Good evening. On behalf of AOFAS, I want to welcome you to the second session of Crack the Codes, Practice Management and Coding Series. Tonight's session, session two, CPT Revised Guidelines for Evaluation and Management of EM Office Outpatient Visits. Tonight's presentations will be given by Jennifer Bell and Jennifer Cabrera. You can find their full biographies and disclosures in the program document posted in the chat box in the on-demand education center. The series is funded by the Orthopedic Foot and Ankle Foundation, supported by grants from Paragon 28. Just a few housekeeping items before we kick off the presentations. For technical difficulties, please try closing your browser and logging back in the same way you did the first time. Registered physician attendees may earn one hour of AMA Category 1 CME credit by completing an evaluation and CME claim form at the end of the full series. Tomorrow you'll receive an email with a link to evaluate this specific session, and then at the end of the seven broadcasts, you'll be able to evaluate and claim CME for the full course. We are recording this broadcast and it will be available in the on-demand education center tomorrow afternoon. The recording will be available for your use for one year. We do encourage you to ask questions during the presentation. To send your questions to the faculty, click on the Q&A tab in your navigation bar and send it over. If we can't get to your question tonight during the live broadcast, the faculty will provide answers that will be posted in the on-demand education center. I'll now turn the program over to the faculty to begin. Great. Thank you so much, Alina. And while I share my screen here, I just want to say I'm Jen Bell. And forgive me. I clearly can't share my screen and talk at the same time. I'm Jen Bell and I'm here with my colleague, Jen Cabrera, and we've got a lot of information to share. And I know last week there was a lot of information and we didn't quite get to Q&A time. So I'm going to be more brief tonight. And tonight we're strictly discussing the 2021 revised guidelines for those office outpatient visits, 99202 to 215. Those are our bread and butter visits in the office. So that's what we're focusing on. So we're actually looking back to what originally happened in January of last year. Here's the team. If you have any questions or need any help with anything with your revenue cycle, feel free to contact us and we'll be more than happy to help. So again, we're just talking about those new and established patient visits tonight. One of the good things to get out of the way up front is that there have been no changes to the definition of a new and established patient. A new patient is still someone who has not received any professional services, has not had a visit with anyone in the exact same specialty and subspecialty within the last three years. So great. No changes there. And again, just to point out, these are the subspecialties, the specialties and subspecialties. CPT says specialty and subspecialty. However, they don't define what they call a, you know, subspecialties. So that leaves us back to going to the Medicare manual where Medicare defines. Some payers might have a little bit more leeway, but most of the payers are looking toward Medicare guidelines at this point. So as you'll see in orthopedic surgery, unfortunately, foot and ankle is not its own specialty. So that would be classified as orthopedic surgery unless, you know, your sports medicine or PM&R and your office staff would be able to let you know how you are registered and credentialed with Medicare on that. So just FYI on that, foot and ankle is actually not its own recognized subspecialty. And just to reiterate, nurse practitioners and PAs and your CNSs all fall under the same specialty as the physician that they are under. Just a quick grid. Let's look over there in the right hand side where it says ortho joints new, and this is just a quick look at what it might be. Okay. So if the patient comes in, new patient's Dr. ortho for a joint issue. And then they complain of hand problems. And so Dr. ortho joint sends the patient to Dr. hand, that would be a new patient. However, now they're back, something's going on there. So Dr. hand says you need ortho spine, again, established. So now ortho spine says, well, I think it's time for PM&R to get involved. That is a separate subspecialty, so that would be a new patient. Back to Dr. hand, and eventually back to ortho foot and ankle. So this patient has made their rounds, and as you'll see, ortho foot and ankle up there is again established. So this is if a patient, and we hope this is not the case, but if a patient ever had these needs within the same three-year period, that's how it would land. And we're getting that information off of those Medicare lists. So changes for 2022, or 2021, excuse me, how did we get here? Well, in 1992, AMA first developed the E&M codes, and CMS in the same year developed the WorkRVU system. Then in 1995, and again in 97, CMS gave us those E&M guidelines, the documentation guidelines that we all know and have used for so very many years. Then in 2021, CPT said it's time to make some changes. EHRs have made a lot of documentation irrelevant and more and more work, and it was to decrease the paperwork for the physicians and make it more meaningful all at the same time. And CMS says, yes, we're going to adopt those changes. So in 2021, the changes we talk about tonight are those changes that happened then. And again, in 2023, January the 1st, as we talked about last week, then they went ahead and adopted these new changes for the hospital inpatient observation, ED visits, and consultation codes. So this probably will look familiar if you saw the last session that we did. So in 2021, on January the 1st, everything to the left-hand side of the hourglass stayed under the old history exam and MDM rules. So that's every other kind of E&M service stayed under the old rules, or the original rules, as we say, and including the box underneath for time, 50% of counseling and coordination of care. So on January the 1st, they said, now for 99202 to 99215, those office visit codes, we can use either time or medical decision-making. And at the bottom, for time, the great news is that they took away the requirements, as you know, for counseling and coordination of care. So now time is not typical time, it's actual time, and they gave us ranges for those times. So we're going to take a look at that. What I want you to look at on these two slides is really, let's take a look at that right-hand side in the yellow column. If you'll notice, the work RVU values, and these are the new patients, the work RVU values actually went up for 2003, 04, and 05. So that's great news. And if you'll notice at the very right-hand column, the times actually changed from, again, from typical time to a time range of exact minutes. And 99201 was deleted because it also, along with 99202, had the overall MDM level of straightforward. So there was no reason to keep that code, the lowest level code, it was redundant. So they decided to go ahead and retire that code. Same for the established patient visits. Take a look, and this time they did not increase the value of the nurse-level visit, the 99211. And of course that would be a nurse or staff-level visit. We do not, we would never want to see a physician or APP billing for that. There is not, it's just not, your lowest level of an established patient visit should always be that 99212. So, again, if you, this time, level two through level five, the work RVUs were increased, and the time was changed from a typical time to date ranges. So first we're going to talk about leveling by time, and then we're going to get into the details of MDM. Because there are more details in the medical decision-making side of it, and it's just easier since we're already in the vein of looking at those time ranges, to go ahead and talk about time. So, again, just the same information you just saw, code 99201 has been deleted, and each of the levels have now changed to those time ranges. And something I want to point out here is, if you'll notice, if you spend 29 minutes with a patient, it's level two for a new patient. If you spend 30 minutes, that bumps it to a level three. Does this mean that we want you providers to go around with a stopwatch in your hand? Absolutely not. That would be crazy. You've got many more better things to do with your time. So, but it does make a difference. So we ask that you can, where you can, put the exact minutes, because it can actually make a difference, as you can see here in the levels. Total time is total time on the date of the encounter. It includes face-to-face and non-face-to-face time, but only the time personally spent by the physician or the APP, okay, on the date of the encounter. What can you include in total time? Prepping to see the patient, looking at history, looking at all records, performing your exam, counseling and educating the patient, family, and caregiver, ordering, again, ordering but not performing procedures, but ordering medications, tests, or procedures, referring and communicating with other healthcare professionals. So you might have to call their PCP or call one of their other specialists. That time would be included, again, as long as it's on the date of the encounter. And hallelujah, you get credit finally for documenting in the medical record. So you can include that time as well. And independently interpreting results. And this is very important, especially for our orthopedic surgeons, to have this opportunity. And we'll talk about that more in data in a minute. But again, it's not separately reported, which means you didn't bill for it separately, okay? So we'll get into that in a little bit. And communicating those results. And any care coordination, whatever that might be, home health agency, setting anything up, anything that the physician or APP does personally, that can be counted. Time qualifiers. Face-to-face encounter. And I can't tell you, we had to put this in because I cannot tell you how many times a provider asked me, well, it says now it's non-face-to-face so do I really have to have a face-to-face with the patient? The answer is yes. There always needs to be a face-to-face encounter with the patient, whether that's through at this time during the PHE, which was actually renewed this week. There always has to be a face-to-face with the patient whether it is virtual or it is in your office. Yes, it does say non-face-to-face time but that's after the face-to-face visit as well. So total time on the date of the encounter can be the combined time of both the physician and the APP but you can't duplicate the time. So if the physician and PA both saw the patient for 10 minutes, the time qualified there would be 10 minutes, not 20 minutes, okay? Clinical staff time does not count and resident and fellow time does not count toward total time. That time is still considered teaching time. Okay, now here I put the 2023 CPT descriptor reads and you can certainly go read that if you want to. The descriptor language changed just a bit simply to clarify the language. Nothing about the code has changed. So if you're already using this code or already familiar with it, the same concept applies but they did go back and restate it to where it made a little more since it was a little ambiguous before. So 99417 is that add-on code for prolonged outpatient E&M service time. So they changed it from office E&M, it's now outpatient. So because you can use it with consults and home visits as well. So they wanted to make sure to broaden that the categories there with or without direct patient contact beyond the required time of the primary service each 15 minutes of total time. And of course you would list that separately in addition to that highest level code for your E&M. And as I just said, it's appended to the highest level E&M. You do not count 15 minutes, excuse me, under 15 minutes. It does need to meet at least 15 minutes of time after that the highest level of your 99205 or 215 CPT and we'll get to this here in just a moment but CPT does allow use of the lower end of that time range. CPT says you can start counting from that lower end of the time range for adding that 15 minutes on. And of course it is an add-on code. However, you can use more than one unit. And here's the wrinkle or the fly in the ointment as we say here in Texas, CMS does not use 99417. They use prolonged service code G2212, okay? And here's why, here's our conundrum as we call it. G2212 has the same explanations, same requirements. It's for office or other outpatient each additional 15 minutes on the date of with or without direct patient contact. You put it, you use it in addition to that highest level visit. However, CMS states for Medicare patients it's beyond the maximum time, okay? So they allow you to count after you reach the maximum minutes listed on the code. So that's a little bit of a conundrum. And of course you'll want to work with your coders and your billers in your office to make sure that time is being counted appropriately. We know that you physicians have many more things to do than to sit there and count the time but we do wanna make you aware of the rules regarding this. So CPT says prolonged services start at 75 minutes for a new patient and 55 minutes for an established patient. Whereas CMS for Medicare patients says that prolonged services start at 89 minutes which is the highest end, the maximum number of minutes for a new patient and 69 minutes, which again is the maximum for an established patient visit. And yes, they have created their own code of the G2212 that we just saw to be used instead. Here's just a quick matrix. Some people like to see it this way. Let's look at that second row there under the new patient visit, the 99205 and that add-on code of 99417, okay? You'll notice at 75 minutes is when we can start adding that first unit of 99417. But Medicare says at 75 to 89 minutes, we can't add the add-on code of G2212 yet. Again, you have to go to the next line down, the row down and Medicare says, okay, you've met the 89 minutes for the 205. So now you can add that one unit. And the same is true as you can see for the established patient code. So now let's talk about medical decision-making. And I debated, Jen and I both debated as to whether or not to include this tool, but I wanted you to see the changes. So take a quick look at this tool. This is the original tool that was used in 2021 and 2022. This has got everything in it that you would need. And we're gonna go over it here in a minute, but it was revised in 2023. So I wanted to teach, even though we're talking about 2021, we're in 2023. So I wanted to make sure and teach the latest updates. So this is the look of the new matrix or tool that we use to get to the level of service for the codes. And you'll notice here in that first column, we've got both levels of each of the straightforward, low, moderate, and high. Each of the codes, both new and established patients now only require two out of three. So that's good. They did make that easier where new patients no longer required three out of three. Both levels now are both not levels, both codes for new and established at the same level require two out of three. And again, you can see that here, the straightforward, low, moderate, and high as we go across the rows down the columns. And so here are three main, just like last week, we went through this part together, the new names of the columns, the number and complexity of problems addressed, amount and or complexity of the data to be reviewed and analyzed, and the risk of complications and or morbidity or mortality of patient management. And these are called the elements. So when you hear us talk about it, you'll hear elements, elements. These are the elements we're talking about. And to make things a little bit easier, we call these problems, data, and risk, okay? So when you hear me say all of that, that's what I'm referring back to is this overall table of problems, data, and risk. And just pointing out here that for each of the rows, for each of the levels of medical decision-making, the individual elements are highlighted here that make up each of the levels. So you can find those within the columns as well. And what's new and different, and we're gonna talk about these here in a second, but you'll notice that I've got two of the problems addressed. Forgive me. Goodness, two of the problems addressed are highlighted. Those are new. And over in the third column, under the risk column, there are two new areas for risk as well. So what does it look like when I say, and I believe I went through this last week as well. Again, forgive me for my dry throat. When we say it meets or exceeds, what does that look like? Well, meeting two out of three looks just like this. Let's say the patient came in, they had a moderate problem, moderate data, and a low risk. Well, it met two out of three levels at a level four. So that would be a level four visit. However, you've got a patient that came in and they had a moderate problem, and we just had a little bit of data, so limited data, but really they didn't really have any risk. There was nothing going on there. Well, meet or exceed. So here we say, okay, at the low level, it meets, it exceeds, meet, excuse me, it meets, I'm getting my words backwards here, it meets a level three. So that would be your level three. It's as simple as that. So now problems addressed. Let's take a look, and first of all, what is a problem? It's a condition, a disease, an illness, whatever the patient is coming in for, anything that brings the patient in, the reason for the visit can be considered a problem. Forgive me, I'm gonna use a cough drop here. Addressed at the encounter, this is very important, okay? So it does need to be addressed at the encounter. It's not just that the patient has all these problems, but it does need to be addressed at the encounter to be qualified as addressed. And it can either be evaluated or treated at the encounter, okay? Doesn't have to be a specific diagnosis that you come up with, and it does not have to be treated, but it does have to be addressed. What counts as evaluated or treated? Consideration of further testing. So you're recommending this for the patient, whether or not they decide to move forward with it does not matter as far as counting toward your problem addressed. You get credit for saying, okay, this is what I recommend, whether the patient moves forward with it or not. You still get credit for that in your medical decision-making under risk. What does not count? Anything, any diagnosis codes that are listed where the patient, excuse me, where you did not address the situation, okay, without additional assessment or some type of care coordination. And of course, if you say, patient's got X, Y, Z, we're referring them to this doctor for this. So any referral out without any type of workup, that is not, that does not count either, okay? Okay, so let's look at that. The first column there, problems addressed, we're gonna look at these individually. Under minimal, self-limiting or minor problem. It's a problem that's, you know, just a prescribed course. It's transient in nature. The patient may not have even probably needed to come in, but they did, it's minimal, it's self-limiting. If you'll notice, two or more self-limiting problems moves that patient up from a minimal to a low level or straightforward, but minimal in that column, up to low, two or more self-limiting or minor problems. And then we have a stable chronic illness. Well, before we know what a stable chronic illness is, I do apologize for my dogs, my coworkers here. Excuse me for just a moment. Thank you, so sorry. Chronic illness, expected duration, it's an illness with an expected duration of at least a year or until the death of the patient. They're considered chronic whether or not it's controlled, it's chronic. Again, this is the only example and I hate that it's here, but this is the example we're given, uncontrolled diabetes versus controlled diabetes are a single chronic condition. We can't count even if it gets severely worse or whatever, whatever the condition is, it's still one chronic illness, a problem. What's a stable chronic illness? It's a chronic illness where the patient is at their treatment goal. If a patient is not at their treatment goal, it is not stable. It's pretty straightforward. If you feel the patient is not at their treatment goal, then that would not be considered a stable chronic illness. Again, we're just talking about low. Next is acute uncomplicated illness or injury. Pretty self-explanatory. It's usually a recent problem. Full recovery without functional impairment is expected. It's a problem that could be self-limiting, but it's just not resolving on its own, and so it's time to go in and see the doctor and get some help with that. This is a new category, stable acute illness. I actually love this one because of the past two and a half, three years that we've been auditing these visits in preparation for the changes in 2021. There was a category and we needed this one, and I think that's why they went ahead and added it. It's a problem that's new or recent. Treatment has been initiated and the patient is improving, but they're just not there yet. They're stable, but it's not completely cured or at their treatment goals. This is a recent addition, and we're actually really glad that they did create this category for all of us. We auditors and coders out there. This is a new one, and I was scratching my head. I think Jen can agree when we read this. I didn't quite understand the name of it, and I'm going to read it here. Acute uncomplicated illness or injury requiring hospital inpatient or observation level care. I'm not sure why an uncomplicated illness would require hospital care, but we did query the AMA about this, and they answered this with an example of what the intention was in adding this level, and it leaned into the social determinants of health. So I'm sure that we have all seen patients. You've seen patients where they didn't really need to be hospitalized, but in order to facilitate them completing the treatment or observing them for a few hours to make sure that everything is okay and that they're okay to be released because maybe they didn't have a home to go to, or they lived alone and didn't have someone there to watch over them, that sort of thing. That's why this level was put into play is you need to keep them at the hospital to monitor what's going on, but it really is not something that the patient would typically be hospitalized for, not the acuity. So that's what this was added for. Now for moderate. So we have quite a few issues here to choose from. So let's get in here to the one or more chronic illnesses with exacerbation, progression, or side effect of treatment. And I will say that down there in the blue box, you see the word mild was removed. So although it doesn't say this, there is another area higher on the table for severe exacerbation. So for this level, it doesn't say mild or moderate, but by process of elimination, I always say, okay, it looks like this was meant for mild and moderate. So with exacerbation, progression, or side effect of illness, it's acute, we've got that chronic illness, now it's getting worse. It's acutely worsening, it's poorly controlled, or it's progressing and we need to stop that snowball effect, okay? And it does require additional support or treatment, okay? Two or more stable chronic illnesses also qualify as moderate. So you remember in low, we had that stable chronic illness. So now if the patient has two or more, then that bumps it up to moderate. And the undiagnosed new problem with uncertain prognosis, I honestly don't see too much of this in orthopedics. I see it in a lot of our other specialties, but I don't really see it in orthopedics as much. However, you certainly can. We would think of these as more like bone tumors or masses or something that could potentially have a high risk of morbidity, something going on in there. It's an undiagnosed new problem, patient comes to you, it's a new problem, and you're not sure where it's going. That could be labeled as this type of problem. Acute illness with systemic symptoms. Again, now it's just not the musculoskeletal system. You've got a patient, maybe they've got a really infected joint, and now they've got fever and they're starting to really have some issues, redness and swelling and the whole nine yards. So that could definitely qualify, but really it's any illness where the patient is starting to show systemic symptoms, obviously for something general, and we wouldn't expect orthopedic surgeons to see people that come in with fever, body aches, or fatigue. For a minor illness, that would be completely different. That would be more of your minimal to low, but for the types of issues that you would see, this is definitely an option, and that's under the moderate level of risk, or, excuse me, problems addressed. Acute complicated injury, pretty straightforward. It's an acute injury that's not uncomplicated. It's definitely complicated. So we've got a complicated fracture here. We've got a shoulder that's not a injury, a big injury, something like that, something bigger with a risk of morbidity associated with it, okay? Again, this is on the moderate level, and it's, or treatment options are multiple. So definitely remember that. You've got an extensive injury, or the treatment options are multiple, okay? Now, the last category is high. So one or more chronic illnesses, again, with severe exacerbation. So this is just like that other chronic illness, only now the exacerbation, or progression, or side effect of treatment is severe, okay? Or that acute or chronic illness or injury that poses a threat to life or bodily function. So let's look at these two pretty quickly. Again, chronic illness with severe. So now it's not just something moderate that maybe can be treated in the office. Perhaps it's something more, and you may require escalation to over to the hospital for that patient. It doesn't automatically mean that they have to be hospitalized, but you may need to escalate their care, okay? And it has significant, this is when there is a significant risk of morbidity, okay? So severe side effects, severe exacerbation. We see a lot of the pain scale, and that's great, but that alone does not qualify as severe as far as when we're looking through documentation and it's very important for you to document, absolutely. But the word severe is, I'm not gonna say it's required, it is not required, but it really helps explain the situation. As I always tell my doctors, you know what you're doing in your head, we just need to see it in writing so we can explain to others what your thought process was. So it always helps if you do have someone that is having this type of an illness flare up that you document it as such, okay? And the last category under problems addressed is that acute or chronic illness that poses an injury, or excuse me, poses a threat to life or bodily function. Now they did say in the near term without treatment. In the near term, the AMA came back in March of 2021 and told us in the near term means imminent. So you're not seeing the patient, getting them comfortable, splitting it up and then waiting a week to do surgery. This is something that you need to take them to the OR today or tomorrow, or something in the near term. I mean, these are big bad things that could definitely threaten their bodily function in the near term, okay? So that's the difference there. So now let's just do a quick, what's the problem? Oh, and forgive me, page I have, yeah. So page 24. So on page 24 is where we are now. So you'll see the different categories there at the top. So we've got an initial visit for a 20 year old female with rheumatoid arthritis. So that would be what type of a problem? Well, we would call that a chronic illness with exacerbation, progression or side effect of treatment, right? It's a chronic illness and she's coming in, she's got issues going on there with her arthritis. So that's where we would say that safely landed. And of course, all of these depend on the documentation of the chart. We can't just say matter of factly that this is what it would be, but we are assuming that the physician or APP has documented appropriately in the chart explaining what is going on. Chronic illness with upset. And we just say upset so that I don't have to keep saying the long-winded exacerbation, progression, et cetera. What about an initial visit for a simple ankle sprain? So generally D, an acute uncomplicated illness or injury. Establish patient visit for an ankle sprain resolving without problems, self-limiting or minor, okay? And now, you know, with that new category, perhaps the new low category, depending on the documentation that said, okay, we've got this resolving issue that instead of just self-limiting or minor, but now, and again, it would just depend on the documentation. What about an initial visit for a 12 year old with spina bifida and bilateral club feet? So now we're looking at acute chronic illness or injury that poses a threat to life or bodily function. Okay, and I, two, you know, two very significant issues here. What about if it was a 12 year old with spina bifida? What would we call it then? Well, we would call both of these actually the same level that acute or chronic illness or injury that poses a threat to life or bodily function because they are so significant. So these are just, you know, all of the KZA colleagues, we all got together and we really talked about it and where would we put these types of conditions? So that's just what we came up with. You may come up with something completely different, of course, with your clinical background, but that's just kind of to give people an idea. So now, problem addressed. We've got an initial visit of a 50 year old male with DJD of the left foot, increased difficulty doing everything, ADLs work, stairs, et cetera. Well, we would call that E, chronic illness with upset, right? So all of a sudden it doesn't say it's severe, it just says really having difficulty now. Well, now this 50 year old is now on, on NSAIDs and having night pain, swelling and difficulty with stairs. Well, he's not getting better. So it didn't go down. It doesn't sound like, it sounds like it's not doing better. It's not saying that it's severely worse. So we would still say E. And so now, let's see, he's been taking his NSAIDs, excellent results. So miraculously it's working, resolution of night pain, good ability to perform ADLs. Everything's looking very good. In that case, then we would say, okay, patients at their treatment goal, stable, chronic illness. And again, these are just examples. So now let's take a look at that data. And just so we're clear here, when we say test, test, unique test, an external note, we're gonna talk about independent historian, independent interpretation. We're gonna get into those definitions as well, but test, unique test, they mean the same thing. An external note means just that, a note that has come from outside of your practice or your specialty, okay? An independent historian, we'll get into that here in a minute. So let's take a look. Data definitions. Tests are imaging, labs, psychometrics, physiologic data. Anything that has a CPT code associated with it is considered, your diagnostics are considered tests. The caveat to that are those metabolic panels, or excuse me, not just metabolic panels, but the panel codes. And one happens to be a basic metabolic panel. There are others for hormones and CBCs and that sort of thing for panels. That's considered one test. So you don't take each of those individual tests out of that panel code because there is a CPT code for those panels, that's considered one. Otherwise, all of the CPT codes under your diagnostics are considered a unique test. Okay, so services separately reported. This is the part I don't like to talk about in ortho because it's not the biggest win for us. This was quite concerning in the beginning when we got this information because of the imaging that is usually performed in the office. So the actual performance and or interpretation, okay? So if it's performed or interpreted in your office, by you, and it's called reported separately, but it means separately billed. So another way of saying reported separately is if you bill for it. If you bill for it, you cannot count that credit as reviewed in the data, okay? So if it's independently interpreted by you, not reported, not billed by you, but an outside external image is brought in and you independently interpret it, you can count that, okay? So that's what all of this is saying here on this page, okay? So bottom line, ordering a test is included. This was another key pain point. Ordering the test includes reviewing the test, okay? So if you ordered the test and then one visit, the patient came back and you reviewed the test before the patient came back, well, you don't get credit under data. You'd get credit for reviewing the record under if you were billing by time, but you would not get credit here for reviewing the test under data because that review, it's inherent that you're gonna review the test when you ordered the test. That's what the AMA has told us, okay? This applies to all physicians and colleagues in the same practice who are considered the same specialty or subspecialty. And again, APPs are considered the same specialty as the provider they practice with, okay? Now, this is a little bit, and I'm just saying because we were cautioned about this, the AMA did caution that, yes, if you've got providers of a different specialty, the question was asked. I believe this large group had a radiologist who actually read all of their x-rays. So they were billing for that professional interpretation of the views. And so then the orthopedic surgeon said, well, then can I also, because I'm not getting credit, that's not going toward me, billing under me for the professional interpretation, can I do an independent interpretation? And the answer was technically yes, however, be very careful because they are looking, everyone out there, all of the auditors are looking, all of the payers are looking for people trying to, and this was a quote from them, game the system. And so I know that none of you out there would want to do that, but just a heads up on that, they are aware of that situation. So you'll definitely wanna talk with your compliance folks at your clinics and make sure of how they want that approached if you find that you're in that situation, okay? So with that said, let's look at the table for data. Straightforward, minimal or no data, plain and simple. Under low is limited. And if you'll notice there, it says at least one of the two categories must be met. So there's two categories, category one are the test or documents, and it's any combination of two of the following three bullets. So it can be one of each of the two bullets, or it can be two bullets if you have unique tests or external notes from different sources, which that's not typically common, but can be, but it just needs to be any combination of two. Review of prior external notes from a unique source, okay? So again, external notes, not in the same specialty, not in the same clinic, not sharing the same EHR, okay? External, review of the results of each unique test, okay? And ordering of each unique test, okay? So just requires two of the three. Or category two, which is an independent historian. So an independent historian, let's define that for a minute. It's maybe it's the parent that comes in with a child and the parent is providing additional history for that patient, that would be an independent historian. Or you've got, you know, a daughter or a son coming in with their parents. We've had to do this rather recently, going in with the parent and giving information because maybe that patient, the parent has dementia or doesn't have a good history recall and they give you additional information. That would be an independent historian. Let's say a spouse that is there and giving you information, but it's not more information than the patient is giving you. Maybe they're just there to voice their opinions. That is not an independent historian. Just to give you the idea. And also translation services. While translation services do count toward time for the visit, they do not count as independent, as an independent historian, okay? So there's low with category one or category two. So now let's move up to moderate. And moderate, as you'll see, it gets a little bit more, there are more options here, okay? So now we have three different categories. And if you'll notice in on that, the top row there under the, where it says moderate must meet one out of three categories below, okay? So now we've got three different options and we still only need to beat one of the three. So category one, again, is test and documents. And now they've moved independent historian up to category one, but now it's increased. You need a combination of three of the following, okay? So three of any of those four bullets would get you a Category 1, which would equal moderate, or Category 2, now we have something new, the independent interpretation of tests. So this is where we feel like we have a little bit of good news for orthos. You do get to count that independent interpretation when it's imaging that has not been built in your office or built under your name or performed under your name in office, okay? So it's external, patient brings it in, and you look at the images, it's not just reviewing the report and verbatim saying what the report says, it's for you, of course, as the orthopedic surgeon, you're going to look at those images and then document an independent interpretation of that. It does not have to be separate, it doesn't have to be terribly formal, it can be within the note of what you found on the images when you reviewed them. But it does need to be clear, and be careful and not say I reviewed, I reviewed the images, I would, you can say viewed, I would say viewed the images, I visualized those kinds of words, not just review so that it can't be misinterpreted that you were just reviewing the report, okay? So that's category two. And category three is discussion of management or test interpretation. So this is going to be with an external physician, again, not someone in your office with the same, not in your clinic with the same specialty or subspecialty, or it could be an appropriate source, okay? So maybe there's a lawyer or a home health worker or someone involved that is a professional but not necessarily a healthcare professional that you need to discuss the information with, and that also does qualify, okay? So that's the moderate level. And again, here we go. So category three, discussion of management or test interpretation, just a little bit more here to make sure that that is soaked in because that's a little bit of a different concept. The external physician or provider is not in the same group practice or is a different specialty or subspecialty. It includes independent licensed professionals and it could be a facility or organizational provider. So you might have to call that radiologist and say, listen, you know, on this MRI, I was looking for this, what do you think about this? Whatever the case may be, whatever your conversation is there, just an example, okay? So not separately reported, definition of appropriate source, again, not separately reported, professionals who are healthcare professionals who are not, excuse me, healthcare professionals, but may be involved. So lawyer, parole officer, case manager, teacher, it does not include discussion with family or informal caregivers. The good news here is on the high category, it's the same criteria as moderate, but it needs to be two out of the three categories. So either one and two, two and three, or one and three, okay? So that's the good takeaway there. So let's do a few of these together. You order foot and ankle films in-house and bill for them. What kind of credit would that be? That would be minimal to none, okay? Because it didn't meet the criteria of two of the following, right? So the criteria for low or limited was not met, so that would be none. You order an MRI that will be performed in an outside facility, okay? So you ordered a unique test, still minimal or none, still only met one of the two that are needed for category one. What about a patient that brings you outside MRIs that were ordered by you and you view the images and describe what they show, okay? So we've got that independent interpretation of the test. So that would actually get you to a moderate level, right? With that category two, that's all you need is one. Parent brings their five-year-old in outside with X-ray reports of the ankle. MD reviews the report and parents provide the history, okay? So it says the MD reviews the report. So there's the review of the report, that's one. And the parent provides the history. Well, you didn't meet it under category one because it just says that there was a review of the report. It didn't say there was an independent interpretation. So that just is the one out of two, so it doesn't meet that level. However, category two is met for a low visit. So this will be limited for category two, which would bring us to that limited level, okay? Physician orders CBC, EMG, and NCS to be performed and billed outside of the practice. So right there, we've got CBC, EMG, and the NCS, which does count as a separate test from the EMG. So right there, you meet a moderate level because you achieved three out of three that are needed for a category one. Patient brings outside x-ray ordered by PCP and reports in the report for one body area, and we're gonna say left foot. MD reviews the report and describes what the images show. So you review the report, but that doesn't really get us anything because it's only one element out of three that are needed. However, you do an independent interpretation. So category two meets that moderate level of data. Same visit, the physician has a question about the images and calls the physician who read them to discuss the findings. Okay, so you reviewed the image, doesn't really get us anything there. However, I believe that that is supposed to be under a category three. So that little check mark moved up a little bit too high. Actually, no, let's see. Okay, well, you did an independent interpretation. It just doesn't say that in the scenario and discussion with an outside physician. So you met it either way under category two or category three in this instance, okay? So that's just kind of to give you an idea of, and actually, yeah, so this would be, you could either say moderate or extensive, and it really would be extensive because you did meet two out of the three categories. So it really would be extensive. That does not mean, and this example actually was put in here to make sure that we reiterate, it doesn't mean that the overall visit is high. It just means that the amount of data is high, okay? So let's talk about risk real quickly, and then we're gonna get into some scenarios because my time, I am running over. All right, risk of complications and morbidity mortality. What you need to remember here is it is of the patient management. The risk is associated with the patient management. Yes, there probably is a correlation to the risk of the problem addressed, but it's the risk for patient management. The nature of the event under consideration, okay? So that's the definition that we have for what we're looking at for risk, okay? And it's based on, risk is based on the usual thought processes of a physician in the same specialty. That again is in the CPT. And they also go on to say that you don't actually have to quantify. If you say it's high risk or medium risk or whatever the level is, you don't have to actually quantify what it is. However, your documentation does need to support the level of risk chosen. Obviously, if the patient was fine and you said the level of risk was high, there might be some issues there. So based upon the consequences, this is what I wanted to make sure that we all got. It's based upon the consequences of the problem addressed at the encounter when appropriately treated. So it's looking at the treatment, the risk of whether or not to treat the patient for the said condition. So it also includes, this is very important. You get credit if you decide and give patients options for the, and of course you have to, it's preferable to say that you recommend this or this for the patient, not just say, we discussed all the options, but say what you recommended or you see as the best line of treatment for this patient. Whether or not they decide to go through with that treatment does not affect the level of risk. If you have said, this is what I think the patient needs, then we give you credit for that documented level of risk. So two things that changed, we're gonna go through here rather quickly on these level of risk. Straightforward is minimal, minimal risk. Minimal or no risk, you're not doing, maybe you're just not even doing any testing or treatment, arrest, gargles, that sort of thing, low risk. There's a low risk from any additional treatment or testing. And they didn't give us any examples at first. And so we went back and asked, what can we use? And they said, you can use the original examples that are in the original table of risk. So for minimal rest, gargles, bandages, low over-the-counter drugs without, just your normal over-the-counter drugs that don't have any type of large risk, minor surgeries with no identified factors, physical therapy, occupational therapy, things like that. So that's where we base those minimal and low risks on. Again, we base them on that, but it does depend on the documentation. So moderate risk for the categories here, and these are examples only, prescription drug management, decision regarding minor surgery with identified risk factors or procedure risk factors. Caveat there, you might wanna check with your MAC on that to see how they interpret. Do they interpret it patient or procedure risk factors? The CPT still does state patient or procedure risk factors. However, we had some, AMA has done some not formal, not through the CPT assistant, but other informal ways of saying that it's really the patient risk factors as it relates to the procedure. So you might wanna check with your or have your billing staff check with your Medicare carrier to see if intrinsic procedure risk factors will still be counted or not. And decision regarding elective surgery without identified factors. And of course, limited by social determinants of health. That was also added to the moderate table of risk. High risk bumps major surgery up to the high risk with identified or documented. When it says with identified, it always means documented. Procedure risk factors, patient or procedure risk factors. And they have added the words for decision regarding hospitalization or escalation of hospital level care. Since this table is also now used for hospital patients and added parental controlled substances as well onto this. So let's quickly go through some E&M scenarios. And that will be the end of the presentation, but these scenarios are pretty good. So let's go through these rather quickly. We've got a 72 year old female new to the clinic, two month history of sharp pain in that right big toe, went to saw the internist. Here today, you did a medically appropriate history and exam. Patient brought in x-rays from her PCP and you reviewed the x-rays and you documented what you saw. And the assessment is the foot pain due to how it's rigidous. So what's the plan? Plan is physical therapy, OTCs is needed, return in six weeks. So this is what we generally, this is how we would audit that note with the information. Problem addressed was moderate. It was chronic condition and it was with exacerbation. Data reviewed was moderate. You did an independent interpretation and risk of management was low. Physical therapy and OTC anti-inflammatories. So we actually coded this at a moderate level of medical decision-making. And there you see it there, either that new patient or established patient level four visit, okay? And here it is, if you want to see it on that audit tool. Next scenario, 60 year old, three-day history of left ankle injury. She turned her ankle, now pain and swelling. She's been icing it, OTC meds all weekend, still in moderate pain, okay? So let's see, left ankle exam shows, excuse me, I skipped ahead there. Left ankle exam shows evidence of a second degree sprain. Okay, so you ordered three views there of the right ankle and it was built by your office. Images don't show fracture. So you explained it to the patient, advised rest, eyes compression, three to four days. OTCs will wear an AFO activities if the ankle feels unstable. So what does that look like? We call that a low problem addressed in acute uncomplicated injury. No, it equated to no data because it was just one review, right? And risk of patient management low and overall low. All right, let's look at the next one. 60 year old patient, a one year history of ankle instability. She brings in her outside MRI. The ankle never felt so good after the injury two years ago. Reports that she is prone because she twisted it, feels painful and steady. Initially advised physical therapy and an AFO. She's continuing with problems. Forgive me for reading this rather quickly. You will find all of these scenarios in your book and you obtained an MRI at an outside facility. So you reviewed the outside images of the left ankle and definitely shows that ATFL ligament, the disruption there, and you suggest that you go to surgery. You explained the risk and benefits, documented all of that well. She agreed to proceed. So now we've got an acute chronic illness with an exacerbation after she re-injured. So we've got a moderate problem addressed. Moderate data review with that independent interpretation and a moderate risk with the elective surgery without identified patient or procedure risk factors. So then let me go back and say risk weren't documented. It didn't say that I elaborated, but for here, we didn't see those documented. So that would bring us to a moderate level of medical decision-making. Scenario four, a new patient seen after being seen in the ED for a left ankle injury. X-rays were taken. She's got a fracture and she was placed in a splint told to follow up with you. Let's see. So you access those images and you agree and you document a transverse fracture without displacement. You're gonna manage it post-op or excuse me, non-operatively with a CAM boot. And of course, tell her what to look out for. She'll return in three weeks. So here, it depends on the patient, clinically. You'll have to be the one to say, okay, this patient is, for whatever reason, it's low versus moderate. It could go either way for problem addressed. Data, moderate, right? You got one point for looking at the ER note and one point for reviewing the X-ray report, but that got you to a low. However, that independent interpretation gets you to a category two under moderate. So that's where we get the moderate from. And the risk of patient management, well, it'd be low or moderate. It's conservative fracture management. But again, that depends on what type of other conditions the patient may or may not have that we weren't privy to here in this note. That would be up to the clinician to decide. So really, this could go either way. As we know, fractures don't automatically fall in that moderate to high risk category anymore. So that would depend on the patient and any comorbidities or other situations that we might not be aware of that the clinician would have and know about, okay? So any questions? Again, we encourage you all to put questions. See if I can get my mouse to work in the chat function. Define minor surgery. I do wanna answer this. Thank you so much for that question. That is the $100 million question. And yeah, we actually did this. Dr. Michael Marks helped me with something we presented together last year. What is minor versus major? There is no set definition for it. Typically what we say at KZA is minor would be something that could be performed in the office under local perhaps, and then lower risk because of the anesthesia factor. And a major procedure would probably be something that's taken to the OR. Potentially not everything that goes to the OR is a major procedure, but obviously your major, your hips, your knees, your major open ORFs, those would be major, but any minor procedure, injections, joint injections, trigger injections, trigger finger injection, trigger points, all of those types of things. We do consider those to be low because they, minor procedures, we consider those to be either low for minor without any patient or procedure risk or moderate minor with procedure or patient risk factors. So that's how we kind of separate in our head, but there honestly is not a set definition. That is left up to the clinician and you might have a minor procedure on a 20-year-old that's a major procedure on an 80-year-old. It just depends, it depends on the situation, but that's kind of the gauge that we have given guidance on. And it tends to hold pretty true to what we see providers are telling us on that level when we get feedback from the physicians. And I see that we have, let's see, define separately reportable, reported. Separately reported means billed, means separately, you're getting that work RVU value from a separate CPT code that you or your office is billing, okay? So if you're doing images in the office or you're doing that injection in the office, either way, the work that's associated with those two codes cannot be given credit for the work associated with that E&M, okay? So that's what that means. Separately reported is a fancy way of saying billed, you're getting credited for it separately through a different CPT code. All right. Okay. And I don't see any more questions. So I, and poor Jennifer, Jen, I didn't give you a chance to get a word in edgewise here. Do you have anything to add for us here today? I have been answering questions through your excellent presentation. We got a lot of questions this time around, a very thoughtful and thought provoking. So if you guys have any additional questions, let us know. But yeah, that's it. Thank you so much, Jen Bell. Awesome. Thank you all. And again, if you think of questions here, put them in that chat and we will definitely get copies of those and be sure and answer those and get those answers back out to you. All right. Thank you all so much for your time and we'll see you again next week. Bye-bye.

revised guidelines

evaluation and management codes

office outpatient visits

problem addressed

data reviewed

risk of complications

medical decision-making

examples

scenarios

separately reported

independent interpretation