Again, I want to thank Dr. Kaplan for joining us. That was a fantastic lecture on hospice and end-of-life care. That was, I think, a blind spot for a lot of us. I want to welcome Dr. Monica Verduzco Gutierrez. Thank you for joining us. We are going to go ahead and get started in just a second. Great. So we're all set. We will skip through a lot of these goals. Housekeeping, as always, we're going to keep everybody audio and video muted except for our presenter. If you have any questions, you can find me. If you click on your participants list, you should be able to see Sterling Herring up near the top of that list. You can double-click my name and send me a message that I will ask our presenter at appropriate times. If you have any general questions, suggestions, concerns about this lecture series overall, please feel free to email Candice. Her email is there on the screen or you can track her down on Twitter. So without further ado, we're excited to have Dr. Monica Verduzco Gutierrez, again, the chair down in Texas. Thank you for joining us. Yeah. Thanks for having me and talking about this important topic. I'm going to start my screen-sharing, which is Billing 101, and some of you may get it in residency, but I always feel maybe you don't get it enough and it's just important to start learning the basics of the rules about billing. Beyond billing, it is also documentation, because what you're writing is what other people are reading, and that includes other physicians who might get your consult notes or see that patient later down the road, what payers are going to be looking at, what Medicare looks at. And if they were to do an audit, the important thing about Medicare is that it is a federal payer, and so that's why I also call this talk How Not to End Up in Jail. So you have to make sure that what you're writing and what you're doing is documented appropriately and goes with an appropriate level of billing. I also like to call it I Don't Look Good in Orange, so I want everything that's reflected from the resident that I work with and my own documentation to be up into compliance, and so that is a big deal. And so, you know, there'll be a little bit of jokes, but it's important to write the right thing and have it down on paper. So fraud and abuse, you can just look up something really quick, like PM&R, fraud, Medicare, and I got 45,000 results in a quarter of a second. So there's a lot of stuff in the news about Medicare fraud, and it goes anywhere from reusing rectal devices on patients, you see that's the most recent news, which is really upsetting, to even now issues with coronavirus. So just keep, follow the rules, stay out of jail, don't reuse rectal devices. Okay, so we're going to start with some basic definitions, and the first one is E&M, and E&M means Evaluation and Management Services. So that is basically what we, when we're seeing patients for consult, for a new visit, for a clinic visit, for an H&P, we're basing our billing on Evaluation and Management Services. CPT is another important thing, Current Procedural Terminology, and so that's a list of terms and codes that is, you know, standardized language that's reported. And so a lot of the CPT codes are going to be the numbers that we use for E&M, but it's also a big CPT thing is our procedures, these are the procedural codes that we use, and those are the ones that make more of the money, and so CPT codes equals how we get paid. So what are the E&M services again? These are just, like I was saying, your outpatient, your inpatient, your consult notes, critical care services, which we don't generally do, but sometimes we do, and clinical care services are more based on time versus what your pure documentation is, but you have to document that you're taking care of a, something critical was happening with the patient. Prolonged services, so those patients that you have a really long visit with or have to take care of a lot of things that day. There's also some non-face-to-face services. Now it's really big, telemedicine people weren't doing it as much before, now we are, and those are services that you can bill for too at current rates that were usually outpatient services and they just need a little modifier, and then you're able to bill like if you were seeing them in an office. And then there's even billing codes for complex chronic care. So along with, we have these codes for services that we're going to bill, but beyond that we need to put ICD-10 codes. So ICD-10 are the medical diagnosis codes, so that is where the problem list is important, and there are thousands and thousands and thousands of ICD-10 codes. We used to have ICD-9 and then it went to ICD-10, which almost doubled the amount of codes that we had. The thing with this is that you want to be as specific as possible when you're picking your ICD-10 codes. I recommend an app that might give you all the detail, the most detailed ones, and so sometimes it's really important as far as to be as, we try to be as detailed as possible with those ICD-10 codes and not use a generic one because even that can be denied by billing companies. They really want it to be as detailed as possible for your ICD-10 codes, so make sure you practice those or if you have an attending ask your attending what codes they're using. So CMS, Center for Medicare and Medicaid Services, they have certain rules that goes with billing and so those can be looked up online, but the number one thing is it's not documented, it hasn't been done. So I used to tell my residents, they had a sign-out sheet that was HIPAA compliant and closed and such, but what was on the sign-out sheet was not in the medical record. So I said, I don't want the sign-out sheet to be better than what's in the medical record. The medical record still needs to show what you're doing, what you're looking up, how you're going to be taking care of the patient. The sign-out sheet is not part of our medical record and it is not going to hold up in a court of law, so please document what you do in the notes. The other important thing about CMS is there has to be medical necessity for it. That's part of fraud. So if you're seeing people and there's no medical necessity or documented medical necessity for the visit, that is also fraudulent. So payers are requiring reasonable documentation to make sure that the service is consistent with the insurance coverage and so things that they want to validate. So site of service, meaning, was there a reason to see this patient in inpatient rehab and remember for one of the rules for inpatient rehab is that they need to have care by a medical physician daily and so are you documenting their need for medical care on a daily basis? Again, that goes with the medical necessity of a diagnostic or therapeutic service provided. So a lot of times if it was in clinic and I do a lot of interventional spasticity and the resident could have done the note, it said, spasticity, do Botox. I said, that might have been our take-home message, but we need to write something about why there's a medical necessity for the procedure to be done. Otherwise, if I'm a payer, if I'm an insurer, I'm just going to look at that and say, do Botox doesn't have a plan. You're not saying that they have spasticity that's limiting their caregiving and causing pain and that they can improve with botulinum toxin injections and that's the difference of just a couple of lines documenting medical necessity and actually a reason to do the procedure and to get paid. And then it's also, you need documentation that the services furnished were accurately reported. So again, document what you're going to do and if it's not documented, it's not done. So first, what type of patients, and this is ones you see in the clinic mostly. So it's either a new patient type or an established patient type. So a new patient is someone that's completely new to you or new to your practice. And then there's also a rule with three years. So let's say I may have seen them six years ago and they kind of fell off and then they've realized that something, their stroke symptoms started bothering them again. So they came back into my practice, but it'd been six years. So they're considered a new patient. But otherwise, if it's someone and it'd been two and a half years, then they'd be considered an established patient. The other thing, it also is someone in your same specialty in the same group practice. So maybe someone saw one of my partners two years ago and now they're seeing me because that partner left, then they're considered an established patient, even though I had never seen them before. That also, you get paid a little bit different based on new versus established. So just something to keep in mind on the timeline. All right, so now we're going to talk about billing codes. And then this is a chart that a lot of the details come out of. But this is for initial hospital care. So it's nice to start from this one because this one, there's three main components for billing D&M services. So history, physical examination, and your medical decision making. When you're doing an initial hospital care or a new patient visit for an outpatient, then you need to meet the rules or the requirements in all three of those components. And so from here, if you look all the way to the right, the 99221, 99222, 99223. So there's three levels for inpatient initial care. And so those are ones for either initial HNPs, patients that are seen in the hospital, or if you're seeing a consult for the first time, then these are the codes you use. Just as an aside, there's the modifier AI. So if they're being admitted to your inpatient rehab team, then the AI modifier is used for the, you're the admitting physician. Otherwise, the consultants can also use these codes, but they don't use that modifier. So level one is going to be the most basic, three is going to be the highest level. And so the first part that we're going to look at is the history. The first thing you see across is reason for visit. So the reason for visit has to be there no matter what. So you, again, this is part of documenting for Medicare, the medical necessity of what you're doing. And so either reason for visit or reason for consult. So if it's a consult, you have to put reason for consult and you have to put who the consulting physician is. So that doesn't mean, so they want to know that you're not just popping into a room and starting to see rehab patients or patients that could maybe get rehab, that there was actually a physician who asked for this consultation and then put a reason for consult, which may be rehabilitation, you know, assessment for rehabilitation needs or spasticity management or pain management or, you know, weakness after having a stroke. So document, again, the medical necessity and it has to be there for all levels. So the other thing about the, if it's regular HMP, the chief complaint has to be there as well. And I like to do it more based on reason for visit, because that's kind of going to be the concise statement of their problem or condition. And then maybe sometimes I'll put also a chief complaint in their own words, but sometimes these patients don't have words. I take care of stroke patients and I've seen once a resident write as a chief complaint, which is not really an appropriate chief complaint. So really reason for visit and I'm writing, you know, if they're coming into inpatient rehab, they have impaired mobility, locomotion and self-care due to stroke now necessitating inpatient rehab. So that's kind of something that I always want to make the case for why they have to be there. I'm not against saying what's in their own words and sometimes it may be appropriate if you're saying, okay, patients coming in for new right shoulder pain, great. And so that's a reason for visit. And then the next part is the history of present illness. So that is, you know, a description of the patient's illness. And so for that, we go back and look here for the HPI for detailed or comprehensive, which is a level one to three, you need four aspects. So I said, okay, that is going to be, that's when you were in med school and you learned all those like old cards on, you know, onset, location, duration, characterization, any of those things. And so, you know, I always feel that's pretty easy to do if you're seeing a patient in clinic for shoulder pain, because it's pretty easy, but like they have shoulder pain, it's on the right, it's throbbing, it's a two, picking it up makes it worse, putting ice on it makes it better. And there you have your five elements. But sometimes when you're doing a consult or an HPI for an admission, then I always say I want people to read this and know that it comes from PM&R, that it's a PM&R note and that the HPI is around their medical condition. So even sometimes if you're writing this patient was in a car accident and they had, you know, two fractures and had a brain injury, that's a little bit more of past medical history. I kind of want to know more about what their mobility is now and use HPI to describe some of that. So I do a lot of consults and I'll say, well, we're, you know, that's what happened to the patient. We're consulted for their rehabilitation needs. And the patient is having a lot of pain coming from his right leg, which he feels limits his mobility as well as, you know, his hurts when he gets up at the side of the bed and just kind of describe what's limiting them from a functional perspective, because that's what we like to focus on. So remember that when you're writing your history of present illness. So there's two types of HPIs, brief and extended. So brief is going to be just one of one to three elements and those are when you're doing clinic notes that you might have a brief. The extended has to be in for HNPs, but in clinic notes it may be just something, I always think the best example is when you have a little kid that's coming in with ear pain and they can just focus on the ear and the ear symptoms. But the extended one is going to be four more elements. Or if you're in clinic, then it's also the status of at least three chronic or inactive conditions. So that means with someone I see patients again with stroke, long-term patients that come back and I can say, you know, regarding, and then if it's the status of their three chronic conditions, then you have to describe if they're getting better or not or the same. So it might be like stroke, remains stable, no symptoms, is on anticoagulation, right hemiparesis, feels like it's getting stronger and it's improving, is doing therapy and explain that. Spasticity, spasticity improves once they get botulinum toxin injections and then it wears off. Ephasia is able to communicate, stable and can communicate with family, you know, something like that. So if you do the status of at least three chronic or inactive conditions, that's considered an extended highest level HPI. All right, so which one is this, brief or extended? So patient complaints of earache, complaints of a dull ache in the left ear over the past 24 hours, patient states he went swimming two days ago, symptoms somewhat relieved by warm compress and ibuprofen. Is that a brief or an extended? Anyone typing anything? So even though that's just a couple of lines, that's actually extended. That actually has five HPI elements in it. You want to write these 20-page HPIs, but I'm not for notebook, I'm for just getting across the important part, documenting what you said and what you heard, but still being efficient about it. All right, review of systems. So how many review of systems do you have to have? The rule is that you need to have, well it depends on the level again. So going back, review of systems for a comprehensive level, so that's billing a two or three for HNPs and consults, you need to have 10. If it's just a detailed, you only have to have two. So one thing to know about the review of systems, these are some of the 10 that you can, these are what you can pick from. So can you just say, well, 10-point review of systems are negative? And the answer to that is no. Even though you may see it, you actually have to say the system and you report what's negative or positive about it. So this is even back in the day when we used to have, when we did paper charts and we weren't in the EMR, the systems were listed down and there was like a line that said negative or positive. And you couldn't even write a straight line down. Even if it was negative, you had to checkbox, each individual checkbox to say that you looked at that or that you asked about that. And so the same thing you can say, constitutional eyes, ears, cardiovascular, respiratory are negative, or you can say neurologic is positive for headache, musculoskeletal is positive for neck pain, psychiatric, ears, cardiovascular, or whatever is negative, then that's fine. So I do recommend that you have to have a template for this that is maybe says what the pertinent positives and negatives are. The other thing is this is something that you can ask the patients to fill out a form before or have your nurse or someone ask this kind of form. And as long as you document that you reviewed the review of systems, but put that as part of the documentation or sometimes some EMRs have where you can check it off and they can actually show that you did review it, then that counts as well. So what if you can't get review of systems? And this is for patients sometimes where they might have disorders of consciousness or have a lot of altered mental status, then you just have to document the reason that you can't get it and that you really made an effort to talk to family, nursing, et cetera. So limited review of systems due to patient's alteration of consciousness and no family was available due to COVID-19 or whatever it might have been. And so that will count as a full review of systems as long as you document the reasons why you can't get the part that you can't get. So again, problem pertinent, just one, if it's an extended two, but a complete review of systems is 10. All right, so past family or social history is the next part of the history. And so there's either a pertinent or a complete. Again, for a level two or three billing for your initial note or consult note, you need to have a complete. And that means you have at least one thing in the family, social and past medical history that you report on. And so past medical history is any like surgeries that they've had, medical events that they've had, just explaining what those are. If you already put it in the HPI, you don't need it again because it's at least documented somewhere. Social history again, what's pertinent for the social history. And I always say in our notes, people always, you learn about asking about drugs, alcohol, but that's important, but we also need to know about what their home situation is, who their support system is, how many stairs they have to get in. You know, is it an apartment, a house? So that's important for social history, what their payer is. And then the big one is family history. And I mean, it's a big one because that's where I see residents mess up the most and even attending physicians is that the family history non-contributory. And yes, maybe the family history is not contributory, but non-contributory does not count as a family history. And that puts you into a lower level of just a pertinent because you're not, you only have to document one item from those three history areas. And so non-contributory is not a family history. And if you put non-contributory, that automatically lowers you to a level one billing. And so that is something that we'd have internal audits before at my other department. And that's probably the thing that a lot of times Scott's physicians was, you know, they looked over the note, they didn't look into detail what the family history was. And it said non-contributory. And even though it'd be, you know, a quad on a ventilator where you put a lot of effort in, of course there are high level, you know, a lot of issues going on with a patient, it was then had to go back and they had to pay Medicare too because they overbilled it just because it said non-contributory for the family history. So ask about pertinence or, and even if they don't know their family history, put the reason why it's not known, they were adopted. Again, if you don't know, cause the patient can't talk to you, cannot get family history because the patient's at BASIC, then that counts as a family history. So if you can get it, please get it. If you can't document why you can't get it. All right, that's my family history. Please put something there. All right, now the physical examinations. So it's either expanded problem, focused, detailed, or comprehensive. And this is where it gets a little, there was two guidelines, 1995 and 1997, that they had for billing types of, or billing and coding. And so there, you have to stick with either one or the other, but basically you can either bill based on organ systems or one complete system or one complete organ. So for the most part, the one complete organ is kind of what ophthalmology uses or what psychiatry uses. So, cause they can put, you know, nine, 10, 12 things about the eye. I don't know that many things about the eye. I'm like eyeball, eyelid. So I can't bill that way, but they can, because they'll know about like the retina and the cornea and the iris and the conjunctiva. And so they have, you know, that many things that they can document from. The same thing goes with psychiatry, but for the rest of us, we're using usually organ systems. And so for a comprehensive and for 1995 guidelines, then you have to have about eight or more organ systems. And if it's just a detail, then it's five to seven. And for expanded problem focused, it's two to four. And so you can also do it by, they have, or you can do it by limb or body area or area system. So that's the 1997. And so, and that's kind of what this, the table talks a little bit about. So some might do musculoskeletal and really expand it because you did it, you know, and you're documenting the everything like inspection, palpation, special tests, strength, sensation, and have little bullets for each type of extremity. Then that one is, you have to, then that's another way that you can bill your physical exam as well. And the other thing is for each area or system, you want to have at least two elements identified by a bullet. And so when I'm doing the organ systems, well, first for the organ systems, the most common mistake I see in the organ systems, and that's when you're doing, you know, general, HEI, HENT, cardiovascular, respiratory, people will put neck. Neck is not an organ system, though it is considered a extremity if you're doing a body part. And then I see also you'll put extremities and extremity is not an organ system that either goes under, it depends on, because usually extremity, you know, clubbing, cyanosis, or edema. Well, those things, clubbing, cyanosis, or edema could probably better go into maybe respiratory, you know, looking at cyanosis or clubbing, and the edema can maybe go either in the musculoskeletal and the cardiovascular part. So extremity is not an organ system. And so, again, if you're going to do a level two or three note, which most of the initial notes are, then eight organ systems. If you're doing, this is the billing codes for the subsequent hospital care. So this is the day-to-day notes when you're in inpatient rehab and you're billing for your day-to-day notes that what you must have. So probably most things, and, you know, when we look back at our billings, are a level two. And so that, you only really need a limited area of an affected body area or a two to four related organ system. So again, this means you don't have to do a note load every day. That's the other thing I'd see. People would just like copy forward their initial HNP exam and put it on every single note. And it's like, oh, every day you are doing a full cranial nerve screen and sensory and an ASIA exam and a rectal. No, you're not doing that every single day. Again, only do what you did. Don't put in things that you didn't do. And for even a level two, you only need two to four organ systems. So it's not like you have to do this full exam every day. Just what the patient needs to be seen. And even for the level three, it's only five to seven. So again, don't go to jail. Do what you, just document what you did. So the last part is the medical decision-making. And the medical decision-making is, this is from a sheet that I have that I love this sheet the best to explain it. So that's why I have it up like I do, where I just took a picture of it and then put it on this because it takes some explanation. So there's three things that go into type of medical decision-making. And from these three things, then two out of three is what makes for what level for medical decision-making. So the type of decision-making can be straightforward, low, moderate, or high. And then this goes into what kind of billing you can do. So the first thing is the number of diagnosis or treatment options. And this is a point system. So are you documenting? So this is where in notes, in assessment and plan, I want to have diagnoses not be, sometimes when you're on the ICU, then you do it by, oh, neuro respiratory, those aren't problems. And in the ICU, you're billing based on time. And so now we're billing based on problems. And so we need to have a problem list and diagnoses list that goes with it. So documentation of, if it's a new problem that needs a workup, then that's four points. And if it's a new problem without a workup, then that needs three points. Established problem that's worsening is two points. And each established problem that's stable, improved, or resolved is one point each. So if you write on your daily notes, just even four problems that are just stable and going as it is, then already that's a level four. Or four, which is a higher complexity, because that's the number of problems that you have. So if one of those things is, okay, this patient, they had multiple trauma and that's stable, they're doing therapy, they had a traumatic brain injury with cognitive deficits, and they're improving and out of PTA, that's probably one point. One point, they have post-traumatic pain that's worsening and you're going to increase their pain meds. And that's two extra points that you get for that. Neurogenic bladder, start time voids, so that's another problem that they have. And it's not worsening, it's probably just stable or improving, so one. But that's still four things that you wrote, just a little plan for each of those things. And in that point system you get, it would have been five. Okay, so now the next part is risk. So what's the highest level of risk documented in one of the following areas? You have their problems, their procedures, or the management options. So minimal, low, moderate, or high. So a lot of things we do don't have, we're not going to stat emergency surgery right away, though sometimes the patient does need that and you are diagnosing that. But just for an example, if you're recommending therapy for a patient, that's a low level thing. If you are recommending medications for a patient that's something that they could get over the counter, that's considered low. If you are recommending a medication that would be a prescription medication, that's considered moderate. If it's a medication that would require some kind of monitoring for it, so let's say they need a heparin drip or they're going to get their INR monitored quite frequently while they're in the inpatient unit, then that's considered high. And then also procedures and how you document procedures also puts it at a certain risk. And so again, it's how you document it. And so when I even document that, when I initially see patients and they're going to get bronchial endotoxin injections, I talk to them about the black box warning and that some of the black box warning is that patients can have distal spread and that it could cause breathing problems, dysphagia, and even death. And that definitely puts it in a higher risk category. So again, it's all about how you document it. The other thing that is sometimes you might see if you're on a consult team and if you're doing a consultation on an agitated brain injury patient and you're recommending something that the patient may need restraints to keep from pulling their life sustaining lines, then restraints is a high risk thing. The other discussion that sometimes we have that's high risk goes with if you're doing a talk about DNR and making patients DNR. Something that's at least moderate risk is when we're talking about patients being ready to be discharged to next level of care. That's also a risky thing because you're saying, okay, not highest, but at least moderate saying that they can go to the next level of care. Amount and complexity of data. So that's the next part of the medical decision-making. So this is again, another point system. So did you review or order labs? That's a point. Radiology tests, that's a point. Some other medical diagnostic tests, that's a point. Did you document the test results with the perform, discuss the test results with a performing physician? That's a point. Did you obtain old medical records or obtain history from a referring physician? That's a point. Again, the other thing about these things, if you're doing them, you need to document that you're doing them. So if you talk to the consulting team, if you had to call a doctor from the hospital that they were at before they came here, someone who's reading the note that's auditing it or are not going to know that unless you wrote that. If they got the medical records from the outside facility, I talked to Dr. Smith, who was the surgeon who clarified the weight-bearing status. So there you have that, you got some old medical records and you talk to a referring physician and then you can put on your plan, I'm ordering a CBC on admission because they have a fever, then that's a point too. This is a big one that I see people miss out a lot and it's two points. And that's a review and summarization of old records or obtaining history from someone other than a patient or discussing the case with another healthcare provider. And that is something like when you initially see a patient, you are reviewing and summarizing their medical records or if we're part of a multidisciplinary team. So how many times are we having conversations with the case manager, with the therapist, with another physician that's a consultant on the team? And so you need a document that you had those conversations because that's two points. And then the other one is, yes, you might write, these were the tests that were done and you did review their labs and the radiology tests, but did you independently visualize it? And so I always look at every single brain scan of patients that I see because I have it and I'm not billing for their radiologic read of it, but I wanna see what it looks like so I know what to expect when I have a patient or are they developing hydrocephalus or something else that I may see. So I write that I personally reviewed the CT images and appears to have diffuse axonal injury or whatever it may be. And so that's also two points. So you can see where that's easily on a new consult or on an H&P, it's easy to get four points because you reviewed and summarize the old records, you're putting lab orders in, you personally reviewed visits, you maybe obtained history from somewhere else. So that's another way to get points. And then with those three things, then we can decide what type of medical decision-making it is. So for that, and so this is like, okay, you estimate the lowest value, then the next level will be the medical decision making value. Or basically if you circle this, okay, I had four problems, I had extensive amount and complexity of data. Yeah, it was only moderate because not everyone's this critically ill, something going on, patient, you know, you prescribe some prescriptions and such. So you can put a line down the one that has two or more items and that would be considered a high complexity. So again, it goes with a level type of three, the highest level of billing of a three. But again, that information needs to be there. All right, new rule in 2021 and on January 1st, then you're going to, before, you know, you have to have all three or three of those things on your initial visit and in clinic, in a follow-up, you have to have two or three of those items between, again, the history, the physical exam and the medical decision making. Well now they're going to be able to, you can document and bill based, the office or outpatient just based on the medical decision making or your time. And so, and then they'll only have 99202 to 205. And so they're going to, it's going to change that way, again, mostly based on your medical decision making. So talk about billing based on time. So again, these are the day-to-day visits that you have with a patient, the 99231, 232, 233. And you know, some of those days where you had team rounds and then you had to call their family and you had to fill out forms and you had to do all these things that took tons of time and called consultants and maybe you're not documenting anything more, but you can bill based on time. So you see on the bottom where it says this average time for a one is 15 minutes, for a two is 25 and for a three is 35. So if you spend more than 35 minutes, so it has to be that greater than half of that time was spent in either counseling or coordination of care. So, but it has to be documented, you know, you do your little note and then I'll put greater than, so sometimes this happens on team rounds days where we're team rounding for 15 plus minutes and then you're talking to the patient about what happened and their family members. So then I say, so greater than half, I spent, and I'll put the total time, you know, 36 minutes, it was greater than half the time in, and then it's either whatever you did and then explain what you did in counseling on stroke outcomes after ICH or whatever I may have explained to them or coordination of care, which included working in team rounds and talking to the case manager from workers comp and filling out a form, you know, so as long as you're saying it was greater than half of that average time and then what you did, then you'll get, you know, paid based on that level. And you don't, it doesn't matter what the other history exam or medical decision making is. So sometimes even the difference is on the inpatient, you don't have to be face to face. In the outpatient setting, you have to be face to face. So if I'm spending a lot of time in the outpatient setting, then I want to do counseling face to face with them, then I'm going to take that form that they want me to fill out and I'm going to fill it out sitting right there in front of them. So that way it's face to face greater than half time that I was doing on coordinating care or on counseling them about their diagnosis. So why does this matter? And the last kind of part is kind of the money part. And money is important, as you know, and so this is why it matters. So just kind of, this is an example of what the payments are for some of what we were just talking about. So these are all, the first three are the inpatient codes. And then you can see Medicare is kind of an average payment. Some payers and insurances pay more, some pay less. It depends also on the kind of deals that your group is able to make with insurers. And then Medicare also depends on where you are. So this is just the national Medicare average. Some places you get paid more for Medicare. And then this Medicaid is Texas Medicaid, and every Medicaid is also different. Medicaid is always less than Medicare. You can see the significant difference right there. The other thing is Medicare again is for patients who are 65 and older, patients who have end stage renal disease, or patients with disability but they had to have been disabled two years before they get switched to Medicare, and also they will have had to have paid into Medicare system before with work credits based on a job that they had in the past. And then they get, that's who gets Medicare. So mostly older individuals, but we take care of disabled patients, so that as well. Medicaid is mostly for patients who are more impoverished, and again, patients also with disabilities. So a lot of our patients will have Medicaid who we see. And then insurance adjusts, usually they're commercial payers. And what you get paid is based on rates that you negotiate with them. So part of NICE, what's being in an academic center is that I have a lot of, we have a big practice, so we can have our big practice of all the physicians in our university come together and make a deal with Blue Cross Blue Shield to get $130 for a 99221 versus someone who is just maybe in practice by themselves. And it's harder to make this great deal with Blue Cross Blue Shield because they don't have a big, you know, numbers behind them. But anyways, you can kind of get the idea of the difference between I documented everything that I already did, and I'm going to get a 99223, $205 versus, oh, I forgot, I made the family history non-contributory, and now all of a sudden it's only going to get paid $100. The same thing when I would, the subsequent hospital care, the bottom numbers, the 99231, 232, and 233, so either 40, kind of 73, or $106. And sometimes on the weekends when we're on call and rounding before, we'd be seeing patients and we'd just, you know, want to get through it and we'd write some really short level one notes. And I said, well, if we're doing things and we're seeing them and we're checking on everything, then if we just, you know, make our notes a little bit better to actually show that what we're doing, then that's the difference of, you know, $33 per patient that you can get just by, you know, really document what you're doing on that day. So again, documentation's important because in the end, you know, you need money to pay your bills and to pay off your student loans. So which of these salaries would you prefer? This is just an example, now I put those numbers into a calculator. So for the first one, so you would have to see 20 level twos, so that's like follow-ups in a day, and then two level three new patients, so either two consults or two admissions. And this is an example of, that would be, this is Medicare payment. Again, it may be more or less depending on the patients that you see and what their payer, you know, if it's Blue Cross or if it's Medicaid. So that could be, you know, $1,600 a day, wow, $8,400 a week. And let's say you work only 48 weeks a year because you want your four weeks of vacation, then that would be $404,000 you could get from Medicare, which is a great salary. And then there's overhead, so let's say you had 33% overhead and you're only getting 66%, that's how someone could make $266,000 a year, but you're seeing 22 patients a day, which is definitely doable, but you're working hard. For residents, you know, right now we have a resident cap because we want you to be learning that resident cap is 14 patients a day. And so at 14 patients a day, that would be, in real life, if you're only seeing 14 patients a day, then only getting like $131,000, it's a little bit harder to pay off your loans that way. So that's based on 12 level 99232s, so like 12 kind of regular inpatient follow-ups, and then two maybe either consults or new admissions, then that's about $1,000 a day, $5,400 a week, $262,000 a year, and then let's say you're in some kind of practice where there's some monstrous overhead, like 50%, which is kind of what it is like in academics, is very much like 50% overhead where you'd only be getting $131,000 a year. This is also to show you, I have some friends that do private practice and they go and they're medical directors, they get a medical director stipend, so that's nice, that's on top of this, so that's very good, and they only do inpatient stuff, they don't do any outpatient. That's kind of where you start having more overhead, because you have to pay for a nurse, you have to pay for a filler, and you have to pay for a coder, and you have to pay for a front desk person, and you have to pay for a calling center, and that's where you start getting a lot of overhead. So a lot of these doctors, they just will do inpatient only, they'll be medical directors, their overhead's going to be less than 10%, so those might make closer to the upper 300s. Again, it just depends on what kind of practice you want and how you want to help patients. At the end, I like doing outpatients and seeing patients long-term, and it's just different practice settings, so some places you might end up a little bit poorer, but know that you're going to have to work a lot harder than you did in residency if you want to start making more money, and unfortunately it does at this time, the way the payment system works, you do get paid based on numbers that you see and procedures that you do that may not be, you know, eventually they want to go towards quality, but they're still working on what that means and what quality is and how you get paid for quality work. So that is pretty much what I have. So questions? Yes, I have a question, can you hear me okay? I can, I can hear you, yes. So we have a couple of questions. One is, you know, going back to, way back to review of systems, you mentioned there's a lot about, there's a lot of review of systems issues, right? I know here we see a lot of review of systems pushback. So identifying what's a system, you mentioned extremities is not a system, right? Cardiovascular, this is a little thing, but cardiovascular versus cardiopulmonary, is cardiopulmonary two systems or is that one system? That's two, you should have like cardio as one and pulmonary or respiratory as another. Okay, excellent, thank you. Another question that we've run into is if you, I don't know the answer to this, if you put that statement in there, I personally reviewed MRI and, you know, found these findings or agree with the findings as follows. Have you heard of the incidences of legal liability for, you know, reading this? I mean, you're not a radiologist, so I would think the bar would be lower or higher. So I say you're not billing for it in the way that a radiologist bills for it, like they're billing a code to read it and I'm just saying that I'm like reviewing it and agreeing or that I saw it personally and so yeah, it's a different level of, but again, you always have to think is this going to, you know, am I going to have to read this into a court of law? So make sure you're actually seeing it and not just putting it in your notes. Okay, that's helpful. That's probably good guidelines in general, thinking everything I put in my note I may have to read out loud on this thing. Yeah, exactly. I forgot that, it's very important. We had somebody else ask, and again, the RLS questions, I feel like the review systems can get a lot of folks in trouble. Can you say the 10 point review systems is negative except for the following or except for as, you know, in the HPI above? So I've heard different answers to this, but I'm always erring on the, say, these systems are positive and the rest are negative, including, you know, skin, endo, whatever it might be. So I still like to list them. The other thing is when I listed the review systems, there was more than 10, there was like 13. So you could at least write out 10 and you could say the others were negative, talking about the other three systems, but still you have to kind of have 10 that are written out. Okay, I think kind of as a, my background, my grad school was on health policy and my experience with this piece is that you cannot go wrong when you do it that way. Right. Obviously you've been doing this, you have a lot more expertise and experience in this thing than I do. But I know recently here at Vanderbilt, for example, we got a new MAC. So Medicare is overseen by these Medicare administrative contractors and they're kind of regional Medicare administrators and our new MAC changed the rules on our review system. So what we were doing before was kind of, I think everybody, everybody did it their own way, but it all kind of worked. And the new one wants us to say all other systems reviewed and negative except, which feels really questionable to me. I feel like I'm going to sit on a stand and be like, did you, how deep did you go? And as far as genitourinary review of systems, like you mentioned, all the parts of an eyeball. I mean, I like your approach of, can we list each one that we reviewed? And I think, you know, you don't have to review 13 systems. Right. Yeah. It depends on where you are, who's your MAC, you know, auditor, and then they have their special rules for your part of the country, but play it safe, right? Play it safe, right. Another question that came through was to what, like what role in your experience, what role does your EMR, if you're on Epic or Cerner or whatever, play on in helping you to appropriately bill or optimize your billing? So there are some of those things. They're trying to really optimize EMRs to help with that so that, you know, they'll, you can click on how many, they'll have an HPI, I know in Epic, you know, you can have some preset HPI that you click on things. And so you'll know how many, if you have the four elements, because they kind of explain each one there. The same thing, it'll help you list out the examination and you can click through different points of the examination. And so, but I see a lot that we end up developing a lot of templates for ourself. So if you're going to do a template, your own template, because sometimes ours is just, it's different what we do and it doesn't always lend itself to perfect like chest pain. Oh, the chest pain is, you know, going to the left arm and it's crushing and, you know, it's better if I, it's worse when I try to, you know, do the Peloton bike or something, then, you know, our problems aren't always like that. So sometimes we make these templates, but then we have to make sure that everything meets the criteria. But yes, make your EMR work for you, not against you. I like it. Okay. I think that's all the questions we have for now. One more is when I get arrested, can I call you to come get me out of jail or is this just prevention? You can. I can't promise, you know, I have money for the bail, but I'll at least like write you a letter. All right. Well, thank you. I appreciate it. But thank you so much. This has been fantastic. I know this is one of the, this is a blind spot for a lot of people, myself included. But there's a fine line between wanting to get paid for the work you do and not wanting to go to jail or saying the wrong thing. So thank you so much for helping to kind of clarify that line for us. Yeah. All right. Thanks. Have a good day. Thank you. And to everybody else, thank you so much for joining us today. We're excited for today's lectures and we have more coming tomorrow. So please, tomorrow, go to podiatry.org slash webinars, you'll see links and a lineup scheduled for the next couple of weeks. And we look forward to having you tomorrow. Again, starts at 11 o'clock central time, noon Eastern. Thanks again.

billing and coding

healthcare providers

proper documentation

levels of service

billing codes

medical decision-making

review of systems

reimbursement rates

insurance payers