Good afternoon. We're going to start this afternoon's program. I'm Dave Petowitz. I wanted to thank you all for coming. I also want to thank Casey and Dan for making time for this symposium. We are all surgeons and caregivers, but we are also small business owners. We run our own personal businesses, and what the Practice Management Committee does is tries to help us stay on top of issues that are critical to providing good care and to the survival of our livelihood. So we're going to have three talks. I'm going to give a little bit of a coding and legislative update. Dr. Inardi is going to give an E&M update, and then Dr. Guyer is going to talk about the disruptive physician and how we manage them. So if we can just start with the first slide. Great. These are my disclosures, none of which are applicable to the content. Okay. So we're going to go over some new changes and a little bit of cleanup coding. All right. So in 2023, there's no setup for any major changes for foot and ankle. In 2022, had the office E&M codes, which were re-evaluated, and in 2023, the plan is for hospital codes, excuse me, to be re-evaluated, but there are no new CPT codes that are coming our way in this calendar year. There has been a conversion factor change, and so I want to give you a little bit of background. For anyone who isn't acutely aware of this, there's a formula for calculating our fee payment, right? The provider fee is equal to some combination of RVUs, work RVUs, the geographic practice cost index, and it's a really complicated formula from the 1980s, but it has a conversion factor in there, which, as everyone can see, can take everything to zero or however you want to make that conversion factor. So if you look at the conversion factors from the last two decades, it's gone from $38 in 2001 to $34 in 2022, and the proposed change for 2023 is $33. That's a 4% decrease. This is 5.1, almost $5.2, which really represents billions of dollars. I'm just providing you with this information. Don't shoot the messenger. This is sort of what our government's doing. So what typically happens when this occurs? Okay, so we all know that there was an E&M update, okay? So we had a conversion factor change, which I just outlined for us. And then we had an E&M update, which increased the value of E&M services, evaluation and management services, services that we provide in our office, right? Now what typically happens when you do that is you get an inadvertent increase in the CPT code reimbursement. Why is that? And that's because an E&M visit or multiple visits, however many times you see a patient in the post-op period, they're included in the bundle calculation, right? The bundle calculation is like your practices overhead, the surgical procedure you're doing, but then also a number of E&M visits, however many you choose to have. So if you increase the value of an E&M visit, then accordingly the CPT code and the bundle then subsequently increases. This was the first time that this did not happen. So there was no update in surgical codes when the E&M went up. I'm not sure why this didn't happen, but essentially it comes down to the Budget Neutrality Act. So E&M codes went up, CPT codes were not adjusted, and the conversion factor decreased. It all stinks, but that's what we're working with, and we just have to make sure that we're good consumers of what we're being faced with. That's as much as I can give you regarding the conversion factor and the non-adjusted CPT codes. I do want to make one small comment about cleanup coding, right? We can't teach ethics, and we are certainly not the coding police in the Practice Management Committee. However, sometimes things can get a little bit messy. So here's an example. It's not always intuitive, right? So down coding, in theory, leads to lost revenue. Up coding can expose us to risk of being audited and charged with improper coding, and proper coding allows us to get paid for the services that we've furnished. Okay, here's an example. We've had many emails of procedures and how they've been coded that come across our desks on this committee. This is just one example. This is not anyone in this room. This is a Kittner procedure, 28238, excision of an accessory navicular bone with advancement of the posterior tibial tendon, 7.9, almost 8 RVUs. And that's the number of codes that were submitted for that procedure. Now, this doesn't necessarily represent any wrongdoing. The only thing that I'm bringing to everyone's attention is that we really need to be diligent to represent what we're doing accurately, because people are out there looking, and we want to make sure that if patterns start to emerge about potentially over-coding, that we're not really guilty of those accusations. So I'm going to kind of leave it at that. I know there's a fine line between sort of telling you what to do and what not to do, and I'm not telling you what to do. I'm just trying to bring it to everyone's attention. So in summary, there were some E&M changes. Without a CPT increase, the conversion factor went up, and we just have to be scrupulous about our coding and adhering to exactly what we're doing in the operating room. Thank you. All right, good afternoon. I'm Mike Anardi from Penn State. I'm gonna go through some of those E&M office changes that Dr. Petowitz just hit on. And at the end, for those of you who work at facilities, go over split shared changes, which changed July 1 this year and then will change again January 1, 2023. These are my disclosures, nothing relevant to this talk. So our basic objectives here, we're gonna go through some of the AMA changes and I'll go through those split shared services. When AMA made these changes in 2021, they wanted to kind of eliminate these EMR generated histories that weren't really relevant so that physicians could actually communicate better. And then they also wanted to allow us to choose whether we wanted to use our documentation based on medical decision-making, which I'll focus on a lot in this lecture, or your total time spent with the patient. They did modify the criteria they're using for medical decision-making and they deleted one code, the new visit, CPT 99201. And they changed the duration of some prolonged services in the 99417 code, mostly related to inpatient rounding in the ICU. So this is the chart, you can find this on the AMA's website. It looks very confusing at first glance, but I'm gonna kind of break it up in sections for you. And I think you'll find that if you're doing some of these things in the office, it's actually easier to code for an orthopedic surgeon at a moderate level than it used to be based on some of the things we're discussing with a patient, such as risk and complications related to procedure, or if you're at a tertiary center and patients are bringing lots of CAT scans, both discs with reports, and you're not billing for those services to actually help increase your E&M service level by reviewing them independently. Again, these are some of the outpatient E&M codes we'll be looking at. Again, they got rid of 99201, so really for a new patient, not seen in the last three years, you can code two through five. They still have one through five for established patient, those who have been seen in your office or outpatient facility. And then consultations, more and more insurance companies aren't accepting these codes, but they do still exist within the AMA. One thing you need to have now when you're documenting is a chief complaint. This is required for all E&M visits. And what it's really doing, when you look at the first part of medical decision making, it's setting the medical necessity for the counter. So you need to document a chief complaint, that's critical. Your history can be whatever you feel is medically appropriate. So in medical school, when they were teaching cold rear sits or whatever mnemonic you learned for documenting the critical portions that insurance companies and third party billers were looking at to reimburse your decision making, they all did away with that because people would generate these histories that weren't relevant. Now, it's what you think is relevant for the reason that chief complaint that they're there at that visit. It has to be relevant to the encounter. And again, they don't care how many words, how many lines, it can be what you deem to be medically appropriate. So I think this is nice. It shortens the visits. It makes the office notes easier to read and communicate when another practitioner is sending someone to you. And I think it's a plus. These are the three things they're looking at when they're talking about medical decision making and coding. The first is the complexity and number of problems you're addressing. Second is data or studies that are being analyzed and reviewed. And the third is risk of complications, the morbidity and mortality of the patient's management. That can be surgery or a prescription of therapeutic drugs. So for the first part, when you're looking at the number of problems, the problems can be minimal, low, moderate, high. Something that would be high would be something, someone with a Charcot or perhaps a malignancy or someone even with an open fracture. This, and we'll get into high in a minute here for that, but toe pain would be under low or minimal. And most fracture work falls under moderate. They define the problem as this disease, condition, or illness for which you're addressing at the encounter. So for example, if you mentioned that they have hypertension in your history, but you're not focusing on that, not documenting it, that is not a problem that you're addressing. And again, highly morbid conditions can drive your medical decision making, coding level even higher, even if the ultimate diagnosis itself is not highly morbid. And so again, it is truly the problem that you're working on in the encounter is what you're basing your medical decision making and coding off of. And that's a critical point for this AMA table. Those things that are, again, another healthcare professional is monitoring, such as heart disease or their diabetes, that can't go into your medical decision making. You're there for the orthopedic care and that's what you need to focus in on. When you look at the type of data you're reviewing and analyzing, that can count for EMGs, that can count for lab studies, that can count for CAT scans, radiographs. The exception there is if you own your x-ray machine and you are billing for the x-ray service, you cannot count that in the complexity of data reviewed. So that would not count as a separate point. We'll get into an example a little later to clarify that. But again, the critical part is that if you are independently reviewing the study and the report and then determining your own interpretation of that, it counts towards your medical decision making level. And a lot of times if you're reviewing an outside study, that one review of an outside test can actually put you at a level three visit immediately. And again, I kind of mentioned this, but you cannot count a billed service and interpretation of an x-ray in your medical decision making. So if you own the x-ray and you're billing for the interpretation of the records, that cannot factor into your level of service. And then the third element here is the risk of complications, morbidity, and mortality. And the AMA actually lists an open fracture as a highly complex condition. Moderate would be anything from elective major surgery as long as they don't have identifiable risk factors. But if you have a highly comorbid patient and you have a long discussion about limb salvage or amputation, that actually can be coded as a high level visit. Things like intraarticular injections actually fall under the AMA's description and narrative for moderate level risk. And so when you're coding these visits, keep that in the back of your mind as long as you document that appropriately. You can be elevating your E&M codes as long as you're using the medical decision making component to bill when you're having these office visits. Again, high here, we talked about emergency major surgery, open fractures, highly comorbid patients, and then the decision for hospitalization. If that's involved in your outpatient visit, that actually counts as a high level visit. Time, this is pretty self-explanatory. I think the one thing that people get in trouble with here is if you look carefully there, I've highlighted it's the total time on the date of the encounter that includes both face-to-face and non-face-to-face time personally spent by the physician. And those non-face-to-face things can include preparing to see the patient, looking at all the tests, going through their seven inch chart before you walk into the room, counseling and educating, whereas before time was face-to-face time, counseling, educating the patient. It now, the AMA wants us to include our time spent going through all these things. What you cannot have if you're billing on time is the impossible day. So if you're billing everyone at a 45 minute visit and they assume you're working somewhere between 10 hours in a day to 12 hours, you can't go over 12 hours if you're billing on time. You'll get flagged and audited. So it can be appropriate to use time. You just need to think about these things if you're gonna bill in that fashion. And we just kind of covered this. The important thing is the time spent. There is a change from the 95 and 97 guidelines which is predominantly for emergency room positions. So we're not gonna talk about that. You can't count travel and you can't count services you're performing in the office as part of that time spent. And teaching with trainees can get a little tricky. If you are there educating the patient and the trainees in the room observing, that does count as face-to-face time. But if you're sitting there outside the room going through the new classification for progressive collapsing flat foot deformity, that wouldn't count. So this is one example. A patient comes in 56 years old. Chief complains ankle pain. So you hit the ankle pain. They're there for a second opinion. You have a very quick history saying they had an ankle fusion and now they have pain. You look at an outside CAT scan that they brought with them and it does show a non-union. You interpret that and you go through the results with the patient. That would be an E3 and the documentation could only be five or six sentences in this instance. Whereas before to catch an E3 you would have to hit review of systems. You'd have past medical history involved and certain physical examination findings. You don't have to document them anymore. You could simply bill that level of a moderate level based on category one, which you see you've reviewed one, any combination of outside tests. And so that would be a way to bill and code this visit. Does anyone have any questions on the updates for medical decision making and time billing before I jump to split shared visits? Okay, we'll have time at the end for questions too if something comes up. So when we say split shared visits and these were just updated in July and they're gonna be updated again in January 1st of 2023. This is a visit that's seen at a facility in combination with nurse practitioner or physician's assistant. This was what Penn State sent us when July one happened and it's incredibly busy and I'm gonna break this down in a much more simpler fashion for you. The change, the big change here is that CMS as of January 1, 2023 only cares about who is spending the lion's share of critical time with a patient in the face-to-face encounter and in the preparation. And so initially they wanted to look at when you're doing a split shared visit, who's doing more of the documenting, who's spending more time with the patient, you could bill on medical decision making and on time and that was in July and then they changed it again coming up in January 1st. And so initially this split shared, again this is, and I underscored, is in a facility setting where the physician and non-physician practitioner, i.e. a PA or NP, are in the same group and seeing a patient and splitting the visit. More than half of the time must be spent by the one who's actually doing the billing and the one who's doing one of those three key components which you're using for your medical decision making. And your total time is actually the time spent by both the nurse practitioner, PA, and the physician. And then the provider who bills is the one who spends the substantive portion of the visit which is the majority, more than 50% of the time. And I'll have an example of not only what that would look like but how you should document these when you're doing these visits. And coverage of these are at an institutional setting. So this won't be applicable to all providers in this room but those are institution or a setting that falls under these categories and seeing patients with a nurse practitioner or physician's assistant can bill this way in a split shared service in the following settings that we've listed here. Again, those are the services where you can bill this. The new ones are these new patient encounters. This started in 2022. Inpatient rounding and encounters and consults. And then in critical care this has application which doesn't really pertain to orthopedic surgeons. And so again, effective, and I apologize, that should be, this was January 1st they rolled this change out where it was either time or the medical decision making and they're changing it in January 1 of 2023 to time only. As of right now, the provider who spends more than half the time signs and dates the record, sends the bill, and that's who's responsible for the billing of this. So for an example here, a substantive portion in this visit would be defined as your practitioner spent 10 minutes with the patient. Physician went in and spent 15 minutes. Your bill would be a 25 minute office visit. The physician would be spending more than half the time so they would be the one submitting the bill. Qualifying time that counts for outpatient services is the exact same as what we listed earlier. All the preparation review of records will count for your time. The only things that don't is teaching and travel. And the other services which we already went through. And again, it's critical that you document in your note who spent the substantive portion and that would be the person billing. You have to do these things when you're doing this documentation to get credit for it. You need the identity of the PANP, the time they spent distinctly. You need to differentiate who was doing what during the visit and the medical necessity of those services and it has to be signed and dated. The slide deck for this will be up online and I believe the AMA has these requirements. I have a template in the next slide which we'll go through. And again, you wanna be the person who's doing the most and this is really for the teaching physicians and those working in a hospital setting. And so this is what it looks like. If you wanna take a screenshot of that or again, they're on the slide deck but this is a template we have at work when we're using this at Penn State and you just come down and you check who did what parts and who spent what time and then you bill accordingly. And again, it must clearly state, this has been said several times now because it's important and they've made it very clear that they will not cover split shared visits unless you're documenting the, not only time but the billing provider has to be the one making the medical decision, medical decisions in the encounter. And again, these rules come into effect January 1, 2023. Where it's truly the time that you are spending not only substantiative but it has to be in the medical decision making process. It has to be documented. And this is disclaimer saying this is for educational purposes for the AMA. All right, thank you. Thank you. That was great, thanks Mike. Now we're gonna have Dr. Guyer talk to us about disruptive physicians and how to manage them. Just as a note to the AV guys in the back, we can't see this screen from where we're sitting. I'm gonna push the screen back. Is that okay? I'm not gonna disrupt it? All right, good afternoon, I'm Aaron Geyer. I'm a foot and ankle specialist at Tallahassee Orthopedic Clinic in Tallahassee, Florida. Just to give you some background, and one of the reasons I'm talking about this today is we are a 34-man private practice group. And as part of our governance, each of the partners will rotate through being a managing partner for two-year periods. I just finished that role up about a year ago. And so I had to deal with a lot of these issues because the managing partner and our medical executive committee are the people who have to deal with difficulties with partners and also nurse practitioners, PAs that work for the practice. These are my disclosures, none of which are really relevant to this talk. So I'm concentrating in this talk on disruptive physicians or other providers. You can apply this to nurse practitioners and PAs as well. And first thing we wanna do is define, what is disruptive? What does it mean to be a disruptive provider? We all know people in our group or at our facilities that have the reputation of being a hothead or throwing fits or doing other things that are considered inappropriate. There's a lot of causes of why people act this way. Sometimes that's just their personality, that's what you chalk it up to. But a lot of times you can also see other causes that may be due to a change in their personal life that could be a red flag as to something else going on that's affecting them. What we need to determine, however, what is this level of disruption? Is it something that is destructive? Is it something that's kind of annoying but not really a destructive problem? And we're gonna go into that a little bit. So the AMA actually has a very good web page that talks about this. And there's a reference to that later on in the talk. And they actually define what disruptive behavior is. Disruptive behavior, as you see here, is any personal conduct, whether verbal, physical, or physical, that negatively affects or that may potentially negatively affect patient care. And this includes but not limited to conduct that interferes with one's ability to work with other members of the healthcare team. One thing to keep in mind is disruptive behavior should not be criticisms that are offered in good faith with the aim of improving patient care. But sometimes, we all have partners, and actually some of you may be this person, that the method in which you provide criticism may not be taken well by other people on the healthcare team. This is just a listing. This is what the AMA actually lists as their guidelines or their guidance for dealing with disruptive physicians and how to define it. And I'm not gonna go through this whole busy slide, but it is here and it's also gonna be in the reference I talk about at the end. I'm gonna go through kind of a summary of this. So disruptive physicians, as I said, we all know them, but this is a topic that a lot of people don't wanna deal with. Sometimes it's very hard for us to confront our colleagues. We, a lot of us are not adversarial. We don't like conflict. We just wanna do our work and care for our patients. But this is a topic and a problem that does make us come out of our comfort zone to address something that's important. One way to make this less intimidating and allowing us to do this is to have a very clearly defined plan and protocol when we have a report of somebody acting inappropriately. And it does take a team approach that I'm gonna go over an example we use in our specific clinic that works very well. And why do we even care about this? Well, we care about this because, and this comes from one of our employment attorneys that we use in our group, is you really need to address this problem because it limits liability to your group, to your hospital, because there have been over the last decade or so a peak in lawsuits regarding actions of people in different facilities, what we call a hostile work environment. And that is something that can be jeopardized, really the future of your practice and of your patient care. So when we do deal with a disruptive provider, we wanna have mechanisms in place that maintain cordial relationships among the physicians and other staff members. And we have to be able that there are mechanisms to place censure on the inappropriate behavior. There's multiple ways to accomplish this, but the thing to keep in mind is you don't want punishment to kind of be the over-aiming part of this. You really have to use education. And you'll see what I mean by this, I'm gonna go into that in detail, because a lot of times we have partners or practitioners that are acting in a certain way and they don't even realize they're acting that way. And I'll give you some examples in my group as we go along, but a lot of people are clueless that their actions are considered disruptive. Now there are several types of inappropriate behavior, some of them are really obvious, like blatant sexual harassment, blatant derogatory comments, violent behavior. But the ones that are a little bit harder to deal with and the ones that a lot of practitioners don't realize they have are some of the passive aggressive behaviors, or even sometimes comments that they don't see as being wrong, but everyone around them does. If you see a practitioner in your group that normally was pretty even keeled, never had any problems, but all of a sudden there's a change there are other reasons that you may want to consider. Could there be some other mental health issues going on? Could there be substance use or abuse problems? Are there other medical conditions that have caused a change? These are things to keep in the back of your mind when you're going through this process of addressing someone with inappropriate behavior, particularly in people that you've seen a change in over time. And there's multiple resources we can use to address each of these conditions, each of these problems or causes of the behavior in addition to what we use for addressing this in general. Now, and this comes directly from the AMA, there should be a clear process to evaluate a complaint. If there is a complaint against a practitioner of inappropriate behavior, we need to have a process that's very well defined. Once a complaint's made, we must have a method to investigate it. And there should be designated people in your practice, whether it be a committee or contact people that the complaint can be assigned to and to investigate that. In our practice, we have a very defined system where our human resources has a contact person and then it can be bumped up to the medical executive committee if needed. If you're in a small group and you don't really have an executive committee, it's recommended, the AMA has recommended that you have a procedure for consulting with another partner that's really an influential person, maybe one of the founders of the group, something like that, that can also help in this process. Documentation is probably the most important thing when you start going through this process of investigating inappropriate behavior. There has to be a system, there has to be a system to report the inappropriate behavior and it should protect the person who's making the reports. And what we've run into, and I ran into this myself in my practice, you have to have both an internal reporting system, but there also needs to be reporting systems at the facilities. We ran into a problem where there was a physician in a group who had been causing problems at the hospital and had an incident that was very well documented by their group, but the hospital itself never documented it, so that when the group, and this was not my group, went to try to censure the person, they couldn't, basically. Their healthcare attorney said, you don't have enough documentation. The facility it actually happened at never documented it. And this can be a problem. Sometimes that's out of our control if you're working at multiple hospitals or a facility not controlled by your group. But that's something to keep in mind that's very important and you definitely should have something set up in your own group for having documentation that's kept on file. Another way you can have a system for both this process of addressing inappropriate behavior and documenting it is actually to have it in employment contracts. Now this is, there should be an outline, basically, of what is considered inappropriate behavior, both clinical, behavioral, and it should also address how someone is acting towards your own employees as well as other facility staff. So a hospital may not be your staff at the hospital, but your partner is working there. And the penalties for inappropriate behavior should be pretty clear, should be spelled out. I'm gonna use our practice, Tallahassee Orthopaedic Clinic, as an example of how we do this. And this is just an example, but it has worked pretty well over the years. So when any of our physicians are hired, either as an employed physician or they become partners, there is actually a disruptive behavior section in their contracts. It actually defines very clearly what behaviors are considered inappropriate. There is also a very defined method for a complaint to be evaluated from both internal and external sources. And the severity of behavior determines kind of what the penalty and evaluation process is. We have a tiered system for each reported offense. And the reason that is is sometimes, you may just have one complaint that's maybe a disgruntled staff member at a hospital, didn't like the way a day went, and you get one complaint against a physician you'd never expect. But if you start to see a pattern of multiple complaints and problems, that's where this tiered system comes in for evaluation and penalties. So in our group, all complaints and reviews are kept confidential. We keep it at the kind of executive level, the CEO and the medical executive committee evaluates it. So if there's a first complaint, there's a meeting with the CEO, the managing partner, and the head of HR. It might be brought to the medical executive committee for review if that's what the CEO and managing partner and the head of HR feels needs to be done. And there's usually, depends on what the behavior is, but usually there's no penalty. And we may recommend counseling or other programs or just have internal counseling or even refer them out to a counselor, depending on what the behavior is. The second complaint, however, it does have the same evaluation initial review process, but usually if it's the same type of complaint, there's a recommendation for additional mandated counseling. And this may be, we may refer them to a psychiatric counselor, for example. There may be a monetary fine. A lot of times that's discussed at the first, if there was a first complaint, that if you do this again, you may have a monetary fine assessed. Sometimes we even will do a written agreement to be signed by the disruptive practitioner as to what the next penalty could be. And that could be, and that again depends on what the inappropriate behavior was. Sometimes it's as bad as if you do this again, you're fired. Other times it could be, if you do this again, you definitely have to go through more counseling or go to a certain program. And so that a lot of times we have, is signed and it's put in the record. If you have the third complaint along the same lines, that is much more serious. There's more severe monetary fines that we have in our contracts. We may suspend the person, we may terminate the person. If you get to this point, or even before this, depending on what the complaint is, a lot of times you need to consult with your practice's employment attorney about what's the best thing to do. Do we have enough documentation? What needs to be the next step? So that is, and then there's, usually we don't go beyond third complaint, but there are mechanisms for addressing it if this behavior was minor and got worse over time. Corrective actions, so again this depends on what the inappropriate behavior was. But we do want to, and this is one of the reasons you see in our tiered structure we have in my practice, that monetary fines or penalties are usually not in that first complaint zone there. We want to identify the cause and provide counseling. And like I said, a lot of practitioners don't even realize, they're kind of surprised. A lot of times we bring this to attention. You had a complaint at the hospital that you did this in the OR. And a lot of times our practitioners are like, really, I don't even remember that. I don't remember doing that. So a lot of times we want to educate first. And that, in most cases of something happening, when we go through that, there's a first complaint. If we do these things correctly, a lot of our physicians, they never have another problem. If, however, you're getting continued problems or somebody's a repeat offender, that's when you can also have a punitive elements such as suspensions, termination, fines. But it should not only be punitive. This is why we use this tiered approach and system to address this. There are other resources out there outside the practice that we use as well. There are certain behaviors that we will recommend. You need to go see a psychiatrist, you need to see a psychologist, you need to see a substance abuse counselor, something like that, depending on what is going on. There are other well-known national programs as well, specifically for physicians. And I've listed one here because this is the one that is, I guess, certified by the state of Florida, their medical board, their board of medicine, to address problems such as this. And this is one of them, there's several ones out there. Your state may be different of which one your board of medicine recommends. But this is the Professionals Research Network. And it's a very comprehensive system. It's used for all kinds of inappropriate behavior and other problems. So if someone has a substance abuse problem, they can address this. If they have harassment problems, they can address this. There's a lot of different things that they can address, but it's a very structured program. And this is important if somebody in your practice has done something that could result in them losing their medical license. And that's one of the reasons, like Florida has chosen this one, for example, the board of medicine has as a certified program to address these things. And this is their phone number and website there. But in your state, you may want to look that up because it could be different from state to state. So in summary, disruptive physician behavior can be detrimental to practice. And this is why we need to address this. And it's very important to have a clearly defined system to handle this problem. It makes it much easier. It helps to document what's going on. And education, I can't stress this enough, education and counseling needs to be the most important part of the solution in addition to punitive measures. It should not just be punitive. We need to educate and counsel. And that's it. Thank you. Aaron, that was terrific. Thanks, that was a great talk. I'm gonna, I just have a couple questions then I'll open it up to the floor. Since Aaron just spoke, so Aaron, I'm at the Rothman Institute in Philadelphia. We're a very large practice. We have over 300 physicians. So we've seen like a lot, right? Like if you have enough people, you'll eventually see everything. And I kind of like wrote it down. We've seen people who have like tried to like game our system to like get more new patients than the other ones, other people in their division. We've had people who've had not only personal opioid abuse, but also opioid abuse in terms of prescribing to what essentially is addicts. We've had partners lying about other partners' behavior and incriminating them in a legal sense. We've had a lot of different stuff. We've had sexual harassment. We've had crimes, people convicted of crimes. And then the last one that I wanted to touch on is we've had people. The Rothman Institute is very large. We have lots of surgical centers and stuff. And we're not the only ones who use these centers. We've had people who've been accused by the FBI of fraud who work at our centers, but they've been accused of it. They have not been convicted of it. So in all these scenarios, they're awkward. They're really uncomfortable. These may, in some ways, sometimes be your friends and colleagues. But this behavior is completely inappropriate and intolerable. So I have two questions for you. The first one is, how do you fire these people when they need to be fired? Because it's super complicated, because they are legally entangled in your group through buy-ins and contracts and owning numerous things. It's been complicated for us. I think at the end of the day, we've had complex negotiations amongst a board, an executive committee, the aggrieved physician. And we've allowed them to leave without a restrictive covenant, which is usually quite cumbersome at the Rothman Institute. And that's how we've parted ways. In the example of the surgery center, we have, as a board, elected to say, you can still get your revenue from the surgery center as a owner. And this person is not part of my organization. But you have to voluntarily withdraw your privileges temporarily until the case is solved. That's unfortunate, because that could be years. And maybe he's not even guilty of it. So again, these are complicated scenarios. How have you guys dealt with these types of things? So it is really complicated. I was trying to give a brief overview. I think the first thing I would do when you have to deal with these problems, when you are in a position such as a managing partner, whenever I, and yes, these are your friends that sometimes you have to deal with. The first thing I say to them when I talk to them about a topic like this, I usually would say to them, I'm talking to you as the managing partner of the group. You do not take this personally. But I have to talk to you on behalf of the group, because I've been appointed to do that. So that's one thing. The second thing is, it depends a little bit on your contracts, of what your employment and partnership contracts say. We have very specific language for certain things. We have more broader language for other things. And this is why, if it's something that's getting to the point where you may need to terminate a partner or an employed physician, you get your health care attorney involved. There is a lot of times in the contracts we have some leeway. So we could, for example, say, like in our contracts we have like firing for cause or without cause. And there's different stipulations of how that has to be done. But there is also a lot of times with the way we've done it, is there is some discretionary part of it that's up to the medical executive committee and the board as a whole. So you can decide, OK, if you just resign, we won't fire you with cause. Because that looks a lot worse on a resume for people. There may be situations where you do not want to do that. You want to fire them if it was something egregious. So you have to have a framework. I think the big point, you have to have a framework that's legally binding in your contracts. You get your health care attorney involved if it ever gets to something severe of getting rid of a partner. But there should also be some degree of leeway that's discretionary to the governing boards of the organization you're with. Yeah, I think that was a really good point. One of the things that we have in an organization is a conduct committee. And so that's the way we handle that. Mike, I do have a couple of questions for you. So how are you measuring time? Are you saying, oh, I felt like I was in there forever? Or what are you doing to actually measure? I saw the form, but like, yeah. Yeah, that's a great question. So I will rarely do time and mostly do medical decision making because you avoid those impossible days. And I don't want to be stuck going, oh, OK, that was a 45-minute encounter. That was a 30. But if it's an instance where maybe out of the 50 in a day, one or two is appropriate for time-based billing. Because you're not reviewing studies, but you spent 45 minutes talking to them about, you know, or the whole thing was 45 minutes, you know, limb salvage or something complex like that. We have a, when the medical assistant sees them in our EMR, you can, there's a timestamp. And then when you enter your charge, there's a timestamp. And so I just use those two. And so what about the shared visits? Because that requires time, like, to be looked at. Yeah, so I, when all of this came out, I find that to be cumbersome. And so I asked our administrator at our, and I'm in an academic institution, and if you're at a hospital-based system, I actually had them set up our practitioner in clinic next to me, seeing their own patients. And I'm seeing my own patients. I just, I find it too difficult. I know there's some of my senior partners who are so accustomed to working with a practitioner on every single patient, it has been very cumbersome for them. Because you've got to sit there and go, okay, who spent more time with the patient? It can be frustrating, because it's a very big change. So my solution to it was just, I'm going to see mine, and they can see theirs. And that's kind of how I address it. And then lastly, like, what's a level two visit? And like, even if there is a level one visit, like, what are those visits for you? What's occurring at that visit? Yeah, so, never. In an orthopedic standpoint, right? It is rare to have a level one in orthopedics now, based on the new medical decision making. If you just hit those few points of documentation, and again, go on the AMA website, print out that card. I have like 15 copies plastered in our clinic, and when the fellow comes in, I make sure they go through it. Same with our residents. And so most visits are a three. Some fours, I never used to do a four. But if you look, and you have a Charcot patient come in with a cuneiform dislocation that's an open fracture, or open injury, and they're high risk, that's a four. But you'll also use time on that one too, right? You could. Frankly, I think it's easier, again, so you don't have to spend time making sure I'm not going over my daily allotment. It's just easier to use the medical decision making, billing, and make sure you hit those bullet points. But if you aren't billing for your own x-ray reports and interpretations, and you're looking at a lot of outside films, very easy to get to a three. Now if you own your own x-ray, and you're not, then you have to be careful about the complexity of the visit. And I think that's where you go to that third column, risk, and you're looking at what you're doing. And I think there's some nice examples, but again, you saw intra-articular injection is a three. And so I think, while you highlighted the conversion factor's gone down, like you said, E&M, they anticipate going up with these changes. Which could be helpful for, I think, hand and foot and ankle, honestly. At least for office billing and coding. That's great. Any questions from the floor? Hi, this is Pinnit Physical from Dakota Dudes. So for a return visit, if we go back and review the x-rays that have been done at the first visit, and those been re-evaluated and re-dictated, can we take credit for those x-ray that used to be done? As long as you didn't bill for the service, yes. No, no, no. I think in the scenario he's talking about, he billed for it before. Like prior x-rays. No, if you are the billing physician, and you cannot reinterpret your interpretation. Okay. But if, like at our institution, a radiologist is interpreting those films, and you went back and said, let's say you have a non-union develop, and you said, did I miss that at week six? Or was something happening? Let's say I reviewed, interpreted, radiographs performed six weeks ago, and noticed a loose screw that I did not notice at that time. That counts as one under your data reviewed and utilized. But in your scenario, you never billed for that original x-ray? I never billed for the x-ray in my institution. So that's a critical part. Now, if you're getting vitamin D levels, and you're reviewing those, and say, patient's vitamin D is 22, I'm going to make a decision off that. That is a, that's one box in your medical decision making. Now you're at a three. And one more thing. And you said there is a, you know, rule for the time that can go over so many hours per day. So is everyone, you know, is kind of actively being monitored and cataloged right now, and, you know, throughout across insurance company and stuff like that. So it's something that really critical that we need to watch out for, or it's hypothetical scenarios. Yeah, so, I mean, correct me, Dave, if I'm wrong. The AMA hasn't, doesn't explain how they audit you, but it's very, with EMR, there is timestamps on when you're going, when patients are going in a room and leaving room in most places, whether you're at a private or academic setting. And so, you know, 10 times 60 is how many minutes are in your day, or, you know, 12 times, you know, 60. And if you're billing more than that, they're going to flag you. It used to be mostly for medical services that were audited within hospitals for medical practitioners who are coding fives, right? And that had a minimum time amount associated with it. And if you had enough of those in a day, it was just an impossible scenario. And so, it was easy to flag at that point. But this is obviously very different now that we're all going to be using time. Hi, Tim Charlton from Cedars. I was coded by, or tasked by my institution to do the coding and billing. So, very familiar. I would appreciate your talk. One thing that the attorneys have spoken to us about, and this is all vetted, is I would actually suggest that your level three coding is actually undercoding. I think we're all leaving money on the table. The coding wizard in Epic really sort of helps you if you have Epic EMR. And if you independently review an X-ray on the date of service, and you talk to them even about surgery in declination, i.e. you don't need surgery, or you give a prescription medication like Celebrex, nonfulterin, that's a level four. That is, by definition, a layup level four. So, I was surprised to see the non-union. A CT scan from an outside institution for a non-union and a CT, that's a layup four. So, I would just, I would love to talk to you about it, but I think we're leaving, if you're not coding a four, you're not trying hard enough. I'm regularly coding fours. I mean, not every patient, obviously, but. Yeah, the risk. Which I didn't used to. It's a great point, Tim. The risk is well-defined on the AMA website. Again, open fractures, hospitalizations, surgery with any comorbid condition will get you to four, yes. And so, yeah, go ahead. Would you mind coming to the microphone? Oh, no, no, no. Would you mind just coming to the microphone? Yeah. They're just recording it, so. As a practical matter, I found, and my coding people have found, that if you have an existing patient, for example, they're past the head surgery, they're past the 90 days, the fusion is in healing, and now you determine you need to go back and bone graft or revise hardware, that's a three. They won't pay you for a four. You can document all you want, but you will not get paid for a four. At least in Texas. Again, back to Tim's question, if there are identifiable risks that make it a high-risk surgery, you should put the four in. Which there should be. And based on the new MDM guidelines the AMA set forth, they should be reimbursing you. So you should be able to get a higher code if it's an established patient. Yeah, and I think so. Even if it has a new problem. The new problem is, you know, fusion with non-union, orthodesis with non-union. So it should. That should be an E4 on that case. And I think that the thing here is forever. It was very rare. That's good news. Very rare for us to bill fours. I mean, raise your hand if you've billed a four, N4, E4, more than one or two a clinic. It's rare. Okay, yeah, a couple hands, but not the majority. Sorry, just for a clarification. Just the procedure, if you're wondering what a major complication procedure is and a minor is, a major procedure is anything with a 90-day global. So if you're doing a Morton's neuroma and you're covered by a 90-day global, that is by definition a major procedure with comorbid stuff. So, I mean, virtually everything that we do is a major procedure. The only thing that's not covered is an injection because that has a 10-day global. Oh, nails. Yeah, no nails. Yes. Jonathan Wolf, Boise Idaho. That discussion for hospitals or the discussion regarding the hospitalization, do you get credit for that, whether it's for or against hospitalization? Can you basically say, you know, I discussed the pros and cons and this person will not need admission. Do you get credit for that? Unclear, but I think if a discussion is well laid out in your narrative and you code a four, that would be very appropriate. Yeah, it sounds like it just makes the interaction more complicated, so more complex. Where do we go if we have a specific coding question that I go to my hospital coders and they know less than I do and I just can't get help? Can I address an email to the Foot Society or someone or who? Yeah, absolutely. It's right on the website on the practice management like resource tab. You can email. We get the emails. Yeah, absolutely. Mike. Yeah, you mentioned level one. I learned that, the way I learned it is that physicians can't code a level one. You have to be a PA or nurse practitioner even to code a level one. That's the way I learned it. So I'm never coding a level one ever. New and one is gone and the established is really meant for PAs and physician's assistants. And then can you code a level two if someone's coming in for like a routine cortisone injection? Or can you only bill for the injection? I know that's become a problem with like knee injections and Medicare patients and stuff like that. Well, Medicare won't. They'll pay for one. They'll only pay for one. If it's a new patient, you can use a 25 modifier as a separately identifiable service at the time of the injection to get paid for the E&M service as well as the injection. But if it's a followed patient, it's one or the other if we're talking about Medicare. And like any other Medicare rule, most private insurers have just followed suit. I knew it was that way before. I didn't know if the changes, now they are paying for it. I just seem kind of. No, I don't think so. Maybe document. Yeah, unfortunately. Well, in the interest of time, I want to thank everyone for attending. I hope this was enjoyable and we look forward to seeing you through the rest of the meeting. Thank you.

coding

legislative updates

E&M office changes

AMA

medical decision-making

disruptive physician behavior

positive work environment

evaluating complaints

confidential documentation