Welcome, everyone. I'm Dr. Claire McGorry, a member of the AADSM's Education Committee and moderator for this evening's presentation on EM coding revisions by Dr. Alex Vaughan. Dr. Vaughan is a board-certified oral facial pain specialist and a founding partner at Virginia Total Sleep in Richmond, Virginia. The practice is limited to the treatment of temporomandibular joint and sleep disorders. Dr. Vaughan admits to a passion for medical billing and he generously agreed to join us tonight to explain the revisions recently implemented by the CMS. And now, I'll turn it over to Dr. Vaughan. I am an oral facial pain specialist in Richmond, Virginia. I started my training in the Army back when I was more allowed to have shorter hair by my wife. So, that was the Army days, but those are good times in the past. So, I started in the Army and then finished up a residency at University of Southern California. And then now, I'm in Richmond, Virginia, started Virginia Total Sleep with my partner, Michael Pagano. And both of us then run that practice and really all we treat is sleep and pain above the neck is the best way I can describe our practice. So, I would describe myself as a coding lay and an expert. I don't think anyone can really be a coding expert. We can all be falling on our faces together in a coordinated fashion. None of us know what we're doing. We pretend to. That is because they are made up. The rules are made up and the points don't matter unless you play those points with Medicare and then they do matter. So, when we're looking at that, a lot of what I've learned, I have no formal training in this. This is more just my own education as well as then running practices and doing this on a day-to-day basis. My brain automatically runs to coding mainly because my background is I was a dental coder and biller way before dental school. So, my background is that. I enjoyed it and I said, you know, let's make this medical. Let's enjoy letting patients enjoy their insurance. They pay a lot of money. We all do for our insurance every single month. So, let's use it. So, finding ways to unlock that for patients I think is key. And the last thing I'll add is the biggest disclaimer is nothing is absolute except when it is. So, I will try to highlight the absolutes, but in general with anything billing and coding, everything is gray except the things that aren't, if that makes sense. And this is my wonderful, wonderful family. So, I've got my beautiful wife there, Megan, a photo of my son, Asher. He is much older now. He was two, I think, in this photo. Now he's five. We live in Virginia and absolutely love getting outdoors and backpacking as much as we can. I want to really quickly highlight. So, in the mastery program, I teach on actual kind of the whole process of medical billing, not just E&M. But I want to quickly highlight the big three things in insurance. And I want you to remember there are three steps to insurance. Each of these steps is like a separate company. So, when you think about working with Anthem or Blue Cross Blue Shield, I want you really to think about working with three different companies called Blue Cross Blue Shield. There's the eligibility and benefit side. That's the side that patients pay their money to and tell them, you know, here, yeah, you can go see your doctor for $20. That's the side that prints the cards. It's the side that tells you when you call in and say, hey, how much, you know, how much does my patient owe or what's their deductible. It's the eligibility and benefit side. Medical necessity, the other name for that is utilization management. So, for example, Anthem here in Virginia, my local Blue Cross Blue Shield is called Anthem. So, Anthem Blue Cross Blue Shield of Virginia, they have another company called Anthem Utilization Management. And that is literally the company of Anthem that handles the decisions of whether or not what you do is necessary. And then you have the payment side, and they're the ones that pay us. As you can imagine, they claim processing and payment. These are three separate companies, all under the same umbrella. And each company has their own rules, regulations, and processes. So, if you've wondered why you've called eligibility and benefits and been told, yes, the patient is eligible for E0486, but then you submit your claim and you don't get paid, it's because these are different companies. So, eligibility can tell you whatever they want. Now, they have to follow it, but just because it's allowed doesn't mean that it's payable, right? So, they're different companies. And the reason I'm highlighting this is because it's going to matter a little bit with E&M. So, what changed? And I apologize, when I say E&M, it is evaluation and management, otherwise known as exams, right? These are office visits. So, up until 2021, the last big revision was 1997. And realistically, the last big revision was 1995. So, 1995, they made a major revision in the way coding is done. And in 97, they, let's say, fixed what was wrong in 95. But really, they didn't fix anything. The nice thing is 2021, I mean, I'm never going to praise the AMA, but they did a much better job this time. And so, really, this is a huge, huge improvement. Throw away most of what you've learned. And the nice thing is in these 20 minutes here, where I'm going over this, we will probably get everything we need to know, which is really why it's so simple. So, where did this all come from? Never mind that physicians have been yelling for 20 years about how stupid these rules are. But what happened is in 2019, 2018, one of those two years, Medicare proposed their rules for 2020 or 2021. And it stated that, hey, you know what? These levels of exams are dumb. You guys are playing the system, and we don't like that. We're just going to pay you the same for everything. So, Medicare said, we're just going to do a single fee. It doesn't matter whether you do a level 2 exam or level 5 exam. We're going to pay you the same amount, which, as you can hopefully imagine, means that they're going to pay you right in the middle of the road to probably the lower end of the middle of the road. So, level 5 exams, these highly complex patients with multiple issues, something we're really not going to treat too often. But imagine a physician treating someone with multiple myeloma or these major chronic conditions, 4 or 5 chronic conditions, level 5 exams all the time. Well, you're going to pay it as if the patient had a sinus infection. That did not go over well. So, the AMA said, you know what? We control CPT. We're just going to change it. And we're going to make it actually smart and try and encourage Medicare to then pay us appropriately because we're going to fix our coding. So, this is one time I'm really going to thank CMS for being heavy handed because they got changes. So, here's the big changes. And, again, if you know the past, this will make more sense. If you don't know the past, you're probably in a better place. But anyway, 99201, the level 1 new patient exam is gone, doesn't exist anymore. The requirements of history, as far as you need these many elements, you need to know the duration and the location and the improving factors and things that make it worse and alternate treatments, gone. You don't need to worry about that anymore. Physical exam requirements, bullets, points, what systems are you in? You need two bullet points and nine systems, gone. That doesn't matter anymore. All that matters are two things, your medical decision making or MDM or time. So, I know here I say MDM is everything. Really, I think it's how most of us are going to be billing. But time is also there. The nice thing is time was also changed. Previously, time was face-to-face with the patient, and 50% of which had to be related to counseling or coordination of care. In other words, don't touch the patient, talk to the patient. And that's gone, that 50% requirement. And the face-to-face is modified. So, what time is, is now not just counseling, coordination of care, and not just face-to-face. So, we're going to get into that. But the biggest thing I want you to take home, this is what I was saying, the different companies, medical necessity still is king. In other words, insurance is not going to say, not going to pay for something that is not medically necessary. And the best way to think of that, that I can relate to, I love hangnails. They're my example for everything. So, I apologize, I'll mention it 20 times. But if you are seeing your patient for 60 minutes for a hangnail, insurance is going to say, I don't think you need to see them for 60 minutes for a hangnail. And they'll deny your claim, or they'll potentially audit it and say, hey, that doesn't make sense. So, it still needs to be necessary for what you bill, which is going to be the gray zone. So, the biggest thing with E&Ms that I want you to think about, throw away everything you know about dentistry, don't throw it away. Maybe take that dentistry hat off, put it in the corner, pick up your medicine hat and put it on. We are in a whole different world when we get to medicine, which is, I think, a more appropriate world, honestly. And that's because we're paid to think and we're paid to do what we went to school for, which is to think and understand and yes, perform and do procedures, but to think is key. And so, E&Ms realistically, when we're looking at are you billing on two different ways, right? Medical decision-making versus time, you're either billing for how hard you have to think or how long you have to think. And that's the best way to look at this. And it's not an antagonistic relationship, you bill for whichever is higher. So, if you thought more than you, I guess, if you thought harder than you took to think, then you bill off of MDM. If you took longer to think than really, and it wasn't hard thinking, you bill off of time. Again, let's look at dental insurance versus medical insurance. Really quickly here, dental insurance diagnosis is optional, right? It's usually implied. If I'm doing a filling, for example, a restoration, right? A composite two-service restoration, composite restoration, it's probably for carries. So, the diagnosis is kind of assumed, but it's not required on the claim form. The diagnosis is always there. Having said that, medicine also does a smart thing, which is create an entire diagnosis list of everything, including the difference between being a passenger in a pickup truck in an automobile accident with a semi versus being the driver of a sedan in an automobile accident with a bicycle, right? Those are all different codes in medicine. As far as the exams are concerned in dentistry, we have a very codified list. This is what's in an exam, right? You need your perio chart, you come into the perio evaluation, your restorative dental evaluation for decay, you know, x-ray and inter-oral exam, very defined. Medicine, much more guidelines, not defined. You don't have to check these boxes, you just have to check three of 12 boxes. And then covered treatment-wise, dentistry is definitely looking at necessity, but there's a defined medical or benefit plan, you know, two exams per year, you know, two periodics and two limiteds. Whereas in medicine, it's more what's necessary and it's unlimited, excuse me, unless they've defined it. So in medicine, if there's no definition, if there's no policy, assume it's unlimited as long as it is rational and makes medical sense. Last kind of overview option before we get into specifics, things I always want you to have in the back of your mind, obviously code what you did or do, and being close doesn't count. So if, and we get into time, you'll see, like, thankfully they changed it instead of saying the previous ones were, for example, at a level two should take about 15 minutes, and the next one was 30 minutes. Well, what if you took 18 minutes? And so we had to use archaic rules. Now, thankfully, their range is 15 to 29 minutes is this code, 30 to 39 minutes is this code. But close doesn't count, code what you do. And don't over code, you're going to make $10 on that claim or $20 more, and you're going to risk thousands of dollars in loss. So code what you do, except the fact that sometimes we're going to code a level three. And it's frustrating, but it's what it's going to be. As far as the Medicare fee physician schedule or physician fee schedule, this is just the public rate of Medicare. It's pretty smart to use this to kind of base your rates off of, I don't pay or I don't charge what Medicare will pay me. I charge more than that, but I still base it off of that because it kind of gives you an idea of what insurance is going to base it off of. The Medicare fee physician fee schedule, you can certainly Google, it's a convoluted system to read. I would just Google the phrase CMAQ rate. CMAQ is the CHAMPMS, which is the VA system, and MAC is some other acronym. But the idea is this is essentially what TRICARE will pay, which is directly 100% correlated to what Medicare will pay. It's the same fee schedule. It's just the website for CMAQ rate is much easier to use. So I would use that right now. It's been down for the last week. So don't go to Google now, it won't work, but give it a month or a couple of weeks and it should be back up. Undercoding is still fraud. So don't, in other words, where we see undercoding is, let's say that cash patient, you bill them for a lower exam code because you don't want to impose on them the same cost, that's still fraud. So bill what you did. This is going to sound harsh, but if you aren't comfortable charging your patients what you bill, don't bill it, bill less. You should be comfortable with whatever you charge. There should be no reason to undercode. And then the last thing is each insurance has their own set of rules. So what I'm going to be reviewing tonight are the American Medical Association's rules for coding. No insurance is required by law to follow those rules. Now Medicare has basically adopted them. So you can assume this is also applicable to Medicare, but each other insurance, Anthem, Blue Cross Blue Shield, Blue Cross Blue Shield of Michigan, Blue Cross Blue Shield of Illinois, all can have different rules. Best way to find that, go to Google, type in whatever insurance you care about, and then E&M coding policy, or E&M policy, or evaluation management policy, and you should be able to find what they have to say. So sleep, what are we looking at? Realistically, a few things. I'm not going to go over E0486, this is all about E&M, but I'm getting two gritty graphs here really quickly. Evaluation management is what we do as a doctor. It's going to be different than dental exam coding, and again, we're paid to think, not do. So when I say it's what makes us a doctor, what I mean by that is it's not ancillary staff, it's not our team member's time, it's not anything our team member can do. So if your team member can do it without you, it does not count for E&M. That's the best way to look at this, other than maybe things like vitals that we may comment on and allow them, you know, that they certainly can take, but we're still going to be the ones making a comment on the vitals, whether or not they're normal, whether or not there's a problem and need a referral. Radiographs, we're going to split down into global versus technical. So in dentistry, we don't really see this divide, but in medicine, global is everything. You build for both the technical and professional. Technical is making the image, professional is interpreting the image. So global means you did both. Where this matters especially is if you only did one or the other, but realistically, in general, we're going to do both, and I want to highlight that because you need to, if you are billing for a radiograph, you need to include both the making of the radiograph for the note and the note of your interpretation. So if it's a normal pan, you still need to have a comment about why it's a normal pan, what you see on it that's normal, and that it's normal. Don't just say exposed panoramic. That will lose on audit immediately. Okay, so E&M types, let's break it down into two big things. We've got the new patient exam and we've got the established patient. New patient, these are very specific. These are going to be 9920 and the last number is going to be whichever level of exam you have, two through five. What makes a new patient is someone that you have not seen in the last three years or has not been seen by anyone in your practice that has the same taxonomy or specialty as you. Why does this matter? This distinction in my practice, my partner's a board certified in dental sleep medicine, but the way taxonomies work, he's a general dentist. So if he sees a patient, it's a new patient exam. If that patient has an oral facial pain complaint and he refers the patient to me, that is a separate new patient exam because I'm a different specialty than he is. So even though we share tax IDs, we're a different taxonomy. Having said that, my patients that I saw at my last practice before moving to my new one, even though I saw them a year ago in a different tax ID, because it's still me, my same NPI, they are not a new patient anymore. They're still an existing patient. Even though none of the records I have, I'm doing a new patient appointment, I bill an established patient because the NPI is the same. Established anyone that isn't new. It's pretty simple there. So let's start with medical decision-making. Again, we have two ways to bill. Medical decision-making is in one corner. Time is in the other. Bill whichever one is going to pay you more. You decide which one you bill. Insurance does not get to decide as long as the code you're billing is medically necessary. So medical decision-making, we're looking at number and complexity of problems. And I'm going to break all these down. So we'll go through each page and try and put it all together. This is the confusing part. So problems, what you've done to evaluate the problems, and what your treatment is going to entail as far as, again, additional thinking on your part. And when we're looking at those three elements, when you bill it, you're going to take, again, this is the weirdest part to say, you're going to take the lowest of the highest two. And I'm going to try and show that in a second. That's going to determine what you bill. So in other words, look at your three, code your three elements, throw away the lowest one, or the least valuable one, and then just look at those two that are left. You'll bill the lowest of those two. And the last big asterisk here, a lot of plans, and this is how I do all of my billing, is I just assume this. A lot of plans require risk or morbidity mortality, which is one of your elements there, to be one of the two. So realistically, when I bill a patient, I just look at that element. That's what I bill. Okay. I make sure the other elements fit that element. In other words, if it's a low level decision, as far as risk is concerned, I don't even waste my time with worrying about the other ones. And document, I mean, I document what it is, but I don't document it perfectly in the little minor issues. I might not document that their snoring is bothering them, right? I'm going to treat their apnea, and I'm not going to worry about their snoring. Yes, I'm treating it, but I'm not going to worry about perfect documentation on it. So as far as what we're looking at, again, the top part here is a blank one. Feel free to... I would create something like this for your office, and check mark the bottom as an example. So on that bottom one, let's say the problem level we reached was low, the data level was straightforward, and the risk was moderate. I'm going to throw away the data level, because it's the lowest, and I'm going to bill off the lowest of the two remaining. So that's the problem. Problem I got to a low level, I'm going to bill a level three exam. So what does it look like? Problems. Again, those four levels, straightforward, low, moderate, high. You're going to see those on every one of these slides. So each of these columns, you're going to fill in based off of what you see. So in a problem, a straightforward, minimal, limited, or minor problem, this is the patient that... Realistically, we're not going to see these patients too much when you're billing medical, but in the dental world, what this would look like is the patient that complains that they've got an aphthous ulcer, self-limited minor problem, pretty quick, easy exam. Low level, one of these three, two or more self-limited or minor, so they've got an aphthous ulcer and they're biting their cheek. One or more stable chronic illness, caries, well-maintained caries. In the medical population, apnea, or one acute uncomplicated illness or injury. What this is is a straightforward, but it is unique. So this would be a fungal infection, right? It's not self-limited, we need to treat it, but it's not really that hard either to treat. Moderate problems, what we're going to see, these are all ORs. So it's not all of these things, one OR or the other. Again, one chronic problem, but with exacerbation, I'll give you an example of that in a minute. Two or more stable chronic problems, so apnea and snoring, for example. Snoring doesn't go away on its own, it's a chronic problem. So that's where you're going to hit your moderates. Undiagnosed new problem, we don't see this too much unless you're seeing undiagnosed apnea, but in that case, that would be that, because we don't know, are they mild, moderate, severe? We don't know their prognosis. Acute illness with systemic symptoms, so this is a little bit more of that sinus infection, right? We're getting a little bit more problem with it. And then a complicated injury, this is a compound fracture or something like that. Highs, it's rare in the dental sleep medicine world, other than your extreme, I would say I see some of these patients with orofacial pain, but they're rarer and maybe one or two a year, even in the orofacial pain world. And that's realistically a chronic with severe exacerbation is going to be the patient that maybe has a severe arthritis that then they're also in closed lock, something that's highly affecting their life. The last one is an acute or chronic illness that poses a threat to life or function. I know we want to say, hey, apnea will kill you, but what this means specifically is imminent threat. So this is the myocardial infarction patient is passed out from, okay, this is not apnea. So don't get too focused on that. As far as data, three different categories. One is testing documents. What did you read? What did you look at? What did you think about before you saw this patient or while you're seeing this patient? And then is there something you relooked at that you're qualified to review? I see this a lot as patients that come to me. I don't, I'm not a general dentist. I don't have a general dentistry compliment, so I don't have pans on my patients. If they come with a pan from the GP, I'm not going to take a new one, but I will reinterpret it. So that might be a reinterpretation of a test. And then discussion or management. If I've got a very complex patient, I may call the physician, you know, document these things in your note. So just because you call the physician, if you didn't write it down, it didn't happen. So put in your note, in the HPI section, when you're talking about your patient, write down, discussed with the attending physician prior to this appointment, concerns regarding X, Y, and Z. So we're looking at data review, again, straightforward, low, moderate, high. Straightforward realistically is just patient came in because their finger hurts, right? It's straight, and I looked at their finger. You know, you didn't really do anything. It's straightforward, simple. Category one is two, or low is two of that category one, remember that's tests and documents. So that's most of our apnea patients are going to be in low or moderate. Reviewed the note, the office note, reviewed the sleep study. Those are two different points of data. If you took a pan and reviewed it, that could be a third. If you've reviewed general dental notes, even if you took the notes, you still reviewed them. Moderate is going to be three of those category one items, or again, now we're getting into more of the weeds of those other categories. And then the high, you need two out of three of those items. So you have to have three category ones and one category two, or two category twos and two category, or I'm sorry, one category two and one category three. I would avoid high. You're not going to get there realistically. And lastly, risk and morbidity mortality. This is the risk of the treatment and the testing, not the condition. So whatever the condition is really doesn't matter what the untreated course is. The matter is what are you doing and what is what you're testing for do, and what are things other than what you could do? So for example, straightforward minimal, again, this is literally a straightforward minimal absence ulcer, a bad example, because we may actually treat that hangnail, go home and wait, right? That's our treatment for hangnail. It'll, it'll fall off. You'll take care of it. So that'd be straightforward, minimal, low is an OTC drug. So let's say absence ulcer, and you say, take some ampasol, you know, put ampasol on that three times a day. That's a low risk, you know, low risk for that treatment, moderate prescription drug management. So where we see this as an oral facial pain, when I'm managing with NSAIDs, you know, take some Motrin four times a day, but I'm going to prescribe three times a day, but I'm prescribed that Motrin. This is why realistically you never leave a physician without a prescription. This is why right here. And then the other thing I highlight here, decision regarding minor surgery. This does not mean that you are doing the surgery. So if you're discussing with the patient Inspire as an alternative to oral appliance, that's a minor surgery, and you've identified their, their risk factors. Put that in your note, discussed opportunity for CPAP or Inspire therapy, patient selected oral appliance therapy, you've discussed the risk and benefits of each, you get points for that. High, again, these are going to be much, much rarer in the, the average dental sleep medicine patient where I see this in oral facial pain is rare. It's mainly my patients that I'm treating for trigeminal neuralgia, where I'm putting them on carbamazepine. For example, I need to do quarterly liver evals and doing blood, you know, taking, taking blood out and looking at liver, liver function tests and, and amount of carbamazepine in the blood. Okay. That's high risk, but that's a rare case. I don't want you really to focus on those. And again, this is based off the possible treatment options, not what was selected. As long as you talked about it. So if you didn't talk about Inspire, don't claim that you considered surgery. But that's the biggest thing here to understand is if you talked about it with the patient, even if you can't perform it, but you are relatively appropriate for that discussion. Okay. Inspire, is that in our scope of care practice as a general dentist? No. Oral surgery, maybe, but general dentist, no. But that doesn't mean we can't discuss it and the risks and benefits. We certainly all know them. So just note it, put it in your note, and now you can claim that tick mark. So again, just a reminder where we are, we're going to look at our problems, our data and our risk. We're going to pick a box for each of those. And then we're going to pick the, I don't want to say the middle because it might not be the middle, but the, the, the, the lowest of the highest two. So here's some examples to really quickly go through. We've got a 42 year old male, BMI 28, uncomplicated history and mild apnea. So let's call this the easy standard patient. This is your lowest level patient. Problem list one, we could just say they have apnea, that's a level, that's a low level. Or if we wanted to hunt for points, we can stay moderate. They have a stable chronic, let's say they had a CPAP history and the CPAP caused nasal irritation. So we're dealing with stable chronic illness with a side effective treatment. So that would be that example. So find out where you lay there. You could also say, for example, you're treating snoring. You could claim snoring. We certainly are. That's a moderate condition. Data review. So what do we look at? We looked at the office notes from the sleep doc. We looked at the sleep study and let's say we ordered a pan. In medicine, the order is key. And that's because when I bill for the pan, if you remember earlier, global, I billed for the making the pan and interpreting it. I did not bill for ordering it. And in medicine, there are three parts to every test, ordering it, doing the test and interpreting the test. And so we have to remember those three elements. So if I order a pan, I can claim it. If I say I reviewed my pan. And I'm using that to give me points for an E&M. And I also billed the pan, which includes the review. Now we're double dipping. Okay. So the big key to highlight here is the ordering of the panoramic image. So put in your note that you ordered a panoramic. Then in a separate note, you expose the pan and you evaluated the pan. For the risk of medical decision-making, realistically, most of these are going to be low risk. It's the safest option. If you are comfortable with potentially having to make an argument on audit, you can certainly get there with moderate. Oral appliances do have risks that are higher than low risk. Remember, low risk is over the counter. So it's certainly easy to say a prescription oral appliance is different than over the counter oral appliance. It's like prescription Motrin is different than over the counter Motrin. So you can make that argument. You just have to be comfortable with pushing back against insurance if they actually go after you. I don't think they will. But that's a personal decision there. In the second... Oh, and I apologize. Assuming on this patient, they'd probably be a level three, a middle of the road level three. Second example here, a little bit older patient, 68, 36 BMI, so a little bit more complicated hypertension and severe apnea. I would probably try to avoid low, but you can certainly claim low. It's a stable chronic illness of apnea. We're not managing their hypertension, so you can't claim that. But again, we've got maybe this irritation from pap. They're severe. They almost certainly have had pap. So review the same notes as the last one. But now for sure, because they're severe, we better be evaluating for Inspire as well. It's a valid treatment. So hopefully you're discussing that with your patients. And even if you say, I think you should do oral appliance before Inspire, you discussed Inspire. And I mean, discuss risk benefits and all the difference there. This case I think is a fairly safe level four. Now remember on insurance, they're not going to see severe versus mild when you bill it. They're going to see obstructive sleep apnea either way. So you may have to defend that a little more. Last example here, 24 year old female, again, under 30 BMI, however she has jaw pain bilaterally and a mild apnea. Now she has two illnesses, apnea and myalgia. Both of those are separate illnesses. So if you address both and treat both, you can claim both. You can simply note her jaw is sore, but you don't put anything about your treatment, even if your treatment is watch and wait, that's still treatment. So if you don't note it anywhere else in your note, then it doesn't count. But if you note it, discuss it in your last steps, in your assessment plan, then count it as a problem. Data review, again, same review as before. And now this time, let's say we put her on Baclofen for myalgia. I would encourage you to do that. Again, it's a prescription drug. You're worrying about the prescription drug management. Is there much risk to Baclofen? No. Just like there isn't much risk to, you know, Flexeril. However, you still turn on your doctor brain and thought about it. And that's what medicine pays us for. It pays us to think. So if anything you do involves you really just taking five seconds to think, is it okay for this patient to do this? Bill for it. So again, this patient, easy level four. No question, any day of the week, this now with these new standards, level four. Last section, remember, we had how hard did you think was the last one? Now it's how long did you think? And so for this, very straightforward, copy and paste this chart. You can get these slides, probably email the AADSM, they can send you these slides. If not, you can go to Google and type in 2021 E&M guidelines time and go to the images. You're going to find a hundred slides like this. What they've done is literally just put time ranges for what you spend. So what can you spend your time on includes these things and only these things. So it has to be something that what I quote qualified healthcare professional. What that means is someone with a license and in the dental world, that means not hygienists. So even though they have a license, it doesn't include hygiene, but on the medical side, it includes PAs and MPs. So for us, it's what you can do, essentially what only you can do. So the time spent doing the vitals does not count. Your time interpreting the vitals does, but not taking the vitals. The time to fax another office for their office notes does not count. Your time for reviewing those other office notes does. So face-to-face, it's obtaining the history with your patient, doing your exam, and then counseling and educating them. With your non-face-to-face, again, reviewing tests, ordering medications and tests, the time it takes you to put that in your computer counts. If you have a convoluted, bad system that takes you 20 minutes to put in a prescription, you get 20 minutes. Referral letter, so the time you spend writing the referral or reviewing the referral your team wrote before signing it, and then documenting. So you actually get paid to write your note now, which is nice. Having said that, it's much more efficient to get paid off of medical decision-making once you're good with it and comfortable with it. But early on, bill off a time. I mean, value your time. Now, you have to account for your time. So you do have to have in your note a statement that says how much time you spent. Now, you don't have to say, I spent five minutes doing this, and six minutes doing this, and 28 minutes doing this. But you do have to say, I spent X number of minutes with the patient before, or X number of minutes, I'm sorry, you don't need to say with the patient anymore. X number of minutes on this visit with time split between, and now I'll list everything you did. Evaluating the patient, taking their history, doing their exam, consulting with their other physicians, documenting my findings. All of that counts. It just has to be in your note, and it has to make sense. If you spent 200 minutes evaluating the patient and talking to their other physician, there's going to be a question. Okay, it has to make sense and be valid and be able to defend it. So if insurance says, how did you really spend that time? You can say, okay, I spent, on average, I spent five minutes on this. I spent 10 minutes on this, and then dah, dah, dah, and you list how much you spend on average. On this patient, I happen to spend this much. If you want to be safe, and having said that, a lot of commercial plans do require this, put the time in and out. So you started the patient encounter at 10.01, you left the room at 10.52, and you spent, you finished writing the note at 10.58, and now you've got that time. You spent 58 minutes with the patient, and you've got your time noted. You don't have to break it down too much, but give them those times. You're going to be much safer. Having said that, it's not required by the AMA, but it's smart. What it doesn't include, again, anything your staff can do. So making your impressions does not count. Making your radiographs does not count. Nevermind, you're going to bill for that separately. Taking vitals doesn't count. And then anything you can bill and report separately does not count. So your Panerax doesn't count. The time for it, the time you spent interpreting it, the time you spent ordering it does, having said that, most of us order it in about 20 seconds. But just understand that distinction. If you can bill for it, it does not count as time spent on the E&M. Again, just re-highlighting this slide, it's key. But again, I'd copy this. It's literally at work, sitting above my computer right in front of me, and it's on the screen for every appointment. So I know exactly which time block I fit into. And so it's a very good handy aid. Whirlwind tour around everything. But let's jump to questions. All right. Thank you. That was wonderful. What insurances are using these new guidelines? Great question. I don't know. So realistically, the best way to do that is, again, go to Google, type in whichever insurance you're billing, and then type in 2021. Honestly, you can probably just type in 2021 guidelines. But if you put in 2021 E&M guidelines or E slash M guidelines, or again, your insurance company, 2021 99204 or 99203 policy, you will probably find that answer. But it's gonna be specific to the insurance, and it's gonna be specific to that. Again, if no policy exists, then you have to go off of the general standard, which is what the AMA says. So unless your insurance has a policy that says we only follow 95 and 97 guidelines, then you should be able to bill the 2021 guideline. Okay. What if I do a free consult first for a patient, then can I bill a new patient visit later? Yeah, I would advise you no. And this is why I do not like free consults. I, again, my policy is if you are uncomfortable paying or asking your patient for money, then you should not be doing this, and you should lower your fees. If you have seen the patient, whether you billed insurance or not, the first time you see the patient is their new patient exam. The second time you see the patient, again, if you did your first one for free, that was on you. That was your poor decision to do the first one for, I shouldn't say poor decision, I apologize. It was your decision to do it that way. However, what that decision means is that you cannot bill a new patient exam in the future. Will insurance catch you? No, because you wouldn't have billed that before. They aren't gonna flag it as a prior billed patient. If they audit you though, they will catch you. And again, I would not, there's a large difference between a new patient and an existing patient. I mean, 30 bucks, $40 on that exam. So, but if you wanna have all your exams overturned and repaid, so thousands of dollars in loss to make 30 bucks on all your patients, you know, that's certainly a decision you can make. But in my opinion, bill for your first exam, don't do free exams. Yep. All right, what's the best way to document time spent reviewing charts and writing notes as part of the total EM coding level support? Yeah, so what I do is I have, in my health record, I have a pre-printed statement at the end of every exam that says I spent XXX time with Miss XXX or Mr. XXX, and then the rest is boilerplate. So when I'm done with an exam, I simply just have to change how much time I spent and their name. The rest of the boilerplate stays the same, and that's because, I mean, I'll certainly change it if something's different, but for the most part, we're gonna take their history, we're gonna review their office notes from their other provider, we're gonna review their sleep study, we're gonna complete an appropriate exam, and we're going to discuss the findings with the patient, recommend treatment, discuss benefits, alternatives, and risks of no treatment and alternative treatment, and discuss risks and benefits of no treatment. Since that's on every appointment we do, that's what my boilerplate says. And then I just, again, change the first number to how long I spent and the patient's name. And that time you spent does need to be, again, appropriate and accurate. So don't just make up numbers there. Be able to support it. In my system, I don't actually put the time, but that's because I'm using a medical health record. In our record system, it actually has a report I can run, and we mark when I walk in the room and when I leave the room. So when I run that report, it shows that, so I can give that to insurance. But if you're using EagleSoft or Dentrix or something like that, I would put in, you know, I spent 46 minutes from 10.52 or 10.02 to 10.48, sorry, math is not easy, at 7.46. You know, and that's why I spend that much time with the patient is the smartest. Who decides the medical necessity of an exam level? Yeah, whoever you least want to. So usually insurance will, I shouldn't say whoever you least want to, whoever has more money at the end of the day. So let's say you bill a level five for a straightforward, uncomplicated apnea patient. Insurance is probably gonna audit that. That is unlikely, extremely unlikely. So that is a big red flag to insurance. They will likely audit you. And when they audit you, you're gonna give them your notes and they're gonna say, okay, great, you did that, you reached level four. And you're gonna say, no, they're this and that. And they'll go, fine, great, but it wasn't necessary. You spent, you're gonna say, well, I spent 90 minutes with the patient. I evaluated them for this and I did all these things and we're proud of what we do because we do spend a lot of time with our patients. We spend much longer with our patients than a physician does. Having said that, insurance is gonna hold you to the physician's standard. And they're gonna say, great, I'm glad you spent 186 minutes with your patient. You were dumb for doing so. And that's what insurance is gonna tell you. I don't agree with that, but that's what they'll say. And can you fight that? Sure. Do you wanna sue Anthem? Do you wanna sue these companies with billions of dollars in their bank? I don't. And realistically, that's where the line is gonna get drawn. And so at the end of the day, your insurance company is gonna determine it unless you wanna go through those lawsuits. So if it's borderline realistic, you can argue that and make a good valid point and argument to your insurance company why you had to spend that time with that patient. But if you're trying to build a level five on apnea, I would advise against it personally, but that's all I can say. Right. Our next one was answered by a moderator. So the following that is, if I'm not in network with insurance and strictly FFS, feeder service, what form would you recommend giving the patients that they can file on their own? Would you recommend to still call insurance for free? Yeah, great, great question. So I formed my practice on the idea of medical billing and medical insurance, but I've worked in fee-for-service practices. And I think there's really good points to both. On fee-for-service side, my advice, and this is gonna sound harsh, but my advice is, if you're gonna go through work for your patient and do all of their work for them for billing their insurance, just bill their insurance and help them out that way. Otherwise, just give them your note. And so as far as what form would I use, creating a super bill is a good idea. They don't technically need that, but it's what insurance is used to seeing. All insurance technically needs for a patient to submit their own claim is each insurance will have their own form. It's for the patient to use. And the patients will be the ones to find it. It's gonna be hard for you to find, but the patient can get it. They may have to call their insurance for it. But there'll be a claim form that they have to fill out. It's not the CMS 1500 that we fill out. It's a claim form from the insurance specifically. And your itemized receipt, it needs to show your billed code, what you billed, so 99204, and what diagnosis you did. That's all the patient needs to file. Now, most of the time, insurance will pay that, especially if it's for an exam. Insurance isn't gonna argue with an exam usually, again, within reason. A level five for apnea, they're gonna argue with. But as far as billing the appliance, then you're gonna need to provide all of the information you got from your sleep physician, all of their notes and all of your notes as to what you did. And the best thing I can advise you with that is overload insurance with data. Give as much as you have, throw it at insurance. They will get tired of reading it. I'm not saying go crazy. I'm not saying throw every little piece of paper you have, but physician's note, the physician that referred the patient to the sleep physician, the sleep study itself, your notes, the shipping label from your appliance, the prescription for your appliance, the notes you had for the delivery of the appliance, the signature your patient put on the receipt that they accepted the delivery. Everything can go to insurance in that case. The big benefit you have on fee-for-service is in general, insurance couldn't care less about you as the provider. You don't pay them anything. They only have to pay you. You are the leech that they hate. The patient is half or a quarter of their customer. So they do at least care a little bit about the patient. So they're usually a lot nicer to the patient. So the patient billing and not having everything, a lot of times insurance will still accept, but it's gonna be specific. But yeah, your notes, sorry, long answer. Your notes, your invoice, and anything you've ever received on that patient from any other provider. Right. Are any of your new patient exams done with telehealth? Yes, I do time with telehealth. I used to, especially the last year. Now it's even easier, right? Before it was hard to hit exam bullets, especially if you're not comfortable with medical billing and knowing what bullets you can hit and can't hit. Nowadays, it's simple. I mean, it's really easy. You're gonna bill the history of what you know about the patient. You're gonna bill your exam, which the exam is simple on telehealth for sleep. Remember, you don't have to necessarily make that decision on the first appointment. So if you're examining a patient for, can they hold onto an appliance in their mouth, have them open their mouth, right? I can at least make a comment that they have enough dentition to hold onto an appliance. They're in complete dangers. I can make that determination if they failed everything else and I'm comfortable with it. But so you can hit level three and level four exams on a telehealth easily now. So absolutely. And then bring them back in in a week to do their new, you know, to do their scans or impressions, do their perio chart, do their evaluation in person, the things you need to look at in person and bill an existing patient office visit. Now you're gonna hit your patient for two co-pays. So just be comfortable with that. But yeah, absolutely. Do I need to sign up with Medicare to provide services to these patients if I'm a fee-for-service office? Only if you want Medicare to pay for it. Technically speaking, as Dennis, we were at one point required to opt out of Medicare. That was delayed. I don't believe it was actually removed. I think it was delayed. So we'll have to see what the new administration does. But, and again, I would not take this advice for perfect. Verify this one. But I'm about 90% sure that Dennis do not have an opt-out requirement any longer with Medicare and that it was delayed. And in that case, because if that's true, again, don't hold me to the fire about it, but 90%, I'm pretty sure that's true. If we don't have the opt-out requirement anymore, then you can bill and not have to worry about individual contracts. Having said all of that, cover your bases, CYA, have an individual contract with the patient. And if you have an individual contract, basically you're gonna have the patient agree that they do not want Medicare to be billed and that they want to pay out of pocket for this, you're gonna be much safer. And again, go to Google, type in Medicare opt-out patient contract and you'll get a good example and modify it for yourself. Right. Do you have to get a pre-authorization? I'm assuming for every case. Asterisk, right, right. Nothing's absolute. If you are in network, most network contracts, because again, no absolutes, most network contracts do require and the burden of pre-authorization is on the provider. So in my practice, because we are in network with many insurances and we do gaps in most of the rest, as a matter of just policy, we pre-auth everything. Out of network, if you do not have to, I will leave that up to you. Your patients will be very unhappy with you if you did not get pre-auth, then they require it and you told them that insurance is gonna pay 2,000 of their appliance and it doesn't. Your patients may not be happy with you, but did you commit any illegal acts? I mean, consult with your lawyer for the real advice, but generally no, if you're out of network, it's optional. However, I would still say do it. Just from a practice management perspective, it's much easier to have a policy of, we pre-auth all sleep appliances rather than we pre-auth some, but not others depending on insurance. Sorry, one other, before I, one other caveat. Most states, again, I don't know about all, but I'm pretty sure all, but let's just say most states do have a law that states that insurance must allow in or out of network providers an ability to get the answer to pre-auth requirements and the ability to do a pre-auth regardless of in or out of network. Now it doesn't require they make that easy, but it does require that they have that opportunity on a daily eight to five business hour basis. They must have a phone number that you as a provider can call and ask those questions. So again, most states, if not all, require that.

E&M coding guidelines

CMS

evaluation and management coding

medical necessity

medical decision-making

time-based coding

face-to-face interaction

non-face-to-face activities