So for, again, this talk this afternoon, so we're gonna talk about billing for PM&R, and we're gonna have two speakers, and they're gonna talk about the inpatient billing and the outpatient billing. And so Dr. Cahan and Dr. Kasprzak will be talking to us. Dr. Cahan is gonna go first. He's gonna talk about the outpatient billing. He's the founder for the Cahan Center for Pain Management in Annapolis, Maryland, and he graduated from the Philadelphia College of Osteopathic Medicine. He's board certified in five medical specialties. And prior to starting the Cahan Center, he was an associate professor at the Albert Einstein College of Medicine. He also served as the chief resident at St. Vincent's Medical Center. He is registered with the DEA and the Controlled Dangerous Substance Board of the CDC, as well as multiple pain specialty and subspecialty credentials. And Dr. Cahan is also very involved with the college. He's our current treasurer. So we're very grateful to him for all the work that he does for the college. And then I will go ahead and introduce Dr. Mike Kasprzak as well. He'll be talking about the inpatient side of billing. And Dr. Kasprzak is going to be our incoming education chair so I'm very excited to have him involved in the college. And he's a board certified physical medicine and rehabilitation doctor who also is certified in brain injury medicine. He completed his brain injury fellowship and residency training at Wayne State University at the Beaumont-Taylor Program in Michigan. And he completed his medical school here in Florida at the Nova Southeastern University College of Osteopathic Medicine. He's currently the program lead for the concussion clinic and the neuroscience service line, as well as an assistant professor for the Department of Rehabilitation Medicine at the University of Minnesota Medical School. He's also the director for the university's rehabilitation medical student clerkship as well as an associate program director for the brain injury fellowship. Please join me in welcoming Dr. Cahan and Dr. Kasprzak. Thank you. Thank you. Okay. Am I turned on? Okay, welcome everyone. I know Jenny talked about things about lifestyle and how the morning was lifestyle. I think reimbursement's a little lifestyle-ish too. I don't know, but depending on what we're doing, we're trying to think about lifestyles and trying not to get sued also improves your lifestyle. It's just a different look at a different part of your life that we're going on. So what I'm gonna kind of basically talk about is billing and coding, how to make the most out of your day. Okay, because I think there's a lot of things that go on that we really don't know that we can actually code for and get reimbursed for. So I always kind of, I don't go outside the box, although Seth will say I do think outside the box. I stay within the box, but I do think outside the box. And some of these things have been found out just from reading and trying it and being like, they paid us? So these are some of the experiences and things that we've gone through as well. Michael, are you talking about telemedicine from an inpatient side as well? Okay, so my first part of the talk, this is what we're gonna talk about. We're gonna talk about telehealth post-COVID. Currently, and things like that, as far as definition, documentation, proper coding, modifiers for your telehealth visits. And then the part two is gonna be talking about modifiers that you use in your day-to-day basis with some of the procedures. Again, I do predominantly prescription and interventional pain management for non-malignant and malignant pain, so it might be a little bit more geared to it. But anyone who's in musculoskeletal stuff, some of these things will be beneficial. And all of us who are doing telehealth, some of these things will be beneficial, especially the first part. And the modifiers are gonna basically be your CMS modifiers and then modifiers to your HCPCS codes with regards to drugs, and then some of the things that you might do in your office on a regular basis and not realize that you can get reimbursed for or how to get reimbursed for it. All right, so let's talk about telehealth. Currently, telehealth is gonna be around until January of 2023. So even though the public health epidemic might, you know, or emergency might go away, at least we know CMS has said that telehealth will be available till 2023. The beautiful thing about COVID, if you didn't know, telehealth has been around for a long time. But as a specialist, we were not allowed to do it. It was only for primary care specialties. The beautiful thing about COVID is that it allowed all of us to develop telehealth aspects to our practice. And I think some of us who have patients that might live in rural environments or travel, I think this has opened up a lot of things for treating these patients and staying in touch with them. So it's open to all areas, and it may be billed with a place of service of 11. For those who don't know what that is, that's your office. Okay? And the difference between billing it as a place of service as 11 in your office is we'll see you can use regular A&M codes. You don't have to use a telehealth code. If you're doing it somewhere else, you don't have to use the telehealth code. Okay? And it's gonna be the same as considered as in-person visits. It's paid at the same rate as in-person visits, and it does not matter where the originating site is. In other words, you can be in Florida and do telehealth according to the current rule and see your patients. The key thing is, is at least in Maryland, you have to have a video and phone capability to be considered telehealth, but because in Maryland we have some rural communities, you can do an audio-only telephone call if they can't figure out how to work the video on the Zoom or whatever platform you have. Okay? So you can do that, at least in Maryland. So you have to know what your states are on an individual basis. Yes? So does that mean you can actually build the E&M visit if you're using telemedicine? I mean, if you're using it by telephone or if you're using telephone visit, right? You have to use, in Maryland, you can build the E&M for Medicare. Oh, the question was, so if you're using only audio-only, do you have to build the phone call only, the telephone call, or can you build the telehealth? In Maryland, you can build the telehealth for Medicare. Now, commercial insurances sometimes are a whole different animal, but for the most part for Medicare, if you have done your due diligence to try to make it so that it is an audio-video, and you've documented that you said, we signed them up for Zoom, we walked them through it, blah, blah, blah, blah. However, the patient could not figure out how to turn the camera on their phone so that we could see them, but they were seen as a participant on the Zoom meeting. That is considered justification that you've done all due diligence for a telehealth visit. Yes, at least in Maryland. And also, just as a clarification, paid at the same rate as in-person visits is no longer true in many states. Right, so we're going to go into some other stuff. Yeah, so that's kind of next as far as some of this stuff. And just the bottom is like, hey, Facebook Live, TikTok, no, you can't, then you're going to have HIPAA violations and you're going to be paying a lot of money. Anyway, so basically, what do you need to document? And this is kind of the things, you have to document the originating site, the healthcare professional site, the statement at the beginning of the office as to how this visit was carried out, live audio-visual or live audio-visual was attempted. However, the patient did not understand how to turn on their video camera. Therefore, all attempts were made and we were able to conduct this with audio only. Okay, but you've done everything for a telehealth. It's kind of like, okay, I wanted to do a procedure, but I couldn't do it. So I have to use the modifier that says, well, I did it, but I didn't complete it. You still get paid for the procedure. You've done all attempts for it. So there are ways, you know, there are things to justify it. And just like- And you have to use that modifier? Well, yeah, you'll see the modifiers we'll talk about in a little bit. Okay, like that. And then you have to say that the statement of the services were clinically appropriate within the scope of the practice of the medical practitioner. And this is all kind of basis. You have to identify the patient. How'd you identify the patient? Visually, phone, date of birth, all that kind of stuff. And usually that's done before you ever get on the phone because your staff is calling them and setting them up and things like that. You have to say who you are. You have to have oral and written consent from the patient or a guardian of the patient, okay, to conduct that telehealth visit. Again, your staff should be doing this and things like that. Now that we're open for business and seeing stuff, we just made it part of our policy. So when they consent to being a patient of the practice, it's also on our practice policy that you consent to telehealth visits, as long as we can still do it, okay? So it's just an automatic signature. You have to talk about the HPI, review of systems, physical exam, assessment, plan, and follow-up, you know, your basic stuff for your normal in-person visit. This is kind of, I know it's a lot on the slide, but this is what we can say in Maryland, okay? The office visit was conducted utilizing telemedicine capability due to waiver 1135 and in compliance with the Coronavirus Preparedness Act of 2020, okay? That's the Maryland clause that we have, whatever 1135 was, and so that is in all my documentation, okay, so at the end of every telehealth note, you're gonna see that, and then it goes on and it's about what the informed consent and how we did it and patient privacy and how the ID was confirmed and you looked at the patient's face and they saw it, and then at the bottom, it says the office visit was conducted utilizing telemedicine capability due to waiver 1135, and again, in compliance with that. During the visit, the patient was located at home while the provider was in the office or an office. Follow-up visits are pursuant to the physical exam and took place, and again, how you confirm their ID. So those are things that you can add. Is 1135 Maryland or federal? Federal, yeah. Okay, Hogan has another thing, I don't think I, yeah, federal, 1135 waiver is federal, so, all right. So that, I always make sure that I have that documented, okay, in the note, and what you can do is if you have an EMR, which most of us have, what you do is in your telehealth template, it's just at the bottom of the page, so you don't have to click on a button or anything. The minute you pick up that telehealth template, it's automatically in there, okay? So that's what you kinda do. If you need that, everything's online, and I know it's a lot of small print, but that's it. Other things that you gotta do is the purpose of the visit, this has to do with the consent, the nature of the telemedicine evaluation visit during the telemedicine visit, the details of the medical history, a physical exam, you can utilize, and you have to say that it was taking place utilizing interactive video. Now, of course, if you go to audio, you have to say a physical exam was not performed today due to visual incapabilities, okay? But, you know, just say, stand up, walk around, how are they looking, did they put a shirt on for the telehealth visit, you know, that kinda stuff. You'd be surprised. Yeah, you'd be surprised. Anyway, and, you know, basically, medical information and things like that and everything's gonna be HIPAA compliant, and that's basically your documentation. And then, more things, the right, they can sit there and withdraw their consent to the telemedicine visit at any time, you know, that kinda stuff. The potential risks and consequences and benefits of telemedicine, you might miss something because it's telemedicine. You might not see it, as opposed to what you can do in the office and things like that. So you have to tell them the risks and benefits that, you know, should this not pan out, and you should come in. And back in the day when this was first written, I think we presented it at our first tele AV thing, like this is part of that original presentation. You know, you weren't allowed to see patients in the office until it was an emergency. You know, so a lot of this stuff was like during 2019. So now, if you're concerned that the patient couldn't get in because of whatever they tested positive for COVID, and their appointment was that, or they had a family member that tested positive, you can do that telehealth visit. And then if you have a concern, document patient will be coming in after they do five days of quarantine, you know, to follow it up if you have a concern. And location. So basically, this is a nice little chart as far as how you can sit there and Medicare thinks about telemedicine services because there's a bunch of them. There's the Medicare telehealth visits, there's the virtual check-in, and then there's the e-visits. And each one has a different code, okay? And when you talked about your phone and audio only type thing, that's going to be kind of your e-visits, the 99421, 422, 423 for your commercial payers. For Medicare, you bill it with the G codes. But the true telehealth where you have the audio visual, that's your normal E&M codes, okay? Your 212s to 215s, depending on what you're doing. And you can do that. And basically, the patient can be new or established because the waiver allows us to do that. And HHS will not conduct audits on that. I don't know if that's changed since this first came out. So don't hold that. That was when this first came out in March of 2019 or April of 2019, when we first started doing things. So just please check with that. The virtual check-in can only be done on established patients and e-visits really should only be done on established patients, okay? So that's the other pertinent thing. So from an IT perspective, these are the things you need to do if you're going to conduct telehealth. You know that HIPAA fines are extremely severe, $10,000 I think per breach or something like that. It's really costly. So you gotta make sure that you have a really good, secure system with multifactorial authentication. I'm sure most of you are already doing that because I'm sure you all know about cybersecurity and that a lot of healthcare practices are getting hacked all the time now. So if you're getting insurance for cybersecurity, your insurance company is gonna make sure that your IT department has all this stuff in place. And basically, it comes down to multifactorial authentication, changing your passwords every three to four months, making it more complex passwords, making sure that you have a private network that's secure to get in. And Zoom and video and then some of the EMR companies that have offered their own like telehealth services that you could subscribe to, they've done all this stuff already for you, okay? So there's the thing. But that's basically what you have to talk to your IT department if you're not doing that. So what CPT codes do I use when I'm doing telehealth? Again, if it's an online digital evaluation, it's a 421 and 423, okay? There's basically only three visits that you can do and it's based on 10 minutes, 11 to 20 minutes, and more than 21 minutes. You're only able to use these e-visit codes once every seven days, okay? So that's for if you're doing like an audio or a phone thing, okay? When you start getting into more of the other ones, when you're doing a true telehealth, where you can have a new patient consultation or a follow-up for a patient, you can use your regular E&M codes, okay? 2-1-1, okay, back in 2019, 2-1-1 and 2-0-1 existed. Now they don't exist. So you can do 2-0-2 to 2-0-5 or 2-1-2 to 2-1-5. The things that you need to make sure is that you're using the modifier CR or 95, okay? That you must attach to your first CPT code for E&M, either 95 or CR. So which one? This is what they are defined of. A 95 modifier is a synchronous telemedicine service defined as real-time interaction with a physician or other qualified healthcare professional. That means your PAs can sit there and do this stuff, okay? They can do the telehealth as well, okay? Who is located at a distant site from the physician or other qualified healthcare professional. Then there's also a GT modifier, which means it was rendered via synchronous telecommunication, okay? You're on the phone with them at the same time. A CQ modifier is asynchronous. In other words, you communicated and somehow they communicated back to you and you communicated. Texting, emailing to the patient through, I wouldn't text, you know, not texting on your phone, but sending messages through your EMR to the patient's email address through a secure server, they respond back to you. So that would be your GQ. So there's a way to bill and code for just, like having messages back and forth with the patient? We'll talk about it. So the question was, is there a way to bill and code for epic messages back and forth to a patient? And we will talk about that going further. I think I put in here prolonged service without direct face-to-face contact, but I'll make sure I touch on that prolonged service. So there's different ways. It all depends on what it's in relations to. If you get a message through your EMR system that the patient wants to talk about something, that's considered, that's usually considered an e-visit, or it could be potentially a virtual check-in, but it's usually an e-visit. So you'd have to use different codes for that. So if you're saying, hey, the patient wants to talk to you about their MRI results, they don't understand what spondylolisthesis means, and you send them a message through your secure system, yeah, e-visit. As long as they reached out to you first, not you reaching out to them. They have to reach out to request a discussion, and then you document it in the chart. So that's your e-visit. Where were we? Here. So that's where you can sit there and use your CQ modifier, okay, for that. And then CR modifier means it's disaster or catastrophe related. So when we talked about Medicare, Medicare requires this for everything through telehealth that you put your CR, because it's related to a disaster. The pandemic of COVID was a disaster. So you have to use your CR modifier as well. So that's basically, and then you add your 95. So you have to use the two. Yes, Lane. A visit with a resident during a teaching. Have no idea. The question was, what about a visit with a resident? That I don't know. Whether they fall in that other healthcare provider situation, I don't know. Because I don't- GS code. You think it's GS code? GC. GC? Okay, GC code, all right. Yeah, because I don't have the resident, so it's not something I do. Yeah. The question I have is for the CR modifier, are we still considered a catastrophe slash disaster? So what I have learned, so the question was with the CR modifier in the current realm of COVID, do, are we still considered a disaster? The fact that we're able to still do telehealth until 2023, I would throw it in there. Because that extension of telehealth was based on the original disaster. So it doesn't hurt to throw it in there. In other words, you're not going to get denied for adding an extra modifier. You're going to get denied if you didn't add the modifier. Okay, so if the current thing for telehealth services that is allowing a specialist who used to never have the capability of running telehealth to do telehealth and we're still able to do it, I would say that we still fit under that 1135 waiver and it's still disaster for the most part. Correct. Yeah, because the non-5 modifier shows that you did an interaction real time utilizing a audio-visual thing and then the CR is saying the reason I being a PM&R specialist doing a telehealth visit is because we're currently still in a disaster crisis. Yeah, well the first one would be more audio, okay, if you can't do the visual because you would just use the 95 and then the second one was what I was talking about if you are communicating with the patient through an email or secure email site. You would use the GQ. Now that's if you want to sit there and do it under telemedicine. Okay, there's other and it's just like they or you want to do build the e-visit. Okay, you're going to have to use that GQ modifier if you're not if you're doing if you're not doing an audio-visual type thing. So like your e-visits can also be an audio phone call. They requested online to talk to you about you. You decided to pick up the phone. That's a synchronous telecommunication. You didn't use video so it's not a telehealth. You just called them on the phone because they requested so it's an e-visit. So you use the 241 or the 242. You use these, okay. You use the online digital type thing for this. Your 422 and your 421 for your discussion because they requested you. You're billing it as an e-visit. If you wind up going to an audio-visual then you fall into the telehealth and it's a 202 to a 212 to a 215. But if you're in that and so but then if you're just returning an email request then you have to use that asynchronous. They asked you something. You asked, you responded to them. So you would like like let's say you sat there and did an audio and a telemedicine audio. They contacted you through your secure website. They said okay I want to talk about my MRI and they want to do that. So you decide to call them on the phone. They request it. You would bill and depending on what how much time you would do. Let's say you spent 10 minutes with them. You'd bill a 499-421 and then you would use, since you talked to them, you both were synchronized. You'd use your GT modifier because you were talking at the same time. If they wanted to talk to you about the same thing, about the same MRI results, but you didn't have time to do that and they have a secure email address in your system, you would bill the same 421 after you sent them the email. You document that you sent it but you'd use the GQ modifier because it wasn't happening at the same time. So that's what I say and that's kind of been the change. The statement was understand that if you're not licensed because we're not in the state of emergency, even though you could still do telehealth, if your patient lives outside of the state that you are practicing in or have a license in, you can't really treat that patient through telehealth anymore. That's if you're billing a telehealth service. That's if you're billing a telehealth visit. That's not if you're doing an e-visit. That's not if you're doing a phone call. It's only if you're doing an audio-visual. It has something to do with the state of itself. I wouldn't bill the insurance. I would just charge cash for that as a consult. So the question was if you get called about a patient who lives in Florida and you're asked an opinion, what do you do for that? I would not go through insurances and you're just asking an opinion. You know again if you're doing medical treatment and that patient carries out the medical treatment and they live in that state but you don't have a license that you're practicing medicine in the state without a license. Now if the patient spends six months in your state and six months outside the state and that patient is your patient in there and they're living there, then that patient is a resident and you've already developed that treatment plan for that patient while that patient was in the state. So but I would sit there and just send a letter to the patient from your office as opposed to calling them and doing this and I also wouldn't bill the insurance company. I wouldn't bill the insurance company. I just wouldn't bill the insurance company. I'm gonna be like look if you're living in Florida six months out of the year and you're calling me to do stuff, sorry that's a separate contract that we're gonna talk about. You know it's a separate thing. Okay sorry I've got to go on. So anyway that's the thing. So which place to use? POS2 means it's just telemedicine doing that and that you're just getting Medicare. You use it when you're just getting reimbursed at a professional component only. POS11 you do it like a regular office visit and it's paid by the primary and tertiary care with modifiers CR and 95. Okay what do you do? This is a nice little slide of how to bill it for which payer. Medicare we have Novitas. I don't know who anyone else you know what other Medicare contracts you have. The CR and the 95 modifier to get full reimbursement with the place of service of 11. Blue Cross Blue Shield in our area we have to use a place of service of two. They don't consider it as an 11 as an office visit so that's just what their rule is. So that's what you got to do if you want to get paid and use the CR and 95 modifier and commercial payers and workers comp they'll allow you to do it with the place of service as 11. Okay so you just got to know what your payers want and basically but so you're either going to be using a place of service of two and that just means it's a telehealth visit or a place of service as an 11 meaning it was an office visit with modifier CR 95 that was done due to catastrophic problems and done via telehealth. That's it. All right these are other things with regards to things like this is Comar. This is Maryland. We have this executive order number 20-04-0101 saying that we can utilize telephonic and electronic means of communication in lieu of face-to-face direct care. This is just specific for Maryland and basically the requirements in the state of Maryland. So again I throw it your state probably has a statement like this about telemedicine. Put it at the bottom of your telehealth notes just so if anyone questions it. If you want to appeal it basically this is a nice little statement talking about again the executive order. So if they deny your visit you want to sit there and send it back with this and so this I'm not going to read through it for time but this is also available on the website in the slides and if you need anything. All right so this is kind of more of your day-to-day stuff so we're gone through telehealth. This is a day-to-day stuff because we're kind of out of this like you said catastrophe and disaster. So these are some of the things that I kind of looked at what I do that maybe other people don't know and how to utilize. So when we talk about modifiers we're talking about modifier 25, 26, 59 and XU. When we're talking about CPT codes we're talking about 77002, 96160, 96130, G0444, 80305, 99496, 36419 and so on and so forth. I'm going to explain all that. So anyway okay modifier 25 is defined as a significant separably identifiable E&M service by the same physician or other qualified health care professional performed on the same day. Okay example is patient is seen for back pain that then also complains of knee pain and you inject the knee. You would use your appropriate E&M code to evaluate for the back pain and the knee pain but then attached to that E&M code you put a modifier 25 because you injected the knee. So you used your 20610 code for a cortisone injection of the knee and then you subsequently list the fact that you used lidocaine and whatever corticosteroid you did. Okay you saw them for back pain they were coming in for back pain there were a follow-up visit for back pain and like oh doc by the way do you do shoulders do you do knees you assess it you inject it that's a separate and identifiable procedure. 25 modifier okay and bill for the procedure. 26 modifier professional component for diagnostic tests. Okay example of this one pulmonary function tests therapeutic radiological procedures and radiation therapy. Most of us when we were doing interventional stuff back in the days we're using this 77002 until they incorporated into our spinal injections. However there are other injections that we do that we utilize for scopic guidance. Hip arthrograms, genicular nerve radiofrequencies, sympathetic blocks. Those are things that you're using or you're using ultrasound okay or you use an ultrasound I use fluoro you're utilizing that fluoroscope to sit there and localize that needle so you include your 77002. If you're doing it in your office and you own your machine you don't have to use a 26 modifier okay because it's all part of the thing you get the full price. If you're doing it in an ambulatory surgery center and you don't own it you put the 26 modifier because you're billing for the professional component to interpret that the needle is in the correct place. Okay so that's where the 26 modifier comes in. 50 non modifier distinct procedural service it's a is used to identify procedures services other than E&M services that are not normally reported together but are appropriate under the circumstances. Okay documentation must support it of course and you might sit and you have to sit there and dictate something different. So example of that is lidocaine. Do you really always need lidocaine in an injection? No you can just do it with steroids but if you use lidocaine use the 59 modifier. Part B news this is something I subscribe to it's from I get no you know I have no what what are those things that conflict of interest or something like that. Yeah so Decision Health is an organization that produces part B news you can get it online then cost 160 bucks but it tells you all the things. The most recent thing that came out like a month ago in Decision Health is the incidence of denials through Medicare for the 59 modifier. So you use what's called the XU modifier for Medicare only and it basically means the same thing. Okay but it's a it's a over non-overlapping service so like if you put lidocaine in there you put the XU modifier. If you do a urine drug screen you put the XU modifier. If you do a PHQ-9 you put the XU modifier for your Medicare patients that kind of stuff. It's saying it's a different service it's a different service that gets billed that you've performed and you've addressed it. So again this is some of the things. So what is each code? 77002 is fluoroscopic guidance. 96160 is a patient focused health risk exam like your cage exam your opioid risk tool your 96130 or G0444 is your PHQ-9 test. Your 80305 is your point-of-service UDS. Your 964406 or 4000F is your tobacco counseling and your 36415 is a venipuncture. If you took the blood out you can bill for it. Yes. Yes. Question was if you do the screens does it have to be part of the note. Yes you have to show documentation that you did it. Absolutely. We have it automatically for our for our opioid risk tool. I conduct it. I ask the questions for our PHQ-9. It's part of our patient paperwork that they fill out online. Yeah. What you do so the question is how do you figure it out so it gets incorporated in your note. You create an Excel file okay with all the questions and then you have four columns to the right that they can pick it and then what you do is you have that column that has your selection it's a it's a value of 0 to 3 and at the bottom you can sum it up and there's a special formula that it will automatically sum up all your values and give you the total and it you create it in an Excel file they create that in your EMR because your EMR is basically an Excel file you know with all different things and then you it'll come in automatically. It's really not that hard. I created the Excel worksheet and I just asked the EMR people to throw it in there so it got incorporated into the EMR program. So it's not that hard. I can send you a copy of my Excel worksheet. Yeah. It's easy. I also did that with Oswestry disability and the opioid risk tool as well. So things like that. So again other things we need to talk about for time is units. Units. Units. Units. If you don't know all your drugs are based on units. Every drug has a unit and is billed based on the unit. Your xylocaine is based on 10 milligram units. If you have 1% xylocaine it's 10 milligrams of xylocaine per ml. So if you inject 1 ml you bill for 1 unit. If you have 2% xylocaine it's 20 milligrams per ml. If you inject 1 ml how many units do I bill? Two units because it's billed in 10 milligram intervals. If you have 4% xylocaine per ml that's 40 milligrams per ml. I inject 1 ml I bill 4 units. Units. Units. Units. That's what it's like. Methylprednisolone. Okay. Bills based on the units per milligram per NDC code. National drug something code. You have to have the NDC code for all your drugs in your EMR program. Otherwise you're not getting paid. You'll get paid something but you're not getting paid for what the price of the drug really is. So for me I listed my NDC codes for basically methylprednisolone because it comes in 40 milligrams per ml, 80 milligrams per ml and 1 ml equals 1 unit. So if I inject 1 ml of an 80 milligram per ml okay that's going to be 8 units because it's 80 milligrams. So 80 milligrams, 8 units. 40 milligrams, 4 units. Okay. Those are important things. Beta methasone. A little bit different. It's billed in 6 milligram units. So usually beta methasone is 6 milligrams. It's 3 milligrams of beta acetate with 3 milligrams of the other one. Huh? Okay. So anyway so if you want to read it it's based on that but remember your units. Oh that was the last slide. So kind of got a little bit of time on that. Okay. A little bit of that. So triamcinolone is billed as 5 milligram units. So if you bill if you have a 40 milligram ml it's billed in 5 milligram units. It's 8. Okay. 5 into 40 is 8. Make sure you put those 8 units. Otherwise you're only going to get reimbursed for 1 milligram. So that's the important thing. So these are things that you're doing every single day. You just want to make the most of your day. It's not like you're beating the system. You're not doing anything illegal. You're just understanding the system and that's what it is. It's make the most of your work. Okay. We're all about working smarter not harder. Okay. That's the thing. Worst case scenario they're going to deny it. You're doing the right thing. They're just going to deny it and say you know what? Sorry. We consider it inclusive of the whole procedure. Some insurance companies do. It's like remember we were able to bill epidurograms separately. That codes totally gone now. Okay. It's all inclusive of that stuff. It all depends on your insurance company. Most of the time Medicare will sit there and you know if you use the correct modifier they don't consider it necessarily inclusive and that's what you have to know. So basically bill in units. Know how units are billed. Is it based on milliliters or is it based on milligrams and your references are the AMA CPT code, HCPCS book and CMS.gov. So just kind of understand what you're doing. Make the most of your day. Quick questions. Sorry I ran long. All right. Any questions you want email me. For those out in virtual land feel free to reach out to me with any questions. Thanks. Sure. Sorry. Green means forward. All right. Wow. We're good. Yeah we'll wait for the slides but yeah that was no problem. All right. So wow you know that was a lot. That was just outpatient coding. You know I think for the medical students listening you know you never stop learning even when you graduate you go through residency you're always adapting, learning. We had to learn about all this telemedicine. It was a really good review there. So I'm gonna talk about inpatient billing and coding. This is primarily for the residents. I would say residents and fellows, you start to, you learn about AKIs, you learn about UTIs, you learn about BKAs, AKAs, you learn about TBIs, but you need to learn about RVUs. So RVUs is kind of how we produce the work that we're doing, our productivity. And in order to get the RVU productivity, you gotta bill appropriately, and you also have to document appropriately. So this is just gonna be an overview about how to get good documentation so that you can kind of get the most RVU per encounter. All right. So just quickly, always, you know, as a medical, I'll be quick with this, just quick overview, but you know, as a medical student, you learn how to take good notes. That doesn't stop when you're attending. You have to have a great note-writing process. We'll talk about mid-level practitioners, understand problem listing, and then the charge capture. This is the RVU generation. And then perhaps introduce diagnosis and patient resources for CMS reimbursement on the inpatient rehab floor. So there's a lot here, and you'll be able to see the slides, but you know, it just, you can either kind of bill on time or you bill on complexity. But this is more or less through, you know, outpatient consultation, so we will go through this again, but it's similar with inpatient visits, which we'll get to that slide. You always gotta have a chief complaint, history of present illness, review of systems, and your social history, family history, and past medical history for your documentation. And here's the history elements. You could have a brief encounter, or you can have more or less an extended encounter. So is it problem-focused, expanded problem-focused, detailed, or comprehensive? And so some of them you need a large history of present illness and no review of systems, and some of them you need to check off all those points, up to 10, to kind of bill the maximum. So these will all be to share. Again, here we come from for our history that you have to have this in your subjective, in your HBI, you know, the onset, the location, the duration, that characterize the pain, what makes it worse or better, does it radiate, and why is the patient, you know, here? It's the chief complaint. You know, it doesn't go away. You know, you always have to have this in your know, in your HBI. You gotta have your review of systems. They're gonna want to kind of bill the highest level. You have to review about 10 review of systems, you know, so you have to go through all of these and have it documented well. Hopefully you have, your EMR is set up and the note's already kind of pre-populated and it makes it really easy, so like every time you're kind of going through all these systems. Of course, again, past medical history, family history, social history, these are all important parts of the overall care, but they also need to be documented in the note and sometimes they're left out. Again, here's more for the physical exam. Is it problem-focused? You just go at the one body part organ system. Is it expanded, detailed, or comprehensive? Then you kind of do a full physical exam. So you can either do a full physical exam and get kind of eight organ systems, or you can spend 80 minutes with the patient. You see how it's kind of, which one did you do? Did you build on time or did you build on kind of your expanded focus? Okay. Body areas, organ systems. I mean, we usually do this every encounter. All right, so I guess thankfully for rehab on the inpatient rehab floor, these patients have tons of comorbidities. You usually don't even have to worry about this because they have hypertension, chronic kidney disease, had a stroke, hyperlipidemia, diabetes, neurogenic bowel and bladder. I mean, all that right there puts you into the high risk and comorbidities. However, this needs to be documented in your notes and show what the patient has, what you're treating. Office consult, so this is more inpatient visits. It's important to document at the end of your visit when counseling and or coordinating care dominates a total encounter patient or family more than 50% of the time, the level of service may be selected on base time. And we always document that I provided this amount of time in this whole encounter. For outpatient visit now, depending on your EMR, it's really nice. It automatically populates. All you do is just hover over your code and it'll say 30 minutes, 50 minutes, 25 minutes and you just click it and you add that right to your note. For inpatient, it doesn't do it as well. There's really three code levels, level one, 15 minutes, level two, 25 minutes and level three, 35 minutes for kind of follow up visits. Again, this is consult and this is your initial visit. So for HBI, you can charge for longer time depending if you did it or not. And usually it's 30, 50, 70 minutes. So that's a 21, a 22 or 23. All these numbers, honestly, they're important but it's all in your charge capture on Epic. So as a resident, you're learning about all these things. There's not a charge capture icon in your Epic. So that's why residents get into your real practice and you don't understand how to bill because there's not a charge capture built into your EMR. But as an attending, the Epic kind of changes and it makes it really nice and easy. You just go to charge capture and depending on how long you did, how complex your visit was, you can charge a one, two or three and it's really that kind of easy. As long as your documentation correlates with it. There could be prolonged visit as well. These are kind of extenders. Maybe you did spend more than an hour with the family. Maybe you had a team meeting to care conference and a prolonged visit with family. So you can tag on additional codes. Because all of these codes correlate to a RVU, a relative value unit. And that is how you're getting paid essentially. So when we talk about RVUs, it's how much time did you spend? How many RVUs? How many RVUs did you do in a day? How many RVUs are you gonna do in a year? And that's kind of like your salary. A lot of times, or you're based purely on productivity. A lot of times as we start our careers, we don't understand that. Again, here's the prolonged care, kind of how you document it. And then we talked about the teaching physician guidelines. You know, when you're working with a resident, you know, we actually, residents are amazing. You work hard, but we actually get reimbursed less with a resident visit. But it's fine, you know, it's not a problem. But we do a .gc code. You kind of do the 223. But again, on Epic, it's really straightforward. It's just a 223, a 221, a 222.gc with an asterisk. But you have to document, you know, that you saw with the resident you personally reviewed and you had the key findings from your encounter with the patient. So more and more mid-level practitioners are helping and being part of the team. It can get a little, it's getting different. The rules are changing every almost year where they don't even need to be co-signed. They can kind of work independently on their own, which is a good thing, but also something that we need to kind of be aware of too because we don't want them helping too much overall in the long run. But it should, again, if you have a good EM&R and a good kind of your Epic or whatever EMR you use, there should be a nice easy dot phrase that says dot mid-level practitioner attestation. And then it'll kind of pop up something. And in order for you to get credit for that visit, you have to do a substantive portion of the visit. Substantive portion of the visit. So at least one of the key components, the history of the exam or the medical decision making. So it's really nice, it should have a nice drop down box where you either click history, exam, or medical decision making, and then you just fill in increased baclofen, increased pain medicine, tested for UTI, or you provided history or did a pertinent physical exam. And so, you know, and again, depending on where you work with, but if you work in a kind of a big group and you have billers and coders that oversee your work and they kind of give you audits mid-year and they kind of say, man, your notes are off, you're under billing, or maybe if you added this to your notes, you can kind of bill more. Like Dr. Cahan talked about tobacco cessation and tobacco education. If you mention that with the patient, which you probably do in every encounter, you can bill for that and that can add a little extra RVU on top of the normal visit. So anyways. Same thing, new shared attestation. It's about mid-level practitioner. And it just, it depends on the time. This is where it can get a little confusing where you're billing for the mid-levels time, but then you also spend 20, 30 minutes doing something on extra. So that's, this can get a little kind of tough because you can kind of combine. It can be instead of just being a 30 minute visit, it can be a 70 minute visit. But again, you have to meet and discuss the patient for it to be counted. You know, you have to see, meet, and discuss the patient. You have to be on site. And here's what I was kind of trying to say about your statement and, you know, how much time you spent versus how much time they spent. And this is the documentation that they're looking for to make sure that it's appropriately, can be appropriately billed. You know, a lot of these billing and coding people, they have no real medical history whatsoever. They just are looking for physical exam. If you write PE, they don't know what that means. They'll say there's no physical exam in the note. If you didn't specify everything out, you know, you're gonna get, not dinged, but miss an opportunity to bill optimally, which if you bill optimally, you produce more. If you produce more, your RVUs go up. If your RVUs go up, you know, that's how you produce. And then there's more changes coming, like we talked about. Now they might say if the mid-level practitioner spent 40 minutes and you only spent 10 minutes, you're not gonna be able to bill for that. So that's coming around the corner. What is this, critical care? Kind of the same, you know, the same flavor here. You just have to have it well quoted. Usually it's really straightforward. You have a dot phrase and kind of, it's always important too, if you're reviewing lab values, if you're reviewing x-rays, that you personally spent the time reviewing the results and findings of these things, instead of just dot phrasing them into your note. That's gonna kind of add to the complexity. Discharge day as well, you know, you can either spend 30 minutes or more than 30 minutes. But really, overall, you know, you're the attending on record. You need a face-to-face encounter. And then it's also, again, pretty straightforward when you're using the EMR. Just simply go to charge capture. It says discharge day. Did you spend 30 minutes or less or more? Again, with resident, without resident, these are the attestations that we wanna see. You know, getting a dot phrase, dot attest, it auto-populates, makes it really, really straightforward. And that's kind of it. That was a quick overview. But really, I think it's very important to document, like I was saying in the beginning. You know, the more you can provide, there's a kind of couple layers to this because we have CMS kind of reimbursement. And so if you're H&P, depending on the comorbidities and what you document, patients can get 14 days of rehab or they can get like 22 days of rehab. So depending on the complexity and what is documented in the note, you know, you can really have an impact on what the patient's gonna get and what kind of care they're gonna get and their length of stay. So that's important and that helps your rehab center. Also, you know, again, I can't, you know, we work hard and help these patients, but ultimately we need to be reimbursed. And, you know, it's completely, we're not doing anything wrong. We're just seeing what we find and putting it on the paper so someone can read it and bill it. And that's how we kind of get the productivity. I don't know, I think that's kind of it. I don't know if there's any, that's it. Thank you, are there any questions? Oh, we've got a couple. And again, it's pretty straightforward once you start practicing. And depending on your EMR. I have two questions. The first question is, I'd like to know from yourself and anyone else in the room, when they see a consult in the intensive care unit, do they bill critical care time? First question. Second one is a statement. The documentation that we make on an inpatient unit is very important because it increases our tiered comorbidities, but it's the GG scores that the therapists document that actually drive the length of stay. But our documentation is highly important as well. So I guess the first one's a question, the second one's kind of a statement. Yeah, yeah. You know, for any consult that I've done, whether it's in the ER or in the ICU, I just usually put routine consult, not critical care time. And in terms of the GG score, you know, there's a, it's kind of, you could have a whole nother lecture on CMS and, you know, CMS reimbursement and the guidelines of, you know, documentation and progress with the patient. In my daily progress notes, I try to have a GG score, you know, like the weekly daily GG score to see the advancement of, you know, what's going on. Sometimes there is no advancement and it really helps you change course or figure out discharge sooner. Yeah. I have a few questions for you. The first question I have is with regards to care conferences, have you got an opinion on how to bill for your time when you're sitting there with the team? Yeah. So what we do is we, I think most of the therapists enjoy it, but like we almost do a walking rounds. So we would spend 20 to 30 minutes care conferencing, 15, 20, 30, it depends on patient. And then we go as a team to patient room and then we talk with patient. I usually count that as an encounter, sometimes physical exams done in the room with all the therapists and everything and the nursing and social worker. And I usually give that an extended visit, usually 35 minutes if that's what it is. Yeah. My second question is when you're billing for the discharge code, you said, you know, it's pretty simple. There's the one less than 30 minutes, the other one's more than 30 minutes. In your interpretation of how to bill that code, do you think that you would use that time as face-to-face time that day or time on the floor or time discussing it with the social worker? Correct. If you're in house, in the floor, on the unit, and you are chart reviewing, you are putting in medications, you're talking with social worker about patient, that is billable time. And that's where I, you know, if I spend 25 minutes doing that and 10, 15 minutes discharging patient, I say over 30 minutes. And if it's easy, you know, 10 minute, you know, if it's less than 30 minutes, it's less than 30 minutes. I agree. You gotta be in house. You can't be at home. You can't bill when you're at home preparing discharge. But when you're in the building, on the floor, down the hallway, that's billable. Also in your understanding of billing on time, although I don't recommend generally billing on time, but if you have to, my interpretation is outpatient is different than inpatient. With regards to inpatient, it's not face-to-face time. It's total time spent on the floor as well. Right. Would you agree with that? Yeah, yeah, yeah. I think so. I mean, theoretically, if you're there all day, you're like, you're not, yeah. It's the time you're chart reviewing that patient on the floor and then your documentation and then seeing patient. And in an outpatient, it's more or less the time in the chart. Because like with televisits, you can have a 20 minute phone call, but you chart reviewed for 40 minutes and you had a five minute phone call, you could bill for 45 minutes. If telehealth is seeing a patient as a, and they are the internal medicine following the patient every day, and they have certain diagnosis there, does rehab have to use those same diagnosis in their report? I don't know. So when you're doing your outpatient note and the telehealth visit, so this telehealth visits for stroke, you do document in your note, patient had past medical history of hypertension, diabetes, hyperlipidemia, whatever, chronic, whatever they have. But you are seeing this patient for right upper extremities, hemiparesis and spasticity and gait instability and speech difficulties and nutrition. And also you can throw in tobacco cessation. So you would put those as your assessment and plan. So you have, that's what I put in the system to code. For inpatient? Well, that was for outpatient, but for inpatient, yeah, I would put those other ones as well. The ones that internal medicine has done, telehealth? Yeah, but for inpatient, honestly, I never really have to put those into my note. It's already kind of in the problem list of my note. Yes. And then it counts as the complexity and then the time you spend with the patient. Okay, all right, thank you. And then just quick, actually on the outpatient side, it changed, it doesn't have to be patient-facing time. It's a total amount of time you spend caring for the patient. So if you review the MRI, if you talk to another specialist, it still counts, it doesn't have to be face-to-face. It just has to be on the date of service. It's not within 24 hours, it has to be on the same date of service, but you can count that time now, even if it's not patient-facing, so. Thank you so much, Dr. Kasperbeck, that was great. All right. Thank you.

Physical Medicine and Rehabilitation

billing practices

outpatient services

inpatient services

telemedicine

CPT codes

modifiers

Relative Value Units

telehealth

COVID-19 adaptations