Good evening. On behalf of AOFAS, I want to welcome you to the first session of Crack the Codes, Practice Management and Coding Series. Tonight's session is Session 1, CPT 2023 Revised Guidelines for Evaluation Management, E&M for Inpatient Observation Services. 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 and in the On Demand Education Center. This series is funded from the Orthopaedic Foot and Ankle Foundation, supported in part by grants from Paragon 28. Just a few housekeeping items to run through before we kick off tonight's presentation. If you have any technical difficulties, try closing your browser and logging back in the way you did the first time. Certified physician attendees may earn 7.5 hours of AMA, PRA, Category 1, CME credit by completing an evaluation and claim form at the end of the full series. Tomorrow, you'll receive an email link to evaluate this specific session only, and we appreciate your feedback. After each broadcast, you'll also receive an evaluation for that specific session. At the end of the full series, we'll send you an email with full instructions on how to claim all of your credit. This webinar is being recorded and will be available as an On Demand product for you to view within your course listing in the On Demand Education Center in approximately 24 hours, and will be available for one year. We do encourage you to ask questions during the presentations. To send your question to the faculty, go ahead and click on the Q&A tab in your navigation bar and send it on over. Anything that's not answered tonight will be posted in the On Demand session on the On Demand Education Center. I'll now turn the program over to Jen and Jennifer. Thanks. Thank you so much. Ladies, let me see. I'm going to go ahead and share my screen here. Forgive me just a moment. Let's see here. Here we go. I am Jennifer Bell, and my colleague, Jennifer Cabrera. It ought to be easy for everyone to remember our names. We're here today with you from Karen Zepko and Associates. We are here to talk about the fun and wonderful world of E&M coding. Specifically, we're going to be talking about the 2023 update. So here's our team, the complete KCA team. Karen is there on the right, and we're here to help you with your revenue cycle needs. Anything from A to Z, we're here ready to go. Just give us a call or an email, and we'll be glad to help you. Before I get started tonight with our session, and we have an hour session tonight, so we're going to discuss the 2023 updates. However, we're going to have to go back. I'm going to go back and do a brief overview of what happened in 2021, and then we're going to jump into the changes and updates for 2023, because we can't talk about 2023 at this point without talking about 2021. So the updates in 2023, as you know, are built on the same model of time versus medical decision making. So looking back at the changes that happened in 2021, anytime you see this hourglass, then you'll know I'm talking about what happened in 2021. So here is the big picture in a nutshell, and we're going to go through each part of this slide quickly. Right in the middle, you'll see the orange box, level of service. So what happened on January the 1st, 2021? On the left-hand side of that box, nothing changed for ER visits, inpatient consultations, and observation care. We still needed to use history, exam, and medical decision making as the three key factors for billing the level of service. And also time, the old definition of how we count time, greater than 50% needed to be spent in counseling and or coordination of care, that stayed true. So anything other than what's on the right side of that hourglass, the outpatient new and established patient visits, the 99202 to 215, and of course 99201 was deleted. Nothing other than that required the original guidelines. But the revised guidelines came into play for just the office visits. There are outliers, I do want to point out that blue box, if you were performing a consultation in the observation department, where it was a Medicare patient or a payer that did not take a consult, the consult codes, then you were advised to use the new and established patient E&Ms. So in that case, the new revised rules would have applied because you are using the codes that it applies to. Otherwise, the new requirement for time in that small box at the bottom, we did away with the requirement for counseling and coordination of care. And it was just based on total time for the range that these codes were given. And we'll get into that here in a little bit. So here it is in just a nutshell. This, what you're looking at now is the original matrix. So this is the original set that the AMA sent out in 2021. It has been updated in 2023. But I want to show you this one so that you can see the difference in a little bit when I show you the revised version that does apply to office as well as hospital. So we started out with this version. And the first thing you'll notice in that first column, both levels are new patient and established for each level is in the same box under the same level of MDM. So now we no longer have to worry about and again, these I'm specifically speaking right now of the for the office outpatient and new and established codes. So for both levels of level two, both levels of three, four, and both levels of five, they just they require two out of the three elements to be met. So we don't have to worry about three out of three anymore for new and two out of three for established. And here are the four levels of medical decision making. And of course, the not applicable level would be for the 99211. And that would be the nurse visit. And that was not we're not talking about nurse visits today, just speaking about physician and or APP visits. So then we have the three categories at the top. And instead of A, B, and C, we now have one, two, and three. And you're going to hear me say this. You'll see the titles here in a minute. They're much bigger. Actually, we're calling these the elements. Okay, so number and complexity of problems addressed. You'll hear me say problems a lot amount and complexity of data to be reviewed and analyzed. So you'll be you'll hear me say data a lot. And then, of course, the risk of complications and or morbidity or mortality of the patient management options. Okay, so in this matrix that was originally put out by AMA, and then we made it into our little audit tool here. The elements themselves for each of the levels are highlighted. Okay, so here is just it's a little bit easier to read here on this slide. But we're not going to talk about this in detail right here in this section. We're going to talk about it in detail in the 2023 section. Number and complexity of problems addressed. The data to be reviewed or analyzed. And then the risk specifically of the patient management. Okay, but first I'm going to say let's talk about time. Because time for office, new patient and established patient visits did not change from 2021. So we're first going to talk about office, then we'll talk about the changes that occurred in for MDM. So again, time what I'm fixing to discuss with you about the office visits did not change in 2023. So in your book, we're going to have to jump to page 13. So if you had an opportunity to download the workbook, because the workbook does have a lot more information than we have time to discuss this evening. So if you were able to download that, you'll get all of the words, but turn to page 13 for me, if you will. Notice the change here in time is now not typical time, but total time. And that does make a difference. If you look in that first section there, the codes, of course, 99201 is deleted, but we've got the ranges of time for both new and established. And this is very important. One minute separates one level from the next. So it is important if you are going to document your time and code by time, you want to make sure to put down the exact minutes as best as you can and not say I spent over 30 minutes. Well, in that case, we can only give you credit for 30 minutes, but I spent 34 minutes. I spent 45 minutes. So right there, 45 minutes for a new patient. That would be the difference between that level three and level four visit. So it's very important to remember to document your specific number of minutes. And, you know, we don't expect anyone to walk around with a stopwatch. Absolutely not. You have much more important things to do, but definitely pin it down to the minute as you can. And just to note that the time ranges, there is a 15 minute increment used for new patient and 10 minute increments of time used for the established patients. Time is the total time on the date of the encounter. So whatever time you spend on the day that you're seeing that patient is the time that you can count. And we'll, we have a list here in a second to tell you what exactly can be counted. It does include both face-to-face and non-face-to-face time. However, it means that it's personally spent by the physician, not clinic or staff time, not resident time and not fellow time. Okay. So it does need to be time spent specifically by the physician or the other QHP or APP. A face-to-face encounter is required by the billing provider. So even though it does say it includes both face-to-face and non-face-to-face, I can't tell you how many times I've gotten that question. You do need to have a face-to-face encounter with the patient in order to bill for the services in office. Total time can be combined. So if CPT does say, and we're going to talk about that in a minute, that you can combine the time, it can't be duplicated. So if the physician and the APP both see the patient together, the time that they're spending together, you can only calculate for one of the two. You can't say, oh, the doctor was in there 10 minutes with the nurse practitioner. So they each get 10 minutes. That's 10 minutes of time. You can't double dip, basically. And time does not, again, include clinical staff resident time or fellow time. What is included? Preparing to see the patient. So you're reviewing your test, your imaging, records, other old records, new records, whatever you're reviewing. Obtaining the history. Performing the exam. Counseling or educating the patient, family members, caregivers. This one, you can count time spent ordering medications, tests, and procedures. However, you cannot count time performing the procedure because that has its own separate CPT code. So they do not allow us to count the time that you spend performing the procedure. And, of course, referring the patient, doing any referrals that, again, this is time that the billing provider spends. And communicating with other healthcare professionals. Easy for me to say when you're not separately reporting a code for that, such as an inter office or, yeah, inter office consult, interprofessional consult. Documenting clinical information in the record. You finally get a chance, and I even have it listed here, hallelujah, you get credit for taking the time to put information into the medical record. Yes, it does count. Independently interpreting results. Again, as long as you did not separately bill for performing any of the imaging. Communicating results and care coordination. You can't count, as I said, performance of procedures or any service that you're reporting separately. You can't count travel. So if you have to travel to a hospital or to another clinic or whatever the case may be, can't count that time. And, of course, teaching time. Resident and or fellow teaching time is not counted for attending physicians. Now, this specifically, I want to talk about shared, I call it shared split. It used to be called shared split. Now CPT is calling it split shared. This is specifically for CPT and not for CMS. We're not talking about the CMS definition of split shared or incident to. This is something new that CPT added in 2021. And it is just what it says it is a visit in which a physician and QHP jointly provide face to face and non face to face work. So CPT is recognizing that yes, you can sum the two together to come up with a visit and bill by time. Here's when it can't be used. Can't be used for 99211 because there are no professional services involved with that code. That's a nurse code. And it cannot be used for a new patient that's under 15 minutes or an established patient that's under 10 minutes. Again, this is strictly the CPT version and prolonged services. So in my opinion, they made prolonged services a little bit easier. They made the code 15 minutes. So it is actually a little bit easier to qualify than the older codes which were 30 minutes to an hour. So 99417 is the code that CPT uses. And it's for prolonged services and this is strictly on those outpatient office visits new and established patient visits requiring total time with or without patient contact. Okay, so you don't have to have full face to face contact to use it. It is face to face or non face to face. Okay, beyond the usual service. However, you only use these for 99205 or 99215 the highest level of the code. So just a couple of stipulations prolonged services of less than 15 minutes should not be reported. So you do have to meet 15 minutes in order to report. However, a little bit of an exciting note here, because remember those time ranges on those new and established patient visits. CPT says you can use prolonged services after the minimum time is reached, not the maximum. That's very important, and you'll see why in a second. So it's an add-on code so you would build your 99205 or 99215 and then have that 15 minutes, and I'm stuck on 30 minutes, that 15 minutes of prolonged services, and you can build that additional unit of 99417. And then, of course, you can build more than one unit of that if time, if it is documented properly in the chart, then you can use more than one unit. CMS, however, and here's the caveat with the minimum time, so we're really excited that CPT says, okay, we can go by that minimum in that time range for those visits, but CPT or CMS does not use 99417. They use G0, excuse me, G2212. Getting ahead of myself here, getting so excited. So this creates a conundrum. So look on page 16 with me. Medicare says, okay, we're going to have a, we don't agree with the CPT code, so we're going to create our own code, and we're going to say the same parameters, each additional 15 minutes on the date of the visit with or without direct patient contact. However, CMS says we're going to use beyond the maximum time. So for, in fact, I'm going to go ahead and go to this next slide, and it will show you what I'm talking about. So in the time ranges that were there, so here we go. Let's look at this. Let's look at this second row here, and you'll see under the new second row, CPT says that once you hit 75 to 89 minutes, you can build that 99417. However, CMS says even up to 88 minutes, you still can only build a 99205. Once you hit that 15-minute mark above the maximum for 99205, then you can add the G2212. So you have to meet 89 minutes before you can add that prolonged service code on for the Medicare patient. Same is true for the established patient visit, and you'll see that in the middle row of the established patient. So just an example to show you. And now that's all I'm going to say about 2021, so now we're going to catch up and look at what happened just a few days ago. So what happened in 2023, January the 1st? So now not only do we have the time versus MDM for outpatient visits, new and established, now they're also for hospital inpatient or observation care, consultation codes, both in and outpatient consultations, and observation care patients as well, both initial and subsequent. So the caveat to these are, if you look in the blue boxes, discharged services only use time. They don't, they've always only used time, and you'll see that here in a minute, the two discharged, they have discharged services only use time, so they don't use MDM. And emergency department codes as historically never use time, they have never been assigned a time value, and they kept that in place. So emergency department visits, those 992-82-85 only use medical decision making, and they don't use time. And forgive me, my screen is stuck. There we go. All right, so if you flip to page 18, here is the new, and you'll want to mark this, you know, put flashing lights around it, pull it out of your book, whatever you need to do. This is the new latest and greatest 2023 revised MDM table for hospital inpatients, observation care, same-day observation care, ED visits, and consultation codes, both inpatient and outpatient codes. And in that first column is where you'll see the codes listed there. I'm going to sit here for just a minute and say it looks awfully similar to what we just looked at, does it not? Yes, it does. However, there are just a few changes, and we're going to go into that. And it's for the better, not anything bad, so it's for the better. But that's why I wanted to show you the original is because it just builds on what was originally put into place in 2021. Now, these on that in that first column, these are all the hospital visits. The next slide and in your next page on page 19, this is the updated version of the office new and established patient codes that we were talking about just a few minutes ago. Okay, this page, going back to the previous slide, is exactly the same slide as what's on page 18. So 18 and 19 are exactly the same, except for that first column. Okay, and we just parse these out to make it a little bit easier so that you can have one that's dedicated, you know, maybe put it in your pocket when you go to the hospital or put it in your computer or your car or whatever you need to do to keep it handy, as opposed to for the office here, and we just have it a little bit, you know, separated out so that it can be a little bit easier to read and a little bit easier to find those codes. On these next on page, let's see, page 19, goodness, having trouble with my mouse here. So this is the same information on these next few slides. It's the same information, it just takes out all the detail. Okay, so first, we've got the four levels. And you'll notice, I do want to point this out, under the initial hospital, that first section there, inpatient or observation care. So you see where they are now calling the observation care codes went away. And they are now using the initial inpatient codes for observation care as well. And you'll see that 99221 can either be straightforward or low medical decision making, because there are only three levels of care. And then of course, the 22 would be moderate, and the 23 would be high. The same for the subsequent, they added observation care to those hospital inpatient codes, the subsequent care codes, and a level 31 can be either straightforward or low MDM. And a level 32 would be moderate, and 33 would be high. The only difference in what you're seeing here, and what we just saw in those two matrices is that the time has been added. So that time column, the orange over on the right hand side, that's been added just a different way. Some people like to look at the information this way. So we provide it in both ways. Moving on to the next section, and I believe it's on one page in your book, the office and outpatient consultations, as well as the inpatient and you'll notice for observation consultations. So now we have the category observation consultations are in there as well for those with those inpatient consultations. They went ahead and deleted the level one, just like they did for the 99201, because it was straightforward as well. And so they just got rid of the code and said, let's make it easier. Now we have four levels, okay, for your consultations. Again, same day, admit and discharge, either observation or inpatient, those same day codes, 99234, 3, 5 and 3, 6, as well as the ED services. And if you'll notice, under the well, I guess we haven't listed ER services here, under your emergency room or emergency department services, you'll notice 99281 says no physician required. That is something new. And we're going to talk about that here in a minute. And you'll notice on that right hand column, it says does not apply, right? Because they never put time in place for the ED services. So again, same for, we talked about the discharge services, the 99238 and 3, 9 have always been time based. That has not changed at all. So MDM does not apply. So what are the overall key changes? So we just saw the key changes. Now let's see it in black and white. Inpatient and observation categories, as you saw, are now combined. So they did away with the observation codes, and they're now using for the inpatient, the initial observation 99221 to 223. That should say, well, yeah, initial inpatient admission and subsequent would be 99221 to 99233. Okay. So it's both initial and the subsequent visits. Observation inpatient same day admit and discharge. So again, they looped observation in, you can now use the 99234 to 99236 for that. Level one consultations are deleted, both the 241 and the 251 and all categories of, except your discharge management, convert to MDM versus time and accept the ED visits as well. Okay. So again, the discharge management has always been time only and ED visits have always been MDM only, no time. Okay. So that's just the quick key changes. I'm not going to go through each one of these. I just want you to see, this is what the CPT now looks like, the actual verbiage in the CPT book for the new codes. And we just have it highlighted here, the, just to stand out the changes in any changes in the time that was made and the fact that it now says medical decision-making on all of these, just like it does for the office and other, office and other outpatient services. Okay. Same for subsequent care. Just, they went ahead and looped in the observation care and then the times where they changed, they made those changes. Some of them went up, some went down, some didn't change. We'll look at that in a minute. And then both of these have in that last row, it says for the code to use for prolonged services, that's the new code 99418. And we're going to discuss that in a minute. The good news here, and this is very important, the general guidelines, just like the general guidelines for using the office visits, didn't change how you calculated your level changed, but the general guidelines of what the visits are intended for did not change. Same is true for all of the hospital visits. Your observation care codes still have all the parameters around it of what an observation care visit is. Your inpatient, initial and subsequent, which is again, now also for observation, they still, the codes still mean the types of codes still have the same meaning. So they didn't throw the baby out with the bath water. In other words, all the other parameters are the same. So for observation care, this is just all going to be, this part is going to be just review. A patient doesn't have to be in a designated area within a hospital that's designated for observation only. They can be in any part of the hospital and the status of course, is that clinical decision. If you put the patient in observation status, then they are considered observation status and you can bill accordingly. Likewise, for a patient admitted and discharged on the same day, or whether they're an inpatient or observation status discharged and admitted on the same day, you can now use the same day, what used to be the same day observation codes. So those same day 99234, 235 and 236 codes. Inpatient or observation care timing guidance. So this is all about the timing and it's a little bit different than it is for office. So as we all know, the hospital setting is a little bit different because the patient doesn't just, it's not transactional. One day they go home, it's done. Maybe they come back. It's different, right? Sometimes they're there more than one day. So the total time when you're talking about calculating time for your hospital visits is on the date by the calendar date. So if you're counting time for reviewing records and talking with the patient and that non face-to-face and face-to-face, whatever time you have with that patient that day, it is by the calendar date. So once it rolls over after midnight, that would be a different date of service. So then the time would start over. Here is the caveat to that. If you have a service, total time, if you have a continuous service that spans two different dates, so you've got someone that came in at 1130 in the ED, you're having to assess them and the visit isn't finished until 1230, one o'clock, whatever the case may be, then you can choose. Neither CPT nor CMS has told us that you have to use one date over the other. I've always said, use the beginning date of service just for consistency's sake, but you can certainly, if you choose to use the date that the visit ends, you can. It's just better. I always say, no matter which date you want to use, make sure that you're consistent and use that date for all of your patients. And hopefully you're not having to be in the hospital too much over the midnight hour. Hopefully everyone's safely tucked in bed, but we know that's not how the real world operates. So just choose one that you won't forget because it does get completely confusing to your billing staff. Trust me, if you've got one physician who likes to do it this way and another provider who wants to do it another way, it's really important that at least within your own clinic to all agree on either using the date that the visit started or the date the visit ended. That's my diatribe. I'm done. An initial service may be reported, and I'm going to read this. It's long-winded, but it gets the point across. An initial service may be reported when the patient has not received any professional services from the physician or other QHP, so NP, PA, someone in your office, or another physician or another QHP of the exact same specialty and subspecialty within the same group practice. So in other words, the same thing applies in 2023 that it did before. One person can get that initial visit if you're the same specialty, some exact subspecialty in the same group, only one person can bill for that initial service during the stay. Everyone else in your clinic, if they're the same specialty or subspecialty would be considered in subsequent visit, okay? So that didn't change. And of course, advanced practitioner providers, when they're working with physicians, they're considered the same specialty as the physician. Okay, so again, like I said, a lot of this is going to sound the same. This is the part that is not the same. So everything else, when I say hospital visits are still hospital visits, observation visits are still observation, et cetera. This is the one thing that CPT, and I was actually really excited about it until I realized that CMS probably isn't going to support this. And in fact, they don't. So that's a big caveat here. We need to remember CMS does not subscribe to this, but CPT says in a nutshell, in the course of an encounter in another site of service, then you see the patient again, separate service on the same date, you can bill for both services. You just, here's a couple of caveats there. So in other words, if you see your patient in the office, and then all of a sudden they go home, the pain goes through the roof, they can't take it. And then they go to the ED and you're called in, or you see them in the hospital, and it's the same day, CPT used to say everything rolls up into that hospital service. However, now they're saying, okay, you can bill for both separate services, but that second service would not be an initial service. Okay, so that's basically what this whole slide is saying, that the second service would need to be a subsequent E&M or an established E&M. Because if the patient, even if the patient actually, if it's a consult, even if the patient is an established patient that you can't get an initial consult if you've seen that patient the same day in a different location, okay? That's the nutshell version. So while you do get to charge according to CPT, and we don't know how many payers are going to allow this. So that's another kind of caveat because a lot of payers do follow Medicare guidelines and may not allow this, but it is a glimmer of hope. Now it is in the CPT book. So we're thankful for that, okay? So if you see the patient in the ED and then later the patient is admitted, you go see the patient again later that day and they called you back in because something else is going on, can't bill a consult for that because you got the initial consult or ED visit there already on that date. So they're just trying to prevent double-dimping here is what it is. So if you consult that second service on the same date needs to be some type of a subsequent visit. And again, bottom line, you can't bill two initial visits on the same date during the same stay, okay? And this, I still am scratching my head at this first bullet. If a consultation is performed in anticipation of or related to an admission by another physician, and then the same consultant performs an encounter once the patient is admitted by the other physician, report the consultants, so the first doctor's inpatient encounter with the appropriate subsequent care code. So I'm not really sure how you're supposed to know without your crystal ball if the patient's gonna be admitted on a subsequent day, but my job is to say what is in the book. So we did ask for clarification. I will tell you that several different ways, and we have not to my knowledge, Jen Cabrera, have we received any information from the AMA that you can recall any clarification on that to date? Not to date, we have not. Okay, so when we get that, if we get that, we will definitely put that up on the alumni site so that everyone can go in there and take a look, and I'm sure we'll send out KZA alerts as well, but we're not quite sure what to think of that first bullet. So the instruction applies whether the consult, oh yeah, and here's the part that's really funny, whether the consult occurred on the date of the admission or a date previous to the admission. So, okay, maybe if you suspect that the patient's going to be admitted, maybe that's what they were trying to get at, but we really can't say because we have not been given any information on that. Okay, so yet again, we've got the hospital inpatient and observation care code. So here, I'm just putting it up for you to take a quick look to let you see that, yes, it has been changed to say time or medical decision-making in the CPT. So this is exactly taken out of the CPT as it looks. Again, nothing about the same day codes really changed. All of the same parameters, if the patient is admitted and discharged on the same date, you can use these services. They do require the 234, 35, and 36 do require two separate visits on the same day. An initial admit and then a discharge visit. So at least two visits by the provider on that date. For patients admitted and discharged, and you only see the patient once at the same encounter, then you're instructed to use the 99221 to 223 codes and not report the 238 to 239, which are the discharge services on a different day. So if you're just seeing them once, yes, we're gonna observe, and then later you get a call, patient's fine, and you send them home, and you only have that one face-to-face, then it would be just the 99221 to 223. Now, Medicare goes on a little bit further when it talks about observation status. And they have the good old eight-hour rule that says if you're putting a patient in observation, they must be there at least eight hours in order to support an observation code. So if the patient is admitted to observation and it's under eight hours, then you would not use the 99221 to 223 for a Medicare patient. You would go back, because they're in observation status, not a true admit status, you would go back and use the new or established outpatient codes and code accordingly and level according to the documentation. CPT, however, does not specify a time limit for observation codes. There is no requirement that they're there a set number of hours. But Medicare was seeing when these codes initially first came out, Medicare was seeing a marked increase in their use. And so they did come up with this, gosh, this was years ago that this was instituted, but nevertheless, that is still in place. And of course, as I say, and I'm from Texas, forgive me the whole enchilada, if you admit the patient on one day, discharge the patient on a different day, that's when you would use the, let's say you admitted a patient on Thursday and discharged them on Saturday, excuse me, on Saturday. So the initial admit code would be on that first day, the subsequent visit, the second day, and then that discharge service on the third day. And again, here are the observation care codes, or excuse me, discharge, for either inpatient or observation care as they are written in the CPT code book. So of course, there've always been time, we'll continue to be time-driven. And these, I could belabor this longer, but nothing has changed for these discharge codes. You still, it includes your final exam discussion, your instructions to the patient, caregivers, discharge papers, prescriptions, referrals, et cetera. Nothing has changed for that. All of those tasks can be included and counted toward that time. Your consultation codes. Here are the officer outpatient consultations as they appear in the CPT book. And the tenants of a consultation code, whether it's inpatient or outpatient are the same. It still requires a request for advice or opinion from a physician or provider, another physician or APP. And then of course, you must see the patient and have a written report back, whether it's through a shared EHR or good old fashioned, I don't, I'm not sure who uses the mail anymore, but I'm sure we might have some out there that do still send letters through the mail or through portals, whatever the case may be. But you do need to have some written communication back to that physician, even if it is just through the shared EHR, okay? So the tenants of a consultation are still the same, must be required in order to bill for that consultation. Initial observation consultation. Okay, so here are the inpatient consultation codes. Same thing for the inpatient or observation. Now, remember we're including observation consultations. However, it's during the stay, right? Again, one consultation by the same specialty or subspecialty within the same clinic during the same stay, okay? So that doesn't change, one per admission. ED visits. So here's where I wanna talk for just a quick minute about the one change, and then I'm going to have to move along here because I've got some more slides to share. Your emergency department, that first level 99281, which may or may not require a physician or APP, that was instituted. We did ask this question. It was answered at the AMA symposium. That was instituted for things like where a patient, and this is on page 27, by the way. This is instituted or put in place for things like someone showing up for a TB test read. I don't see that this would ever be used in orthopedics, or somebody comes in and just needs a stitch removed and their doctor's office is closed, and it's the weekend and they can't get in or whatever. So I don't really see this code being used much. It is not a code that a medical professional should be using. So your lowest level of code would be that 99282 should you bill the ED visits, but I did want to make sure and discuss that while we're here. So they did try, go ahead and put, go ahead and revamp this code for those very rare circumstances that might occur. And the guidance, again, can't be, you can't use ED visits for the convenience of a physician, report it to report services when a patient is admitted to the hospital, then you would want to see your other services under the correct category of code, whether it's the admit, observation, care, et cetera. And then procedures and services that are done separately in the ED, if they are separately billable, you would want to seek that out as well. So changes to problems addressed, no changes for, and I'm going to start going quite a bit quicker through these categories because I see I am running out of time. So no changes here for, not applicable for that first level and minimal. Okay, here we have a few changes in the low section. And let's see, let's look on page 28 is where we're at. So you'll see the changes for 2023 have been the strikethrough there. So they decided to take out the examples for the levels. They didn't want to pin anyone into certain scenarios. So they decided to take out the examples that were already in there because it should be according to the clinician as to what level of service the patient may be at, whether they have comorbidities and maybe the condition means it's higher or lower. So that was their rationale in taking out the examples so that you wouldn't feel like you were pinned into one specific example or one specific scenario of a condition. They did add, if you'll notice here on the left, two new categories. And these are the only two new categories that were added. One stable acute illness. And I'm really glad they added that quite frankly, because in orthopedics, we might have a patient who is actually stable. So you've got them stabilized and they are improving. They're just not at their goal, but they are improving. So we kind of needed some place for them to land because the other categories, as we found through the auditing process, didn't really give us a good place to land for a category. So I'm glad they added that one. And that is a problem that is new or recent for which treatment has been initiated. The patient is improved. And while resolution may not be complete, it is stable with respect to this condition. So that's great. I'm really glad they added this one. And the second one that they added, an acute uncomplicated illness or injury requiring inpatient or observation level of care. And I just had a really, all of us had a big question mark over our heads on this one. And we actually did, I submitted some questions to the AMA and they answered it during the symposium. And this is for, they said it's not pointing to one particular situation. However, it's for possibly those patients, social determinants of health will come in here. And this is where we see that being a big factor in choosing this, where you've got someone who doesn't have a safe place to go and may need to be watched more carefully. Again, it may be an uncomplicated injury or illness, but you do need to keep an eye on them or keep them a little bit longer. They did say that the social determinants of health did play a big part in that. The way it reads is a recent or new short-term problem with a low risk of morbidity for which treatment is required. There's little to no risk of mortality with treatment and full recovery without functional impairment is expected. The treatment required is delivered in the hospital inpatient or observation level setting. Again, I believe it was, my understanding, the way it was explained is that it was based more on the social determinants of not being able to have a perhaps clean clinical or home environment to recuperate in. Just some fancy arrows to point out what we just discussed, that the examples have been removed and we've got two new codes there. And again, for your moderate level, we don't have anything new that was added from 2021, but they did go ahead, and now that we've got the same table used for hospital and outpatient, they went ahead and took out A, the examples, and then took out that reference on that very first chronic illness with exacerbation, took out the reference to consideration of hospital level of care, because the patient may already be in the hospital. And on high, the changes here under the first category there, chronic illness with severe exacerbation, they did go ahead and take out may require hospital level of care and put in may require escalation, because the patient may already be in the hospital. And I do want to point out there in the second category, acute or chronic illness that poses an injury to or a threat to life or bodily function, in the near term without treatment, in the near term, they do, they did come back and explain that they do mean imminent. And, you know, within the next day or two, not, hey, let's schedule you for a repair in a week or 10 days. It would be something that was more of an urgent emergent manner. And some symptoms, this was added, I believe this was updated in March of 2021. This is on page 30 is where you'll find this information. Some symptoms may represent a condition that significantly, probably, okay, poses a threat, a potential threat to life or bodily function. Okay. So that's what we're going for. That's what they were going for here for this change to the problem addressed. Again, just pointing out the obvious data, everybody breathe a sigh of relief, data did not change in any way, I will briefly go through this. Under data, this was the same for 2021. And it's the same for 2023. For low, we have category one or two, either two of any one of those three external notes, a unique test, reviewing a unique test or ordering a unique test, again, test that you did not bill for separately or perform. Okay, or getting information from an independent historian. And the easiest one, if especially if you're a pediatric orthopedic foot and ankle surgeon, then you know, your parent, if you document that, then that automatically can give you at least a level low under category two. Okay. Now for moderate, if you'll notice that independent historian, look at the very last bullet under category one, it moved up. Or now we have category two, which is a new category, independent interpretation of tests. And this would be your imaging when you yourself take an external image that you did not bill for that was not performed in your clinic. And you took the images, reviewed them, and performed an independent interpretation, you do not have to have a separate written report. It can be just a sentence or two of what you found when you reviewed the imaging, it can be within the progress note. So that is a category two, if it is documented appropriately. Or if you have if you get images back, and you're like, nope, this, this is missing what I was looking for. And I need to call and ask questions to the radiologist or whoever did the test. Some other could be any test, but imaging mostly for ortho, then you can also get moderate by any one of the three categories by documenting your conversation with that physician or provider, external provider, or appropriate source. Okay, so for moderate, it's one of any of the three. And you will please do notice under category one, instead of two of the following, it now says one or any combination of three of the following. So it just went up by one number there. Okay, and for high, the good part about high is it doesn't change. Extensive is the same as moderate. However, it's now two out of three, instead of one out of three. Okay. So changes to data definitions, there were two very quick changes. Under independent historian, the AMA did come back and clarify it does not include translation services, they are not considered independent historians. And independent interpretation, they just clarified the wording here, it was just kind of worded in an off in a weird way. This does not apply to a physician, or QHP who reports the E&M service, and also reports the test. So the way it was worded, you couldn't really tell what they were talking about. So they just clarified that to say that if you are billing for the test, or reporting the test, you cannot get an independent credit, or an independent interpretation of a test. Even if you have a radiologist in house, you can't get credit for that in your clinic. This does not usually come up often in orthopedics that we've seen much of, but it is in your book, I won't belabor the point here, but they did update the definition just a little bit for drug therapy requiring intensive monitoring for toxicity. They did, let's see, yeah, they removed the example of electrolytes and renal function, and then added cytopenia, and the use for antineoplastic agents. So they did change it a little bit to make it read easier. We just don't find that this is used all that much in orthopedics, but we do want to make sure that you are aware of it. And the change to risk, there was one change to risk on that table, and it is in the category, the high category, where now that this table is going to be used for hospital, as well as office visits, they changed the wording there under decision regarding hospitalization, that third bullet, or escalation of hospital-level care. In the last bullet, they did add also examples of a high risk of morbidity for parenteral-controlled substances. So that's on page 32 as well. So let's take a look at page 33, and everyone, please do pat yourself on the back. It is 9 o'clock, and I will go through these very briefly. We've got one scenario here of an 80-year-old who is having difficulty walking, and pain around the left foot and calf brought into the ED. Dr. Foote was called in for a consult and did the appropriate history and exam, no previous history of injury, didn't do any imaging, clinical findings were consistent with an Achilles tendon rupture. You splinted the patient, provided crutches, and said let's follow up with the foot doctor a week later. What kind of, where would that land for an ED visit? And of course, it's a Medicare patient, so Medicare says use the ED visit codes when you see a patient in the ED. Well, we categorized this when we reviewed it as a low problem addressed, it's an acute uncomplicated injury, limited data, and low medical decision making. They're going to use splinting and crutches, so ultimately that was a low level of MDM. So that would bring us to a 99283, just a different way to look at the same information here. Scenario two, we've got a 40-year-old with left ankle pain, brought into the ED, and Dr. Ortho was called to consult. She fell several days ago, underwent a closed reduction of a left bimalleolar fracture in the ED, excuse me, by another physician, that's important. She's now coming in due to continued pain, so you see the patient called in, and I don't know why that slide did that. Okay, so the imaging shows x-rays were ordered by the ED, viewed by Dr. Ortho, he described that they showed a fracture, that it was displaced. Okay, so now you've talked to the patient, needs internal fixation, she'll be taken to the OR tomorrow. Excuse me, I cannot read. We'll be taken to the OR today, and we'll go home tomorrow. Tonight does make a difference. So here, I wanted to give you a scenario which, it really depends on the patient's clinical presentation and the clinician's assessment. This could be a moderate fracture, or it could be a high fracture. It just, it depends on your clinical view. If you've got a patient with lots of comorbidities and high risk factors, of course, then, you know, that would depend on how you rate it. So we said it could be moderate or high, either acute complicated injury, or an acute chronic illness that poses a threat to life or bodily function. I'm going to take them to the OR tomorrow, so, or today. I'm set on saying tomorrow, and moderate data, right? You did an independent interpretation, and then high decision making for that emergency surgery. So that would, but yeah, so this slide I put in here, emergent procedure is typically performed, and we talked about that, immediately or within a minimal delay of seeing the patient to allow for patient stabilization. That's that day or two after, not, that's just the update that they, the AMA came back and updated their meaning of in the near term. So it could be a level four or a level five consult. It just depends on what you as the clinician decide is the risk for that patient. Last scenario, 83-year-old Medicare patient presents with back pain and right hip pain. And again, this is not your typical foot and ankle, but I'm sure that you see in ortho, you see a lot of these complex patients. Okay. She fell, having groin pain as well, presented to the ED. Ortho, Dr. Ortho was called in to consult. Okay. She's got a history here, lumbar fusion, bilateral hip, nailing osteoporosis and dementia. So did CT shows that she's got fracture, Ramey fractures, excuse me, Rami fractures and chronic compression fractures. Your plan was to, is to admit her and then treat the fractures non-operatively. Okay. So could be low versus moderate. Again, it depends. Not all fractures are created equal. As we know, they took that out of the, out of the mix in 2021. So it's up to the clinical presentation there and you would decide, is it low or moderate? And then the independent interpretation of the test moderate and high on that decision regarding hospitalization, bringing the overall level to a moderate level. So what does that look like for an inpatient admission? That would be a 99222. Moderate and either, you know, lower moderate on that problem addressed, moderate on data, and then high would give us two out of three would meet that level too. I'm not going to go over these slides. This information is in your book, but I do want you to take a quick minute to look at the revised times that were given for the hospital visits, the different categories. Okay. So the inpatient observation services, the, they increased. So in order to meet a level, the times were increased because now it's not just the inpatient visits, but observation. So that's something to look at. These did increase. Same day observations increased somewhat that level, that third level, the 206 increased pretty significantly. Outpatient consultations went down. So that's good news. It doesn't take as long to meet the levels for both inpatient, here are the inpatient and the outpatient consultations. Okay. The prolonged service code for the inpatient setting is 99418. It's the same with or without direct patient contact each additional 15 minutes. It's the same idea and the same protocol as the 99417 for the outpatient. It's just that if you have prolonged services in the inpatient setting, it's the 418. And of course you use it only with the highest level of each of the categories, the inpatient or observation care, the same day, the consults, both inpatient and outpatient visits. And then the 306 and 310, those are nursing, I believe nursing facility codes as well. So prolonged time equals 15 minutes beyond the time required. And I'm going to show you that here in just a moment. Again, same parameters as the 99417 just for the hospital visits. And then of course you have other prolonged services codes still apply if it's not on the same day as the, if your prolonged services are on a different day. There are other codes. Those do still apply. I do want to make sure that everyone understands that you'll just take a look at this. This is in your book. The consult codes do have a threshold. They don't have, you see how in the bottom matrix, the 99205 and 215 both have the span there, the minutes that range. However, for the consult codes, you are required to wait the full 15 minutes because there is no minimum range. In the bottom, you can, as I said earlier, use the minimum range according to CPT. This is not true for CMS. Again, they don't allow that for the G2212. They want you to use the maximum. And here for hospital services, there are no ranges on the hospital codes, but CMS said, well, we're going to go ahead and grab our own codes and use our own service times. So please do look over this. I'm not going to belabor the point here, but for Medicare patients, CMS says that they are going to use their times, their threshold times that they have assigned to these codes. They did not give any reason why except to say that they are doing it. And just to know that there are other timed prolonged service codes for nursing facility codes and others for home visits, but we don't, we don't have any of those at, we are not discussing that today. And unfortunately we are out of time for questions, but I will say before everybody goes, thank you today for joining me and Jen. Thank you. She didn't get a word in edgewise today, but thank you for joining us. And if you have any Q and A, please do add your question in the Q and A section. And those questions will be collected and sent to us, and we will be more than happy to answer them or join us next week. And we'll have the full version of the 2021 guidelines. If you want to take a look at those and we can certainly answer questions then, but we thank you for staying with us this evening. And we hope to see you again, same time next week. Thank you so much.

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