Look, I am lucky I have a husband who does laundry. I don't do laundry. We have a division of chores. I cook, he does laundry, so it works out well. There's your housekeeping rules, your social media, your check-in code that was already referenced. This is my information and financial disclosures. So what are we going to talk about today? I hope this is an interesting segment. So many times we, as speakers, are asked to submit topics for these different events, and when we submit topics, we fail to remember exactly sometimes who we're talking to. And it's very important that when we're talking about coding, remember who the audience is and what your duties are as far as your job responsibilities when we talk about coding. You are not here to learn coding, and I am not here to teach you coding. That is my commitment to you during our 60 minutes together, I promise. I'm not here to teach you coding. I'm not here to teach you E&M, I promise. I understand that your day is full of compliance duties, HR duties, custodial duties, H&R block. You do a lot of different things, you wear a lot of different hats, and I understand that sometimes coder may fall into that, biller may fall into that. So what I want to do in this session is help you figure out how to ease some of those tensions when that does happen. But before we can really dive into that, what I want to talk about is when we think about E&M, let's talk about exactly what we need to make sure we're looking at and diving into within the world of E&M. E&M is very complex in how it impacts your practice. Remember, your surgical codes are high dollar codes, but E&M is high volume. So just like those high dollar surgery codes can get you in trouble, your high volume E&M codes can certainly get you in trouble. And I know you've had sessions while you've been here at AAOE on Incident 2, and I know that orthopedic practices always have mid-levels. Those E&M codes can certainly get you in a lot of trouble with those mid-levels real quick. So again, E&M codes can certainly get us in trouble really quick. So things we're going to talk about include our reimbursement, the complex rules, complex billing issues related to co-surgeons, Incident 2 and those types of issues, skilled nursing home patients and fracture care. Then we're lastly going to talk about some of the documentation complex issues with fraud and abuse. First of all, I want to talk about the elephant that sits in your practices day in and day out, and that's the reimbursement issue that we have as we move through our practices in 2023. So first of all, as you know, we have our conversion factor. That conversion factor multiplies times our RVUs that are assigned to each CPT code, which gives us our reimbursement for each procedure that we bill to an insurance company. So there's two ways reimbursement gets cut. Either they cut the conversion factor or they change our RVUs, one of the two. So here's our conversion factor changes over the past few years, reaching now at 2023, our conversion factor has decreased down to 33.8872. We continue to decline and decline and decline, and I don't need to tell you that because you see the money trickling in, trickle being the optimal word in that sentence. You see it trickling as it's coming in. We actually even saw a rise in the conversion factor for a little while, but that was kind of smoke and mirrors, right, because that's the year that they really changed RVUs up. So it was a smoke and mirrors effect, even in those couple of years that we did see the conversion factor move in a positive direction for our practices. So as we consider the conversion factor and the shifts, I realize you can't read this, okay, but when you download the slides, you will be able to. On my version of the slide, you could read it a little bit better. But what I tried to do for you on this slide is using Frank Cohen's, Frank Cohen has some amazing tools out there, and you can visit his website, the Frank Cohen Group. He also has an amazing risk-based analyzer called Compliance Risk Analyzer that looks at your services based on risk analyzation as opposed to just looking at it routinely through audits. But what I did was I used Frank's benchmark data. This is in ranking order. You can see the, I don't know if you can see this, but this goes one to 30. These are the top 30 CPT codes billed by orthopedic surgeon practices, the top 30 CPT codes. So what I did here was I took those CPT codes, the top 30, I gave you the 2023 reimbursement rate. By the way, your non-facility RVUs, because I know all those physicians love to see the RVUs. I kept the RVUs on there. Here's your 2023 reimbursement. Here's your 2022 reimbursement. And by the way, for kicks and giggles, I said it nicely, for kicks and giggles, I threw in the 2020 reimbursement as well. Here's our three-year trend shift. Do you see a single positive shift in reimbursement? Every one of them is a loss. And some of them weigh more than others, 395 per procedure, 393 per procedure. Some of these are really big hits per CPT code. So we take those and let's drill down to the top. It says it's going to be the top 10, but somehow, I think in the transposition into their format, it lost the last 10, sorry. So it's the top nine CPT codes. So when we look at the top nine of those CPT codes, we can now even see a little bit more clear each one of those CPTs and how we're losing revenue in each one of those. So when you look at the current year, so now we've removed that 2020 reimbursement rate out, and we're just looking at 2023 to 2022 and seeing the, I'm going to kill myself over that leg, and we're seeing the loss in revenue there. So while you may look here and think that's not a huge shift, we have to start thinking about patient volumes times the number of physicians in your practice, then looking at it whole scale. But guess what? I did that for you. So current year, here's just E&M. If we consider E&M only, I took your E&M codes only, I even included initial inpatient that were the most commonly used by orthopedic providers and your subsequent inpatient. And I gave you the reimbursement loss, by the way, one gain, one whole gain. I gave you those there for you. And it does still include where they rank and number of CPT codes billed for orthopedic providers. Your RVU is still included there for you. And then on the next slide, I did include for you the ranking distribution if you wanted that information here. So according to national benchmark averages, what is an orthopedic surgeon supposedly supposed to be billing? Do you notice I'm using air quotes and say supposedly? Please know, we don't want to push our providers to build the norm. We know if they bill outside the norm, we have a chance of being audited. We have a chance of receiving the letter, the CBR, the comparative billing report that we're not falling in the norm, but it's their scare tactic to tell us to build the norm. But that should be a red flag to us to say, hey, we need to do an audit on Dr. X to make sure they're using that code right. It shouldn't be, wait a minute, time out. He needs to stop billing so many of ... That should never be our response to a comparative billing report. Our response should be, we just noticed that she's over utilizing this code compared to her peers. We just need to do a spot check target audit to make sure we're on track here. That's what a CBR is about. So this is your benchmarks. A lot of you have this built into your practice management system. If you don't, get with Trevor and Sean through the AAOE. There's benchmarking for you. Get with me. I can help you get access to that. Benchmarking is absolutely available, but that's what your norms are supposed to be. And again, if you're above or below, if you're below the norm, you definitely want to pull those providers along because I'm here to tell you right now, we need to protect the integrity and the revenue of your practice. If we're losing money based on that conversion factor and on RVU changes, we have to protect the revenue of the practice. We want to make sure we're billing every penny we can for the work that was done, but we also want to bill compliantly. Now if I did a case study for you, if a provider sees on average 6,000 annual patients, okay? So remember this is E&M's only, billable patients. That's five patients an hour for a six hour clinic day, four clinic days a week, 52 weeks in a year. We don't give this provider any vacation time if you noticed. And now what we're going to consider is the benchmark indicates that 21% of those patients will be new. And by the way, benchmark standards do go into that. They show us how many patients should be new versus established. And that would leave, there's 4,700 of those patients would be established. So if our new patients using the benchmark standards from the last slide, this is my reimbursement rate, my established patient reimbursement rate using the variables of those same numbers, that's the reimbursement I can expect for those 6,000 patients. Total negative impact per provider for 2023 is negative $11,000 per provider based on normals for a 6,000 patient case study. Now why are you sitting in a coding session? Negative $11,000 per provider. And again, that seems like it's every year. Every year we're in here talking about, oh, it's negative $11,000 again this year, oh, it's negative $11,000 this year. So I don't know about you, but when people hear what you do for a living, do you ever get kind of the smirky, evil look? I'm really kind of serious for a minute. Really you just help the richer get richer? Seriously? Because I'm going to tell you as a consultant, when people ask me what do I do, the easiest answer for me to tell them what I do is I'm an auditor in healthcare because then I don't have to get the snarky story. But if I tell them I'm a consultant and I work with helping physicians and help them get their documentation right to ensure appropriate reimbursement, oh, so you just help them make more money because that's all they need to do is make more money. Okay, so let me just break that down for you. So they're making the average code that an orthopedist is supposed to get reimbursed for is a 99213. A 99213 reimburses what, everybody? 85, 90 bucks in your area? For 85, 90 bucks a patient, you got to pay all the staff in the office, the mortgage, the liability insurance, the malpractice insurance, and I'm not even going to stand here and go on and on and on, but that's what the average person doesn't understand. We understand that. And the reimbursement just keeps going down and down and down and down. Now why am I standing here lecturing you as a practice manager? It's like singing to the choir, you already know this story. Because I want you to stop hiring billers that don't know what the heck they're doing. Your billing staff should be some of the best staff you hire. They should be in protecting the integrity of every dime that comes into your practice. And if you're outsourcing your billing, you need to be auditing your billing company because nobody loves your money like you love your money. And if your AR looks so good with your billing company, or even with your billers, your radar should be going up because nobody's AR should look pretty. What's the plan? Are you going to bill higher for that $11,000? That ain't helping. Billing higher doesn't do anything. Are you going to see more patients? Where are they going to fit on the schedule? What are you going to do? Are you going to stay open from 7A to 7P? Nobody's going to live that kind of a life. Are you going to bill more procedures? Are you going to adapt new service lines? Are you going to add more providers? All of that sounds great, but it increases overhead. The first thing I'm going to tell you that's the best thing to do is take a deep breath and make sure we got our house in order. Are we billing effectively and efficiently for what we're doing right now? A lot of coders would probably kick me out, and by the way, I'm a coder, I have a CPC. A lot of coders would probably kick me out for saying what I'm about to say. But if you're doing 100% coder validation in your organization, stop it. Train your physicians and stop doing 100% coder vow. That's one of the best ways to streamline your overhead expense. Your physician should be savvy enough to be able to be trained how to pick an E&M code for God's sakes. They went to med school. We can teach them. Here's the thing. Coders have their place. And here's what. When we say get rid of coder validation, I don't mean get rid of it all. We still need to have 25 modifiers coder validated. We still need to have some surgeries validated. Total knees, no. You're using a template on your op report. I don't need to validate that. But if there's something funky that went on and you put a 20, thank you, I was like 21. When you're talking in your minds, if you're putting a 22 modifier on that, then yeah, we need to send that through to validation. If there's a lot of 59s and 51s that need to be added, we don't need your physicians trying to learn rules for modifiers and going through NCCI edits. And we don't need 22 ICD-10 codes on any one claim. Absolutely not. So when I say eliminate coding val, I'm not talking about 100% elimination. I'm talking about number one, E&M. And number two, we have to first make sure we're efficient. We have to go take those providers and put them through segregated coding eval to make sure, okay, I haven't changed any of your codes in the past two weeks. We're not going to check you again. We're going to do a 10% spot check every two weeks. And if you maintain integrity, we're letting you go. And now you're going to be on a retrospective audit evaluation. That's how you move off of that program. And now you're saving tons of overhead expense. And now we're going to take those coders and we're going to train them to become auditors. And we're going to move them. Will you retain all of them? I'm sorry, but probably not. But we could repurpose them. Some of them would make awesome scribes in your practice and make your providers way more efficient in clinic. Complex rules of documentation. What we've learned from 2021 documentation guidelines, we thought physicians didn't like HPI, ROS, PFSH. What turns out, they must really like it because that's how they're still documenting. But honestly, I really think, it says here, providers like their templates. I honestly think what it is with the templates is there's a lot of money and a lot of time and investment that went into building those templates. And I don't know about you, but when I spend a lot of time and a lot of blood, sweat and tears investing in something, it's really hard for me to change. So I respect physicians and not wanting to jump and bolt and change those templates. But guess what? It's time because that will make them more efficient in clinic. Maybe providers really didn't mind documenting the way they were. It was the scoring they minded. Didn't we all? Let me count these HPI and let me count these ROS and let me see if I've got bingo now. I mean, the scoring rules that we had were antiquated and ridiculous. Maybe when we train providers, we shouldn't have compared it to the old guidelines. And I think that's the real bingo here. I know personally, and I'll own this personally, when I trained physicians for 2021, I would say things like, well, now when you document the history, we're not gonna have to score it. And what I should have said is you no longer are going to be documenting history. And then I would have got their attention. That's not how we taught physicians. What we want our physicians to now document is the description of the patient. The provider is responsible for telling us what is the complexity of the presenting problem of the patient. And when they're using a template that's HPI, ROS, PFSH, I'm not getting complexity of the presenting problem, just not getting it. So we need our providers to take the templates and revise them and move to description of the patient. Take those templates and advance them and move them into where they need to be. Now, I recognize that this is not an orthopedic note, but I wanna show you what I mean about using templates and old ways of documenting. In this note, it shows pulmonary thromboembolism, primary hypertension, closed non-displaced fracture of the right tibia, mixed hyperlipidemia. Treatment, pulmonary thromboembolism, refill of medication, refill, and refill of Zestro. And then we come down here and it says notes, same meds, and look at DC Eliquis. He'll return to work in Alaska, PRN, blah, blah, blah. Closed non-displaced fracture. Here's my point with this note. What I have when I look at this note is I have a note that this... I'm sorry. No, go ahead. It's the most important, but we have a laundry list of diagnoses and then we have problems that they're not always all addressed in the appropriate way. And we wanna make sure that things are aligned and things are treated and things are addressed because when we look at the realism of what the note, how the note was actually documented, six-week follow-up. Here for follow-up, patient is doing a little bit better, continuing with physical therapy through home health. Patient taking one QD decided on this to drop the Eliquis. Who is seeing this patient? What are we actually seeing this patient for today? Is this really fracture care follow-up? Is it the primary care provider? Now, the auditor auditing this note obviously knows who the provider is, but here's the thing. That's not what we're supposed to rely on. I don't know. Patient is here for six-week follow-up. Six-week follow-up of what? And when we look at the assessment of what the patient is here for, PE is the primary diagnosis, but when I look at the history of present illness, it starts off talking about the follow-up of the injury or the actual problem of the patient. So again, we want things to align in the documentation where we're not focused on HPI, ROS, PFSH. What tell us, describe the patient to us and tell us how that patient has changed from the last visit to today's visit, interval care. Providers really didn't mind documenting the way they were. It was scoring they mind, and we've talked about that. And when we talked about the fact that the average orthopedic practice is gonna end up losing in 2023 $11,000 per provider, it's imperative that when we score notes in 2023, those notes get scored to the highest possible level compliantly. I don't want you to think I'm trying to promote overcoding. That's not what I'm trying to do here. Compliantly, the highest level they support based on medical necessity. So what we wanna make sure, this is causing the administrator manager to get involved as a sounding board often. Because what happens sometimes is now the provider is gonna be the physician is gonna be stressed out because their paycheck's gonna go down. So who are they gonna come to for that? Then they're gonna go to the coder because when the coder down codes them, they're gonna get, excuse me, pissed off at the coder. So they're gonna be mad at the coder. So who's gonna come to you now? The coder. And that's why I kind of felt like this was a timely way to bring it to you, the practice manager, because you're gonna get stuck in the middle. You're the middleman. Because they're both coming to you because nobody can understand what the heck is going on. When we look at this table and I gave you our revision, if you didn't get one, I have some up here. You can see me at the end of the session. When we look at this chart by AMA and the revision one we gave you, there are ways that your orthopedist can document that I know they're not doing it to tell the whole story about the patient to support the work they're doing. They're just not doing it. I know that because I've read enough orthopedic notes. I'll tell you for example. Geez, I'm gonna fall up here in a minute. We have over here, so let me just real quick, I'm not trying to make you a coder, but there's a way this chart works. We have column one, column two, and column three. We have to get two columns to match or meeting the highest level. That's level two, level three, level four, level five. That's how we choose our level of service. This middle column, stay away. It's a trap. It's nothing but difficulty. This is where providers get points and value and credit for things like ordering tests and reviewing notes and things like that. That is very true. However, there had to be medical necessity behind why they reviewed it. They can't just say, oh, I've looked at the past 12 years, MRIs, and we give them 12 points for looking at those MRIs. They've got to give value of why they needed to look at the past 12 years MRIs. So if they're willing to go to that extent in their documentation, okay, I'll see you there, and we can talk about using this middle column. But that's the problem with the middle column. Also, when we talk about the point of ordering test, if your group owns your MRI, you can't use that because you're already getting credit for the reimbursement. So you can't then also get credit in the middle column for ordering. So there's rules around that middle. So the easiest way to teach our providers how to pick your code and for you to understand as a practice manager, the down and dirty of how E&M works is column one and column three. And the way we do that is how sick or how bad was the patient's problem, what were the risk associated with treating the patient? If the patient's problem was acute and uncomplicated, a sprained ankle, and we gave them over-the-counter medication, that's low risk, low, low, it's a level three, it's that easy now. If their problem was actually an acute injury that was complicated, number one, the physician's gotta document what made it complicated, and I assume then we're gonna give that patient some type of prescription drug for pain management potentially, non-narcotic of course, but prescription drug management. Now I have a level four. But there are other things that your providers could be documenting. There's chronic problems, and when chronic problems aren't meeting treatment goals, if your providers are documenting those right, those are level fours, not level threes. But those oftentimes get down-coded because providers are not documenting them right. We need to make sure that they understand how to document those. I have to tell you, they put your slides on their template, and it confuses you as a speaker. Practices continue to lose the efficiencies that physicians use. Okay, we're just gonna skip it. Oh, this is just talking about the efficiencies that physicians use. I know what background I'm expecting to come up, and when it changes the background, I'm like, that doesn't look familiar to me. Okay, I love that EMRs offer us efficiencies in how to create notes, and we should not prevent physicians from using them. I know, I am that person who likes these efficiencies, and I'm rare, especially as a coder and an auditor, but I like them. Let me ask you this. Do you? Hey, Siri, where's the best restaurant to eat in Orlando? How many of you, hey, Siri, or hey, Google, or hey, Alexa? I was leaving my mom's, oh, sorry. Oh, my gosh, it didn't do it the first time. I was waiting on somebody's phone. I actually was waiting on your wife's. Oh, that's true. Exactly what I thought was gonna get it. So I was leaving my mom's in a nursing home. She's on hospice for congestive heart failure. She's had five hip surgeries, and they finally just took the joint out. They're like, but anyway, I was leaving the nursing home seeing my mom the other day, and there was a sign on the door that said, just say, hey, G word, and that way nobody's phone will go off, and the door, and tell Google to open the door, and I'm like, seriously? We can't even have a door attendant anymore, but now that's how you get in and out of the door at the nursing home. Hey, Google, open the door. You're right, we all like that. Yeah. Why is it so wrong that physicians use it? That's what I don't get. Do attorneys copy and paste all day long, and they're writing legislation. They're getting you out of a marriage. They're doing serious, just as serious things as a physician does, and they copy and paste, but nobody's raising heck about what they're doing. Why is it physicians that get picked on for copy and paste? Do you really think copy and paste impacts patients' lives that much at the end of the day? We're not in the exhibit hall anymore, and I'm not sure, I don't think they were there. Hover to discover was one of the worst things that ever hit our industry, in my humble opinion. Epic, and epic. If you have epic, and you have hover to discover, it is my understanding, epic is the only EMR that has that level of hover to discover, and if you don't have epic and don't know what I'm talking about, epic has this little magic thing where you can take a mouse and put it over documentation and hover, and it tells you who the author was, who the original author was, and where it was copy and pasted from. So if I stole your documentation from two weeks ago, it will show that I copy and pasted her documentation. So it's clinical plagiarism, and it's not allowed, because what they say is that shows that I'm claiming your work as my work. That may be taking it a little far. I don't think I'm claiming your work as my work. I think what I'm doing is short-cutting documentation. But here's what we need to make sure providers understand, you don't need to do that anymore. Rules and guidelines don't require that anymore in an office note. It is describe the patient, give us their complexity, and tell us the risk of managing them, that's it. That's all that's required. No HPI, no ROS, no PFSH, no lengthy backline history, none of that's required anymore. Heck, the exam is only what you find clinically relevant. So why are you copy and pasting? The only thing you have to copy and paste is, let's say, what's your name, Cooler? Kimberly, I won't call you Cooler if I know your name. Kimberly, if Kimberly wrote a jam-up history on a patient and I wanna be able to recall that history because it's such a great history, I should cite and source it. Per Kimberly, that's all I have to do. Now it's perfect. So there's really no need for copy and paste. You don't need it. Now, on that note, that's why your coders should let it go. It's not a battle to fight anymore. Templates. Guys, templates are amazing. But if I'm gonna sit down and write a new resume because I'm looking for a job and I log in to Microsoft Word and I pull up a template for a resume, is it gonna have Kimberly's resume already filled in for me? Come on, wake up. No, it's gonna have a resume with placeholders with Latin. That, my friends, is a template. Not pre-populated office visits. That's the problem we have with the templates we have. They're pre-populated, auto-filled, already completed notes. If we create templates that are truly templates, I'll help you with them. A template is saying when a patient comes in for an injection, we need a description of the patient, an exam of the impacted body area, and we need to know are they having any other secondary problems. Potential modifier 25 issue. And if they are, what are they? A description of that problem and a treatment plan for both problems. I'll help you build that template. But then we're not gonna pre-populate it. Nope, no questions allowed. Go ahead. So we were talking yesterday about a particular insurance company that has a review arm, and it seems like maybe a lot of us are having issues with level four visits. It seems like no matter what we do, we cannot get these level fours paid, even with appeals in having outside coders review and saying that it meets level. So have you had a chance to look at any of these reviews and see where providers are kind of tripping up on their documentation with these level four visits? Do you have any idea what I'm talking about? I don't, but I would love to be involved. Can I be involved? I don't know if you guys know what I'm talking about, but yeah, you guys are having the same problem. It's the O company, right? Yes, the O&U company. Yeah, the O&U, yeah. 99% of our level fours, they have down-coded to a level three, even though they meet requirements according to our outsource coding and our doctor's coding. So let me tell you, all right, it can meet it on the chart, but are you meeting it for medical necessity? So there's two elements that are required, documentation, medical necessity. Medical necessity says, okay, now wait a minute. We can look at this chart and say we meet it here, but then we have to look at the risk elements of the patient, the complexity of the patient, and then we have to say, medical necessity, if I tell a physician I'm looking at your medical necessity, they're going to say, no, wait a minute, you're not a clinician. Medical necessity is based on the documentation. Was the level of service met? So sometimes we have patients come in and you're telling me it's a level four, but when we look at the documentation, the clear underlying complexity of either a chronic problem that's exacerbated or an acute problem with systemic underlying problems is just clearly not there in the documentation. So while we say it's two of the three columns, if you really want to understand medical necessity, column one always has to be one of those columns. That's the easiest way I can tell you. There's no rule, but if you want the easiest way to understand medical necessity, medical necessity is driven by the patient's presenting problem. Page 14 of the AMA 2023 documentation guidelines, it says that the evaluation and treatment of the patient should be driven by the presenting problem of the patient. And the reason the AMA put that statement in documentation guidelines is to align themselves with CMS, where in the CMS claims processing manual 30.6.1, it states medical necessity is the overarching criterion in your E&M choice. It's not the volume of documentation. So now AMA and CMS have aligned themselves saying it is medical necessity. So when AMA says the evaluation and treatment should be in line with the presenting problem, what they're saying to you is column two and column three may score level fours, but if column one is also not a four, you're screwed. Okay, it doesn't say that, but that's what it means. Macros, oh, yes ma'am. Whoa, time out. Your physician should not be billing on time in your specialty. Sorry, I didn't mean to pick on you, and I didn't mean to interrupt you. Well, I did, but I didn't. Okay, so time should only be used when they are consuming that amount of time. It's time or MDM. And I hope your physicians aren't spending that kind of time in the room. So, I'm sorry, you want me to go? Oh, sorry, go ahead. So, patient. Sure. Okay. Well wait, you you beat me. So when it's MDM, it has to have column 1. But when it's time, obviously the MDM rules don't count. It's time or MDM. And the way, the way, wait a minute, let me finish. The way we validate medical necessity with time is, okay, where's your time statement? If you say you needed 45 minutes, you can't just say 45 minutes. You've got to also include a time-based statement of why you needed 45 minutes. I'll give you an example. It's not in your specialty, but it'll help explain that rationale. If we have a pediatrician that says, I spent 45 minutes in the room with a patient with strep throat, aren't we all going to scratch our heads and go, are you kidding me? Why in the world would you spend 45 minutes in the room with a patient with strep throat? But then if the time-based statement explained, the patient had a significantly high fever. They were a preemie. They're now three years old. The last time the patient had strep throat, they developed into roseola, spiked a high fever, ended up in the PICU. Parents are super paranoid. They spent copious times given reassuring guidance. Just as they were finally getting mom out of the office, here comes dad, and they had to start the visit all over again. Now does 45 minutes make sense? Are we going to get that kind of documentation? But that's what we need to justify 45 minutes for strep throat. So if you're going to spend 30 or 45 minutes reviewing an MRI, I just need you to say, because that's a long time to review an MRI. That's a long time to sit in a room and review an MRI. So I need more than I spent 30 minutes reviewing the MRI. What else did you talk about for 30 minutes? That's a long time to talk about an MRI. Did you compare it to other MRIs? Did you talk about surgical options, non-surgical options? I just need more. That is what I'm saying. So that's how we validate medical necessity with a time statement. Okay. Let me keep moving. All right. Billing an encounter. Here's what I want you to think about. This is a sobering thought on a Saturday. That red and white claim form, it is red and white if you didn't know that, the 1500 claim form that gets sent electronically into the insurance company. You, you are ultimately responsible. You are ultimately liable for every single one of those claim forms that go out just as much as the physicians are, just as much as the biller is. How many of them do you know are accurate? What steps are you doing to ensure their accuracy? We do all this auditing and monitoring for documentation and coding. How much auditing and monitoring are you doing for the billing? I am honestly tired of the modifier 25 conversations. I'm sorry because we keep telling practices over and over. Here's the rules. Here's what's right. Here's what's wrong. Here's how you do it. If there's not an NCCI edit, you don't need it. If there is an NCCI edit, you need it. Yes, commercial insurances make their own rules when the wind blows, but also here's when you can use it. Here's when you can't use it. If you're going to violate those rules, that's fine, but you need to know that risk and your name is part of that risk as the practice manager. Do you have that concept? Do you know that the NCCI rules about 25 modifier? I can take you there right now on Google. It literally says the instances of billing an E&M encounter with a 25 modifier should be limited in your office. How many of you can say those instances are literally limited use in your office? E&M with a 25 modifier. You are responsible. $10,000 per claim, triple the claim amount, five years in jail. Practice managers are just as liable as physicians. Sean Weiss is the scare tactic presenter, not me, but I bring this up in this talk because I think so often our practice managers are so concentrated on the first slide, H&R block, clerical duties, custodial duties. You have so many other duties. And the one thing we know that you know you do need to get done is a coding documentation audit. The one thing we fail to focus on is the need to do a billing audit. We're not doing billing audits. And the thing that amazes me is how much revenue you can sometimes find you are losing out on in a billing audit as well. Also, things we can find in a billing audit are other risk areas, other opportunities as well. Incident two. Oh yeah, don't forget about those new sneaky split shared rules. If you are a physician office in place of service 11, you should not be billing split shared. So there's no sharing an encounter between your mid-level and your physician. Zero. None. Incident two, the difference between incident two is the mid-level does the entire visit and bills it under the physician's billing information. That's the difference. If a physician is coming in at any point in the visit, that is a split shared visit. The only way around that is if your mid-level is acting as a scribe. And if your mid-level is acting as a scribe, we need to go back to the conversation we were having about overhead and have that conversation. Because a $95,000 a year plus scribe, let's have another talk about changing your coder into a scribe because that would be a much more efficient and less costly to overhead scribe. Unfortunately, documentation caused by our providers can leave our practices vulnerable. Obviously, we have our legal concerns, our fraud and abuse. And unfortunately, nine times out of 10, our providers view documentation as homework. And nobody likes to do homework. Okay, I shouldn't say nobody. There are those weird people that like to do homework. I was never that weird person and I did not bring two weird people into this world, trust me. I chased them every day. So what we need to do is help our providers embrace these changes. And I have to tell you, what should be exciting and fun is they should actually like these changes because they could literally like sit a recorder in the room now because that's how the guidelines work. Describe your patient. When we get to the treatment plan, everybody's still documenting treatment plans. Do you know it's not just a treatment plan we score anymore? If you look at the third column of MDM, somebody asked about the downcoding. Carol, that third column of MDM, providers are still only documenting treatment plan. That third column of MDM, do you know how it starts off? Read the first three or four words. Put your readers on. The purple. Risk of complications of patient management. If your providers are only documenting the treatment plan, are we getting risks? Nope. So remember how your providers are wanting to get credit for the fact that they're injecting the patient, but the patient has diabetes and nobody's giving them credit for that? That is a risk of complication. But you got to tell me. And then we rank the risk. Is that risk? Is it a straightforward risk? Is it a low risk? Is it an average risk? Is it an above average risk? And that's why the AMA says on that chart, these are only examples. You can't go by these because they're just examples. Because in reality, you should be going by the keywords. It is straightforward risk, low risk, average risk, excuse me, straightforward risk, below average risk, average risk, above average risk. Doesn't that make sense? Oh, and by the way, the another great window that AMA open is it's not just the treatment that we're rendering, it's the treatment we considered. If the patient has fracture and I consider doing open fracture repair and decided not to, if I document it, I get credit as if I did, if I was doing the decision to do open fracture care. But if you don't document it, I don't know. Those are how we help our providers capture the work they're truly doing behind the closed doors. Documentation is often the only representation of the work that many have. So when we see what's going, we can't see what's going on behind the closure. I wish we could just sit a dictaphone in the room because I'm going to tell you a lot of times we definitely have a lot higher level of service than we do based on the documentation. Because documentation is an afterthought. Documentation is not always the forefront of mind of what's going on. It's an afterthought of what it's done when we can. And even if it's done during the visit, I almost kind of hate that. I almost don't like that some physicians document during the encounter. The good news is now it's done. The bad news is it's probably not the best documentation in the whole world. Do you multitask? Do you listen to your spouse or significant other talk and type at the same time and then think, what did I just type? That's what our providers are doing when they're treating patients, right? Consider first on your modifier 25. And here's your rules. I'm out of time. Aren't I? I'm supposed to end it for? Thought so. What I want to show you right now, these are just the rules for modifier 25. When you are considering the modifier 25 in your office and whether you should use it or not, and this is just showing you the NCCI edits, new patients have zero, zero NCCI edits with any orthopedic service codes. You never need a 25 modifier with a new patient. 57, yes, but not a 25. So you see here I've got 20610 and 20552 with new patient codes. There's no NCCI edits. Now, of course, blue, U, O, they can have their own rules. But my biggest point here is please make sure with 25 modifier there's two rules. Was the E&M visit separate? Was it significant? It takes both of them. If they say the patient had a knee injection, but they also had back pain, was the back pain, obviously it's a separate problem, but was the documentation for the back pain significant? Was it documented enough to show that it was also addressed? Was it significant? If we can meet those two rules, I have an example in here for you. If we can meet those two rules, then absolutely. There's some information in here for you on Incident 2 services, a chart example on Incident 2. I'm sorry we didn't make it through everything. And just some information on audit plans. Please make sure you're proactively looking at your documentation and you're getting what you need. You don't have to externalize your audits, do it internally. Advance your coders, get them the training they need, and do it in-house. If you need some of these handouts, come up front and get them. I also have a little code that just has some benchmark statistics and E&M tidbits on the back. Thank you for having me. Okay, can you hear me? Okay, good. All right, so as you can see up here, the checkout code is 843-276. Oh, I'm sorry, it is 843-267, actually. 843-267. And then the AAPC credit code is 84733CJD. And we do have a gift for you, Shannon. Thank you very much for presenting today. We appreciate it.

accurate documentation

billing

medical practice

division of chores

coding topics

E&M codes

practice revenue

templates in documentation

modifier 25

internal billing audits