's about a half for the first, and a quarter for the second you tack on. This one also includes an anomaly, the uterocyclic ligament suspension, which you might consider to be just another part of this procedure. NCCI had originally bundled this with vaginal hysterectomy, but extensive lobbying by ACOG and SGS convinced them that that was an incorrect move. Their fix was to call it a totally separate procedure, which accounts for the modifier, which is usually used for totally non-related surgeries. This is another scenario that we often run into as your gynecologist or female urologist. A general gynecologist wants to perform a TVH and BSO or hysterectomy, and he calls in a urogynecologist to help him with some urogynecologic procedure. They don't assist each other, so you can't use an assistance code, but we do have other odds. Unfortunately, the hooker in here is that although a single surgeon would report all of them, because you have two surgeons, which are basically considered by CMS to be the same kind of specialty, you can't do that. They're considered to be co-surgeons, so it's two surgeons working together, so you have to use a code 62, which tells CMS and the payers that you are two surgeons working together. Unfortunately, this causes them to have the opportunity to reduce your payments. The last one I want to talk about is a different side of the same thing. A gynecologic oncologist does his thing with a malignant uterus, and he calls you in to fix the prolapse that he didn't want to deal with. Both of them assess each other with different parts of their surgery. In this case, because they're separate and distinct specialties, each one of these people can charge for his or her side of the surgery. The gynecologist bills for the hysterectomy and staging procedures. If he does staging, he gets to use a slightly different code, which pays him more. The gynecologist bills for the gynecologic stuff. Again, notice that he uses a main procedure and a 51 modifier to say he's tacking on something else. Each can then bill as their other's assistant, assuming that there's no resident around. One thing I did want to point out to you is that I listed cystoscopy on the first slide. Cystoscopy can't be billed separately because NCCI has decided that cystoscopy as an intrinsic part of the urogynecological procedure and you can't use it just to check your work. Obviously, if you're going to do some surgery on a bladder, that's a different issue, although it would still be bundled with that particular procedure. What's the take-home message? It's actually a lot shorter than the rest of the talk. You want to get paid. The way to do that is review carefully the descriptors in the ICOGCO coding manual so you understand the elements which are supposed to be included in the procedure, included in the global period. A really important thing to do is take the time to do the right kind of full documentation that supports all the elements of the primary and ancillary procedures as listed in the ACOG manual. Finally, you want to document very carefully the indications for and the performance of any ancillary procedures or any activities that require a modifier. I know all of you have really become experts this year, but in case there's any little minor details I've left out, please shoot. Thank you, Dr. Metz. We did have one question and we also have Dr. Mitch Schuster here with us this evening to help answering questions. So Dr. Metz and Dr. Schuster, I'm just going to go back to this slide. I believe this question is related. I'm looking for the sling slide. I'm thinking here we had a question about why is a sling only modifier 59 as it's not part of a hysterectomy? I'm guessing this is this patient regarding the intraperitoneal 57283 and then we have the sling, etc. So we've got a question on that that we may need to talk a little more about this scenario. The sling is actually a 51 modifier here. I think the, as I mentioned before, 59 applies to a totally unrelated procedure, such as doing a hysterectomy and then turning around and I don't know doing a breast biopsy or something. So we don't, we've almost never used a 59 for the things that we do, and to be honest with you, I'm not familiar with the XS or XU nomenclature. So Steve, the 59 modifier, that really is kind of almost a joint. It was really a decision made by NCCI. So they send out these edits quarterly and went, you know, we'll get 500 to 1,000 edits where they want to put these pairs together. The uterocircular ligament suspension was actually in a different section of these thousands of pairs that we got to review, and to be honest with you, both AUGS and ACOG missed that particular edit, and so about a week after it went through, we caught it, and so we went back to NCCI and we said, hey, this was an accident. This is not supposed to be this way, but because it was already through, they refused it. So AUGS took the lead on this and we kept pushing it and finally got Dr. Rosen, who's the chief of NCCI, kind of the boss of that, to review it. We showed, we submitted all the data that it was in a different location. It was a different operative site and should not have been bundled with the typical hysterectomy. They see uterocircular ligament. They say, well, that's right where the uterus is. They don't realize we're working on the proximal end and not the distal end where the uterus is connecting to it. So through the work of AUGS, we were able to get all that changed, but their actual way they wanted to handle it was, okay, we're going to let you do it, but we're not going to take that edit out. We're just going to make you submit it with that 59 modifier. So anytime someone was doing the hysterectomy, if they're going to do a high uterocircular ligament suspension in their operative report, they need to say, I'm having to do extra work because, and then list that out, and then they need to have a separate paragraph that kind of says something along the lines. After completion of the hysterectomy, the apex was not going to be well supported, so we proceeded on to the uterocircular ligament suspension, and then you would describe that in a whole separate paragraph. So it's a distinct procedure. You do that and then submit it with the 59 modifier should get paid, and so that's the reason 59 is used for the uterocircular ligament suspension. The 51 modifiers is basically just a multiple procedure modifier. It's kind of like a la carte ordering in the restaurant. We get to continue to do these things, but we do take a reduction because there's duplicative services for all these things, like the anterior corporeal there, the 57240. In the valuation of that particular code, there's preoperative work, postoperative work, and the intraoperative work, but because it's being done with these other procedures, they don't want to pay CMS or any of the third-party payers. They don't want to pay us for the preoperative work and the postoperative works at the same time that we're already doing for these other procedures, so they call that a multiple procedure reduction, and that's the reason we end up getting the reduction on that. So the 51 modifier is correct for the mid urethral sling there, as well as the anterior corporeal. The 59 is telling the payor that, hey, this is a separate procedure. This is not the typical suspension type of work that we do for a routine hysterectomy. Does that answer that question? So also, we got an interesting question. I think I want to elaborate on that because that's confusing to a lot of people. Yeah. We also got an interesting question about the use of the dash 51 modifier. As Mitch said, that is the multiple procedure reduction modifier. It is the modifier you put on a second surgical procedure if there's not an NCCI at it to note that it is the second or if you have a third or a fourth, and I am not aware that contractors, i.e. Medicare contractors, we have someone who has their contractor as an iridium, are no longer using these modifiers. So every surgical society that we know teaches on the second, third, or fourth procedure to use the dash 51. So that would be something that might be specific to your contractor or regional thing if they're no longer requiring the multiple procedure reduction modifier because definitely CMS has a very lengthy multiple procedure reduction list in regards to what codes are on that list and have to have the use of the modifiers. So the 59 modifier is an NCCI modifier. Also, you may recall NCCI has a group of alpha modifiers that they are transitioning in their use. Different insurers have transitioned at a different pace and so the 59 is actually synonymous with the XS, excuse me, and so some contractors have moved over to the alpha NCCI or edit bundle modifiers versus the numeric one. So it depends on your contractor in regards to the dash 59 versus the dash XS. OGS does have a very nice coding fact sheet on the website about the use of modifiers and lists all the modifiers there that are typical for urogynecologists, particularly surgical modifiers, and so I would definitely encourage everyone to do that. So we have a question, Dr. Metz and Mitch, about taxonomy codes and general OBGYN has a different taxonomy number than a urogynecologist. That is true, but they do not have different two-digit specialty codes. They're both specialty code 16, although there are different taxonomy numbers, and so the question is if the two have a different part of the surgery and don't help each other, then the 62 modifier should be unnecessary and both should get their full payment. I think it depends on whether the payer is using taxonomy numbers or whether the payer is using two-digit specialty codes in regards to contracting, et cetera. Dr. Metz and Mitch Schuster, I don't know if you want to speak to that, either one of you. Well, I'll give it the first time. I remember what he said that the codes cover both the pre, intra, and the post-operative care. If you have two surgeons that are sort of doing the same thing and having the same pre and post-op care, the CMS doesn't want to pay for the whole thing to both of them. So the rule is, is if basically you're two surgeons who are sort of the same background doing the same thing, they consider it sort of two halves of the same coin and that's why they reduce the pay. Steve, I agree with that completely. You know, I think it's different for every situation and when you're in either with a large group or in a university setting or things, you certainly could submit these codes as two groups, you know, two surgeons in the same specialty, if you will, and you're going to automatically get that reduction. In our area, what we typically do is I just kind of have a working relationship with these guys and I just say, hey, you bill all your stuff. Let's bill me as an assistant. Let's throw all the money together and then divide it the way we think that it is. That way, we're the ones within ourselves making those reductions. We kind of do it internally instead of letting the payer automatically do it for us. I mean, that means you're going to have to have a good relationship with these other physicians, but most of the time that's the case. We know who we're operating with and we're going to handle it much more equitably than a lot of times the payers will. They're interested only in trying to cut as much money out as they can. So that's just the way we do it in the southeast. You have to be a little careful when you do it that way, though, and if you happen to be working in a teaching situation, if there's a resident involved, that doesn't let you be the assistant then. Yeah, I agree. With the resident involved, you have to be very careful because resident fees are already included as part of the teaching stipend that the government provides those teaching facilities. So yeah, you cannot do it in those situations. And I was looking, I'm looking at the chat line as it's going through here. Someone's saying they're not neridian. Jill, you might know this. It's not honoring the 51 modifier. Yeah, that's kind of shocking to me. That's what I was mentioning earlier that everyone teaches that second surgery requires the dash 51. So I am interested about that and will do a little research, I think, and get back to the Oggs family on that because that would be very interesting news. Now the dash 59 or migrating to the dash XS to replace the 59, I could see that happening, but I don't know how else any contractor would know to reduce the second by half or also to know which is the first, i.e. unless they're just automatically adjudicating the highest paying RVU surgery first and then cutting, cut the next one, highest RVU by half and the next one down to 0.25 percent, the next one down to 0.25 percent. So maybe neridians nicely just automatically processing without modifiers, but that's not a normal occurrence, at least that I'm aware of. Yeah, I would be, that would be very, I would think CMS would want to know that their contractors who are working for CMS that, I mean, possibly this is a rogue group. Yeah, I mean, I think that's something that needs to be, we'll do some investigation. Yeah, so then we have this question about cystoscopy, which cystoscopy is a separate procedure designation. So I think that's an interesting question and goes to this slide right here. So regardless of this question's about doing a cystoscopy with a sling, but the reality is cystoscopy on any claim with another surgical procedure doesn't get paid. Cystoscopy on a claim with any procedure, not just cystoscopy, doesn't get paid. Well, it gets, Jill, it does get paid, but if you've got a preoperative diagnosis, like if you're doing a bad cyst for menorrhage, or are you doing it for prolapse even, but she's also having a lot of bladder pain, and you evaluate it in the office, and in your H&P, you're saying, hey, she's having a lot of pain. We're doing a cystoscopy for evaluation of bladder pain syndrome I see you know that kind of thing if you're doing the documentation and then doing the procedure you can bill it with that. Now you're gonna have to do that with a 51 modifier because it's you know it's an additional procedure but you don't just have to totally not bill it like you do with the sling or with the sling because cystoscopy is considered part of the sling. Cystoscopy is because you're checking your work and it's considered that way for hysterectomies as well but if you're doing the cystoscopy for a separate procedure you certainly it is certainly within CPT rules to go ahead and bill that as long as you're documenting why it was done you know and you've got all the data to support that in the office setting and that kind of stuff. I would like to reemphasize that in your odd node you may be well served at the time to say indication procedure patient has you know persistent bladder pain or some other thing that would be an indication all by itself for cystoscopy and then down in the body of the dictation described very carefully the total part of the procedure not just the cystoscopy was done. I would suggest that it'd be a good idea to highlight the particular steps you took to do the cystoscopy. Or especially if you're doing a biopsy because you see something in there that you think yeah this might be something we need to look at. Okay well good questions everybody and and we may have some more time at the end for questions but also I just want to remind everyone that we do have the opportunity for AUGS members to ask their individual coding questions by going to the practice management page under coding of the AUGS website and there is a electronic form that you fill in and then the coding committee will answer your question directly in writing back to you and we will be putting some of those questions and answers in the monthly Friday AUGS email newsletter on the third Fridays of the month so you can be aware of that. So as Dr. Metz said my name is Jill Rathbun and I'm the managing partner of Galileo Consulting Group here in the Washington DC area and I have been doing health policy government relations reimbursement policy work now for close to 30 years and I work with medical societies I've worked with AUGS off and on for probably 10 plus years of that 30 years and so we're going to talk a little bit now about the 2019 Medicare Physician Fee Schedule. There are some changes that will affect all surgeons, all AUGS members and there are some things that did not happen luckily that would have negatively potentially impacted many AUGS members but there are some new codes coming that we want to make sure you're aware of and particularly relate to office-based care coordination of care. So everything I'm about to talk about today is effective January 1, 2019 and and so we do have a couple weeks here to get ready. So the 2019 physician conversion factor will be $36.0391 that is a slight I say very slight increase to the current 2018 conversion factor it's about four cents in RVU but it is an increase and there have been many years where it's been a decrease so at least we're not going backward and we just a little information here about how we get to that how CMS gets to that little bit of increase. Congress have provided a quarter percentage point increase the entire Physician Fee Schedule pool. We unfortunately have budget neutrality when the volume increases as well on the pool and so we didn't get all of the .25 we got .11 that equated to four cents of an increase so there we go. So that is the number that gets multiplied after you do geographic adjustment to the RVU for all physicians to understand their payment. So CMS, Dr. Metz went through how you today go through and assign figure out what level of E&M office visit you are going to select and bill for that patient's care and how you're going to document that. So CMS is changing we hope to the better for all of you some of the documentation requirements for January 1, 2019 and beyond so going forward and we hope this will help you to save time in your practice versus having to do a lot of paperwork. So first they're eliminating the requirement to document the medical necessity if you do any home visits in lieu of an office visit. So if you do end up seeing any patients at home versus seeing them in your office you no longer have to document why you're seeing them at home. So that hopefully will if you do any of that that will help you but but here's one of the big ones that we think hopefully will be extremely helpful to everyone. So as Dr. Metz said you have to document history and physical exam for established patient offices right so when that patient comes in today you re-document all of their medical history you re-document the reasons for their exam etc. Even if you just saw the patient a week ago even if you just saw the patient a couple months ago you have to re-document everything. So now what CMS is saying is that for these established patient visits practitioners may choose to only focus their documentation on what has changed for that patient since the last visit. So if a patient has particular items that have not changed since the last time you saw them regarding their history and physical exam you will not need to re-record in the patient's record the defined list of required elements that Dr. Metz went through and we have more detail on the OGS website and in the ACOG coding manual. If there's evidence that there's no change and that you reviewed the previous information and documented that it didn't need to be updated or you just updated the few things that that that changed. So hopefully this will be helpful to people's time not having to retype in things that didn't change in the history and physical exam. We are hoping to get some additional information before January 1st from the Medicare contractors regarding how they will audit this change and we hope the electronic health record companies will be very helpful in regards to allowing people to cut and paste things that have not changed to not have to retype in the field. But we think that this will be a big advantage and saving of time for physicians to not have to document things that have not changed. So that will be effective January 1, 2019. The other thing that will be effective January 1, 2019 is that if you practice with an ancillary staff provider or you have your beneficiaries type in information through a web portal prior to seeing you at the start of the visit, right? Today any of that information has to be re-entered by you and that is kind of a not good use of your time. So CMS is now saying that they're clarifying for the chief complaint and history for both new and established patients that as the physician you will not need to re-enter that medical record information if it was already entered by ancillary staff or the beneficiary. All you will need to do is indicate in the medical record that you reviewed the information and you verified the correctness of the information. You will not have to retype in the information. So if many of you use web portals for your patients to fill out information prior to a new office visit or you have a nurse or a med tech or practicing with you in the office visit and they can you know do your iPad and put on all the data while you're talking to the patient and you will not have to retype in all that information going forward after January 1, 2019. You will just have to attest to its correctness. So we hope that that will be very helpful to all of you. These couple changes about how to handle your documentation of office visits going forward in 2019. Now CMS is not moving forward. Many of you may have been aware, many of you may have helped us do analysis that CMS was going to change all of the payments for the evaluation and management office visits for 2019. They were going to collapse the payments and have a single payment for level 2 through 5 new patients, have a single payment for level 2 through 5 established patients. CMS has chosen not to move forward with that for 2019. We are very pleased with that in the data work that the coding committee did. It looked like AUG's members in some circumstances would be cut in those instances and so we have been working with the AMA, CPT, and RUC committees on a modification of what CMS proposed, continuing to have the existing codes and non-combined levels of payment. But CMS has chosen not to move forward with those changes. You will continue to have individual payments for each E&M code for 2019. They did put forward some thoughts for 2021 if we as the physician community can't get our act together and give them some better, easier ways for you all to select and document your level of office visit, i.e. only using time or only using medical decision-making, but that is still a work in progress. So for 2019, all the codes stay the same and the payments we will have for you on the AUG's coding website, but they are basically individual payment for each level of service. So if you were concerned about that for your practice, if you see a lot of complex patients, you do not have to worry that your payment for a level 2 will be the same as your payment for a level 5 for 2019. So that is something to consider. Now CMS is creating some new CPT codes regarding advancing what they're calling virtual care. So this may be care that you have been providing over the years to your patients that you were like, I'm doing this but I'm not getting paid for it, right? So now CMS is going to pay with new codes for some of the work that you're doing. So there's three areas that they're going to pay and so they're going to, they've created a series of new codes for what's known as virtual check-ins. These are brief, non-face-to-face assessments via communication technology, right? So this is not when the patient is there with you in the office, this is via virtual technology. So what do we mean when we say virtual technology and what do we mean when we say brief? Well that is a good question and so we're going to go through that quickly right now. And so what we are talking about here is virtual check-ins. This is evaluation, could be evaluation of patient submitted photos, could be looking at, you know, talking to a patient to see if they need to come in over the email or over the telephone. It has some rules around not being able to be used within X amount of time of an office visit, i.e. like the evening that they were in to see you during an office visit or X amount of time prior to an inpatient hospitalization. But this is the ability to have a quick check-in with the patient, give the patient some care and over the phone and then or the email and a bill for it and actually get a little bit of a payment. So we'll be getting these new codes out to you and so that you will be able to see them, see how much they're going to pay, etc. So this is a new set of CPT codes. Then we also have some new codes regarding telehealth and we have some new codes regarding interprofessional internet consultation. So what do I mean when I say interprofessional internet consultation? What I mean is if you are working with a colleague and you are providing them with clinical information about a patient via the internet and you, i.e. email, and you are talking with them about a patient and you are providing them with care plan information, you're providing them with your personal expertise on that patient's case, there will now be two new CPT codes 99451, 99452 that will allow you to bill for that work. Now this is colleague to colleague, physician to physician. This is not internet consultation with a patient. That would be part of these new brief non-face-to-face virtual checking codes. But so we do have these two new pieces coming as well as some changes in telehealth for preventative services work that we will be providing you with those codes and the numbers. But I think that this we hope will be helpful to physicians for 2019 to have the ability to bill for some of these non-face-to-face and electronic communications that you've been long having with the patients and you've been having with each other. So those are coming for 2019. I suspect we're going to have a little bit of bumbling on those new codes by the contractors right out of the gate in January. So we'll be working to provide you with any articles and things that we see the contractors putting out, the CMS Medicare contractors, your MACs, so that we're we're making sure folks are aware if say Novitas or Noridian or WPS etc. is having trouble recognizing these new codes and isn't paying them so that you don't get a bunch of denials. Instead we get it done for you. So luckily AUGS was not subjected to having many codes re-reviewed for 2019, i.e. you know where they go through review from the Resource Update Committee of the AMA and we ask you for a survey of your time and your intensity. Luckily we only had two codes that went through this process. One is a code, both are codes I'm sure everybody on this phone is very well aware of and uses very often in their practice. One was CPT code 57150, that's of course the general vaginal irrigation code, and one was the pessary fitting code CPT code 57160. Currently those codes pay about what they're going to pay after the review, which is amazing given what we sometimes have happen when codes go through these reviews. So 57150 got a slight nick in its work RVU but only 0.05 and actually the overall payment for this code is going up by 0.10 because the practice expense RVUs are going up because we repriced all of the practice expense RVUs at the same time when we have to redo the physician work. The pessary fitting code, the work RVUs are going to be the same, 0.89, that's almost a miracle. But unfortunately the overall RVUs are going down by 0.36 because we had changes in the practice expense inputs for the code and so that is impacting the overall payment amount. But as we know the code does not include the pessary itself, that is separately payable on the HCPCS codes. So those are the only coding changes in regards to RVUs that are changing based on a specific activity by AUGS or and ACOG together. However, we do have some up and down going on with the fee schedule in general this year. And if you have looked at your own fee schedules for your own region, your city, your state, etc, you're noticing a little bit of gyration, I'll call it, in the overall RVUs. And so here's why. So the reason why you're seeing some of this, particularly for office-based procedures that you perform, is that CMS hired an outside contractor and repriced verified pricing for all of the supplies and equipment prices that CMS uses to calculate the practice expense RVUs for all CPT codes. So particularly for office-based procedures, this makes a difference because if it's a code down your office and it requires a supply or a special piece of equipment, that's going to have quite an impact when that gets repriced up or down on your office-based RVUs. Similarly, we have some repricing in some of the visit packs and things that impact your global period office visits. And so you may see some up and down movement there. This is so dramatic to the fee schedule. CMS is phasing it in over four years. So you may not see much of a change today, for 19, but by the end of the four-year transition, we'll see the total impact. So OGS is updating all of our coding sheets now for the 2019 numbers. Your Medicare contractors should be putting out local fee schedules for you that would be available off of their Medicare Part B websites. And so you need to check your current charges that you submit, make sure the RVUs have not dramatically changed due to this repricing. As I said, it will mostly impact office-based procedures, with office RVUs. If you were in one of the nine states, there are nine states. We have information on the OGS website, exactly what nine, if you've forgotten. You are required to submit information on global surgery package office visit data. CMS is going to be sending a new letter out to all practices that did not and did submit data. It's really important that your practice do this. We will be having this as one of our first articles in the Friday newsletter, because CMS is contemplating cutting the E&Ms out of the global periods, both the 10-day and the 90-day in the future. This does have a dramatic impact on RVUs and would have a dramatic impact on surgery in general RVUs. So again, we will be sending new updating information, but CMS has not reduced this requirement. They still have it on the books and they still want people to use the 99024 to fill their office visits, even if they just fill them with a penny, so that they can track them in the system and make sure that for a 10-day global, people are doing an office visit and follow-up. For a 90-day, that people are doing two to three office visits and a follow-up, because that's what's included in most surgical codes with a 10-day and a 90-day. So we will put the list of nine states out. I unfortunately didn't print it off before we started tonight and get back to you. The one that pops in my mind right off the top of my head is New Jersey. There's also some of the Midwest states, etc. So we'll let you know there on that and remind you all. So the physician fee schedule has its own big page on the CMS website. It is, as Dr. Metz said, a plethora of information. All of the agenda for the rules are there, all the practice expense inputs. You can see how many minutes CMS believes you spend on each code that you perform. You can get the rule itself. It's just quite a wealth of knowledge. And so I do recommend everybody at least get familiar with that webpage and know it's there and know what's on it when you have a minute or have your office managers take a look at it and understand what's on it. And we also have quite a bit of different pieces of it available right through the OGS website. So there we go. So we may have a couple minutes here for questions. It looks like we only have about four minutes, although Alex, will we automatically be kicked off at 8 o'clock or can we go a little longer? Well, wait, Alex. I wanted to point out that if people have questions that we can't answer, they can send the questions via our coding forms that you mentioned earlier and we'll try to get an answer to them. Yes, excellent, Dr. Metz. That is correct. So let me reiterate, if you are in one of the nine states required to do office visit billing during the global period, the CPT code is 99024. And some claims processing, you can just put it in with no charge on it. Some, to get it in, you have to put a charge. So people have been instructed by CMS to put a penny, but that is CPT code 99024. And we'll get you the nine states, but it's also on the website right now. So we had a question that I find fascinating. So, Dr. Metz and Dr. Schuster, is anybody aware of why, I'm assuming they is CMS or Medicare Insurance Company, stopped. We have a question about somebody who has not had payment for pessary supplies since October. Do we know anything about that? Steve, the only thing that I'm aware of, typically CMS has looked at pessaries as DME, durable medical equipment. And there was a time where CMS was requiring it to go through a DME supplier before they would pay. And so that's the only thing I'm aware of. I would check with the local MAC and see what the ruling is on that, try to figure that out. Maybe it's more of a coding issue than a supply issue. I think it has to do with the contractor too, Mitch. Yeah, that's what I'm saying. Yes, exactly. And the DME contractors are CGS for half of the United States and Meridian for the Midwest Western half of the United States. So there's only two now, there used to be four. So that may be an issue too. But Nancy, if you put a little note into our coding question, we'll do some research for you and see if the DME MACs we can find anything there. Okay. So we have a question here from Dr. Lucente. When coding for a six-month post-surgical check, what is the best diagnosis to use? Is it appropriate to use the surgical diagnosis in state improved, i.e. prolapse-improved? My opinion is that it would not be appropriate to do that because you're outside the goal period. And I would think that this would be on more ICD-10 code, depending, you know, talking about exactly what you would fix so that because they are detailed and in state improved. Yeah, I think I'm saying the same thing here, Steve, as you just said. It is outside that global period, so you would want to bill it. I think Vince's question is, hey, we did her surgery for prolapse. Can we say that the reason she came back for, you know, a 99213 visit is for follow-up on her prolapse and then just write the prolapse is improved? I think you can certainly do that. Now, you couldn't bill that as a 99214, but you certainly could get a two or three out of it. Yeah, but I think the point I'm trying to make, Mitch, is this an EM, not a surgical code. Yeah, you're outside the goal period. And the non-face-to-face assessment can be a telephone call, is my understanding. Is that your... Right, telephone or virtual, i.e. computer, exactly. There was a question, too, about any new bundles for 19. I'm not aware of anything, and then in terms of RUC stuff, we have, what the next, well, the next RUC is coming up. We're having to look at the biofeedback codes. And for 2020, there will be new CPT codes for biofeedback. So we will, you know, don't, you know, don't have to do anything for 19, but we just want to give you a heads up that there will be new CPT codes for biofeedback for 2020. And so just be aware of that, and they're having to go through a survey process now. Oh, Jill, someone was kind enough to put those states in, so I'll just say it verbally here. Florida, Kentucky, Louisiana, Nevada, New Jersey, North Dakota, Ohio, Oregon, and Rhode Island. And so those are those states. And you're gonna put something else on the website, is that correct? Well, we have a memo about it on the website and all the instructions for billing the 99024 and the states. And yeah, so we'll put that back out in an article with the link. But yes, thank you. I think that's probably gonna be one of our coding corners. Yeah, that's a great idea. All right. And yeah. So before we go here, I'm gonna make a plug. Mitch already made one plug in the chat box. But the OGS Coding Committee is looking for a couple new members. We have a lot of work to do, and we have a good committee of about 10 to 12 members, but we need a few more. And looks like we might have some people from this webinar who would like to join us. And so please let Colleen Hughes at OGS headquarters know, or you could let Dr. Schuster know directly. But we are looking for another two, three, four members. And if this is your passion, we would love to have you join the committee if you're an OGS member. So that's our little plug, right Mitch? I think that's great, Jill. Thank you. Absolutely. I would support that 100%. So I'm just gonna quickly look through the questions here, make sure that we've gotten all of them answered. We are just a minute or two over time, but no worries on that. Okay. So again, I'm gonna go back quickly, Dr. Metz, to our resource slide so that everybody can see the links here for asking the coding committee a question. Our fact sheets, we probably have 10 plus fact sheets on different coding areas, procedure coding for different procedures, aerodynamics coding, inter-stem coding, lots and lots of fact sheets. And we'll have all the 2019 payment amounts on those sheets. OGS coding today, which description service, very helpful. And then of course you can ask us a specific question. So there's a lot of good resources on the OGS website under practice management, coding. So I hope that everyone will check those out. I'd like to thank everyone for attending this evening. And Jill, great work. And Stephen, thank you again. Great job. Thank you for putting it all together. Thank you much. And thanks everybody for stopping in and visiting with us tonight.

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