And now the fun part evaluation and management. This is your exam. How do you code your exam? I will tell you right now, if you're watching this in 2020, then these rules apply. If you're watching in 2021, hopefully, I can get in a time capsule here and time machine and give you an update later, because these are all changing January 1, 2021. Most likely. So these guidelines have been set since 1995. So 25 years of coding exams the exact same way. In 97, they adjusted them slightly, but the paradigm was the same. So realistically, it's 25 years of coding the same thing. So this is a huge update coming in 2021. And they've not released all the details yet. I'll go into what we know now. But medical necessity still applies to your exam. That is the overarching across all of insurance is medical necessity. What I mean by that is when we get into this, you're going to see levels of exams. The level of exam still needs to be necessary. So I can't build a level five exam, which is a highly complex exam for a hangnail. That makes no sense that there would be any reason to do that. So from an insurance perspective, they should absolutely deny that claim, or audit you and ask, okay, prove to me why a hangnail deserve that kind of exam. And again, this is our doctoring time. This is what makes us doctors. Making a sleep appliance is not hard, right? It is it itself is not what makes us doctors. What makes us doctors is evaluating the patient and treatment planning and managing their care. So that's what falls under this category. Last thing is, we can build this two different ways. We can build by the elements, meaning what is in your exam, or by the time, how long did your exam take? You decide what you want to do. So it's a choose your own adventure you pick, but know what the requirements are. That's what we're going to go into. And again, medical necessity applies. A 90 minute exam for a hangnail also doesn't make sense. So just because you spent my 90 minutes, they're not going to argue that they're going to say, well, you didn't need to. Types of E&Ms. I should apologize. I didn't give that definition earlier. Evaluation management, often shorthanded E&M, or think of it H&P, right? History and physicals, the first half of the E&M. So new patient exams, you're going to see those are coded 9920. And then the last digit is the specific, but 9920 means a new patient, a new outpatient patient. And then the 1, 2, 3, 4, 5 is the level. Now, new patient is applied at the tax ID level first, then the NPI level, and then lastly, the taxonomy. But you need all three to determine, is that patient new? So I shouldn't put them in that order. All three of those apply, let's say. And it is a three year history. So if I have not seen the patient for three years, brand new to me, either brand new, so I've never seen them, or it was three years ago was the last time I saw them, they're a new patient. Now, if the provider who sees the patient has a different taxonomy code or has a different specialty, then they're a new patient. So in other words, in my practice, my partner is board certified in dental sleep medicine, which does not have a taxonomy code, isn't recognized as a specialty. So right now it's a general dentist, right? Certainly he's board certified, an expert and specialist in his own right. But from an intern's perspective, they're going to look at that as a general dentist. He'll build a new patient exam. If the patient has a pain complaint, and he refers to me, I'm in the same tax ID, different NPI, same tax ID, but different taxonomy, new patient. So we can both build new patient exams. Conversely, though, patients that I saw, for example, before I became board certified, or before I became a diplomat, or fellow or facial pain, and before the taxonomy code existed, those patients, because I saw them still within the last three years, and it's the same NPI, they're not a new patient, even though I have a new taxonomy, and a new tax ID, same NPI. So it's a new patient or an established patient. So it can get a little tricky there. And that's kind of in the weeds that you may not need to worry about. But if, for example, you have an oral surgeon in your practice, you can both build new patients. Or if you're an oral surgeon, and general dentist is supporting it, you can both build new patients. Established patient, anyone who isn't new, a best way to look at that, if they don't fit the new new patient criteria, they are established. Same idea 992, but now one meaning established patient, and then still levels one through five. And then console, I should probably should have an asterisk here, I would just encourage you don't build a console. And there are a lot more specific requirements of console, and it's a lot pickier. You can do it, I would have, again, advise against it, unless you've really taken an extra course in this. But broadly speaking, you'll, you'll see that nine into four, meaning console. And what makes it a console versus a new patient or an established patient is that they were referred to you, and a report was issued. So you can't just take a consult and build a console, you must send a report back to the referring doctor. Now that's appropriate for a console. Anyway, most of us are doing that. But it's just, I would advise against it in general, there's no no insurance, it's gonna say, hey, you should have built a console, not a new patient. They won't complain, if you do it that way, they will complain the opposite, though, they may might say, okay, you should build a new patient, you build a console, the elements of the the EMM, again, you can build by element or by time. So we're going to go over elements right now. And then we'll go on time at the end. So history, this is part of what's changing in 2021. History is broken down into problem focused. These are the levels of history, if you will. Again, we have those levels of exam 12345. I'm going to give you a rubric here that's going to help you determine how they all fit. But each of our elements also has levels. So the level of history is is either problem focused, expanded problem focused, detailed or comprehensive exam, very similar problem focused, expanded problem focused, detailed or comprehensive medical decision making or complexity. This is probably the most important part of your exam, or your EMM, that you'll you'll be straightforward, low, moderate or high complexity. And then time is not really an element, but is somewhat now that time right now is focused on face to face time with the patient. How long were you in that room? Or how long were you on the telehealth? Doctor face to face? Not your assistant? Not how long were they in the exam room? Not how long did your assistant do the history, med history checks? How long did you spend with the patient? And then time is also going to look at how much what was that burden of of majority of the time dominated, in other words, greater than 50% counseling and coordination of care. So you're going to look at your time, how much did you spend examining the patient, but that does not count when you're looking at time for related to counseling, coordination of care. Again, I'll give you specifics as we put this all together. So breaking down history. These are your elements of the history. Again, it is stacked on top of each other, you're gonna love the changes coming in 2021. But history, chief complaint always required period period exclamation point, no asterisk always required. Chief complaint does not have to be anything extreme, though. My teeth hurt, great chief complaint. My physician sent me to you. I have sleep apnea. I'm here for follow up, whatever. Why are they there? Put it in quotes, make it clear. I like to put CC in my note or chief complaint, then in quotes to show this is what the patient said is a much better way to do that. Your HPI, your history of present illness can be broken down to the level of brief or extended. Well, break all these down, don't worry. Review of systems are broken down basically into these one system, two to nine systems or 10 plus system boxes. Pet peeve of mine, this is the review of systems, not review of symptoms, even though it will be a list of symptoms. But if you put in your note review of symptoms, it implies that you don't know what you're talking about. Gonna put red flags off to the coder at the insurance who might review your note on audit. So review of systems. And then lastly, we have past medical family and or social history. Detailed exam of this is one element. Comprehensive one element, meaning you look at their past medical or their past family or their past social history. Medical being what we would expect it to be. How many surgeries did you have? When have you had surgeries? What medical medications are you on? What conditions do you have? Family medical history. Again, same things we're used to. Social history. What's your occupation? Do you drink alcohol regularly? Caffeine use? Drug use? Social history, right? What other elements are there? So a detailed history is one element. And a comprehensive history is, again, this is where now this new versus established is going to be interesting. On a new patient, you need all three elements to call it a comprehensive PFSH. For an established patient, you only need two. So that's a lot of times if you go to your doctor, you'll see those are the updates they request. First time you have held all the paperwork. Second time you go in, any changes in your medical history? No. Any changes in your drug? Do you smoke still? Whatever. Update that. You've got your two elements. Again, breaking down the HPI a little bit more. So the HPI is broken down into these separate elements. So we have the location. And again, this is what the patient, this is the history of the present illness. What are you treating them for? Where? The location. So again, we're going to kind of do this mock sleep patient. Location. This is a hard one to hit. I'll be honest. Do they snore? Are we really going to list that they're snoring in their throat, their soft palate, their nose, or pharynx? I would, for something generalized like apnea and snoring, you're not going to list location. As far as these other elements, we can come up with them. You don't need to list them all. Don't feel like you need to. But this is, again, choose your own adventure. Pick and choose what you think is the most important to list out of here to hit your metrics. And if it's appropriate. So quality. What does their snoring sound like? Is it loud snoring? Is it quiet snoring? Do they snort? Those are all great quality examples. Severity. Mild, moderate, severe, OSA. Duration. How long? So duration is not how long do they snore that night. You know, they don't snore for eight hours. It's how long have they had this condition. So the duration of the condition. So they've snored for the last 10 years. They've had apnea for the last 10 years. What's the timing? All night long. At the start of the night. At the end of the night. Feel free to, again, timing is when are they experiencing this condition? Context is what's going on when they're experiencing this condition. So it could just be during sleep. But context is a little better when they're sleeping on their back. So their apnea is worsened on their back or their apnea is worsened during REM sleep. Modifying factors. What makes it better or worse? You don't necessarily need both. But modifying factors. Worse with alcohol use. Great modifying factor for apnea. And then what comes with it? Associated signs and symptoms. So here we might have excesses of daytime sleepiness, hypertension, depression, all wonderful associated signs and symptoms to list. Again, don't feel you need to list all of these in your HPI. But these pick and choose of what's appropriate. Review of systems. These are the systems. These are the systems that exist as far as Medicare is concerned in these 95-97 guidelines. And we're going to break these down a little bit in a minute. And then family and social history. Again, kind of like I said, you've got medical, diagnosis, surgical, all these things. Allergies. I apologize. I didn't list that in there. Allergies, both drug allergies, seasonal allergies, environmental allergies, all great things to list. You don't need to list every element of each of these either, though. So I don't want you to think you have to list every single one of these things on screen. I would encourage you to. I think it's appropriate to list all of these. It's not hard to get these. But you don't, for example, need to list their profession. I think it's good to have. And then our exam. So the exam is broken down into two different bullets. Part of our exam will have bullets underneath it. I'm going to show you all the bullets that are recognized right now. And then how we code the exam as far as points, if you will, which exam, was it problem focused or whatnot, is how many bullets you had. So you'll see problem focus is one bullet. Patient sneezes when, or that's not even a good one. It hurts when I pinch their cheek. If that's what you're examining is pain on their cheek, and if they can feel pain, great, there's your one bullet. You got a problem focused exam. Expanded problem focus is where a lot of times we're going to be. And what this is is six bullets and then detail. So we're oftentimes in sleep going to be bouncing between these two on our exam. And then last but not least is comprehensive. I'll be honest, if you do a comprehensive physical exam on sleep, interns almost every time will argue that was not medically necessary. And you'll see why as I get into this, because 18 bullets total at a minimum, and you need two bullets, at least in nine different systems. So it is an extensive exam. It's rare that on the pain side, when I'm treating an extremely extensive pain patient, that I do a comprehensive physical exam. It's even hard for a dentist to reach. But here are the slides. Here's our key codes, if you will, on the exam systems. Light blue, or I should say any shade of blue, whether it's the greenish blue or the light blue, means it's something that's well within our scope and appropriate for us to report on. Green means what we will likely report on, okay, on a sleep patient or average patient. But I'm listing them all because if you're examining a pain patient, which is very common in sleep, you might go down these routes. And so I want you to understand that it's fine for you to build this. This is within our scope if you're trained in it, which most of us were in dental school for a lot of these. So constitutional three vital signs, any three you pick and choose. It doesn't have to be a specific three, but it has to be three separate ones. So blood pressure, respirations per minute, pulse, O2 sats, all great things to list. You should be specific if you can. So in other words, you shouldn't say, you know, 120 over 80, it'd be nice to add the right wrist seated or whatnot, for how you're seeing them, but they aren't going to interpret it on that. If you list 120 over 80, you'll be covered. You say their pulse was 60, you'll be fine. Yes, 60 regular, you know, a regular pulse at 60 beats per minute is a better descriptor. It's going to make you look more appropriate to your physician colleagues, honestly. But from a coding perspective, you just need to write the basic vitals. And then general appearance of patient and that's general patient appears well groomed, you know, patient is in limited distress, you know, if they're if they're cringing patients in no distress, you know, a general description of the patient. Your eyes, comment on the conjunctiva and lids, certainly something we can do. Again, not the most common thing we're going to do, but it's not wrong, especially if you're looking at a patient with with concomitant allergies, and we're going to try and highlight that in our kind of assessment portion, then hey, it's perfectly fine to comment on that. Pupils and irises, again, it may be commented on, it's rare that I will other than looking at do, you know, are the pupils accommodating correctly? And if I'm doing a light test, and are they reacting to light? Optic discs? I mean, I briefly remember from dental school, certainly in pain residency, we focused on this a little bit more when you're looking at the disc reflex. I don't think many of us have the equipment to evaluate those. But if you do, great. Is it appropriate for sleep? Not sure. Ear, nose, mouth and throat. I want you to notice one thing. This is a system ear, mouth, ear, nose, mouth, and throat itself is one of those systems. When I was saying to get a comprehensive exam, you need two bullets from nine systems. They might as well just said everything that we look at, you know, 90% of what we look at is going to fall under here. So if we're looking for a comprehensive exam, you only get two points from here. So that's why it's very hard for us to get to a comprehensive exam. But if you're using a detailed exam, remember, we didn't need as many, we only needed basically a smorgasbord of bullet points on that one. And so those can all come from one area. Only comprehensive exam requires two bullets from nine systems. The rest is just total number of bullets. So in the ear, nose, mouth and throat category, you'll often see this written ENMT, ENMT. You got your ears, nose, external ears and nose. So, you know, look at the external auditory meatus, or there's earwax all over the place, or, you know, their nose is, they have, you know, a crusting on the edge of their nose. General look at that. Again, extra auditory canals and tympanic membrane. For a TMD patient, this is something I do regularly. I'm going to look at their tympanic membrane. Do I see swelling there? Do I see inflammation? I'm not going to diagnose the problem, but that doesn't mean I can't comment on it. And so I may comment here, get a nasal mucosa, septum, turbinates, certainly something we'll look at in the sleep realm and on some patients. Lips, teeth and gums, right? This is, this is our wheelhouse. Again, I want to, once you know all of dentistry, one bullet point. So you can comment on how many fraction lesions, you can comment on attrition, you can comment on torii, you can comment on, you know, the lips are cracked, all of that, you can list 30 different things, you get one bullet point. So that's why I want you to see the other bullets, because if you're looking at your exam and you go, well, I looked at their teeth, I looked at their periodontal status, I looked at this, that's one point. So be careful there. Now we're all fairing to where we're going to get our other point usually on a sleep, right? Because we're going to comment oftentimes male and potty score, we're going to comment on tonsils, those are going to fall under there. But just, just be aware, you need more than just commenting on what their teeth look like and what their mouth, if you're just going to limit your exam to the oral cavity, the oral pharynx, you're going to get two bullets. Let's say you added vital signs and the general appearance, you've got four bullets. So you're, you know, focused exam still, but not detailed by any means. Neck. So general appearance of the neck, if there's any enlargements, is it symmetrical, any problems there? And then thyroid, certainly something we can very well evaluate. Respiratory, if you're going to try and hunt for a bullet somewhere and you want to comment on their effort, that's appropriate, especially in an apnea patient. If you're concerned for potentially COPD involvement and you want to say that, hey, I'm going to send them to a pulmonologist to rule this out, you can comment on effort. Percussion, palpation, auscultation. Within the scope, generally, I wouldn't suggest adding it in there. You're going to have boards that disagree with that. I think it's fine if we listen to lungs. It's certainly something I was trained on. And I think any oral surgeon on the planet is going to agree it's appropriate. But just stay away from it on your exams. You're going to have insurances arguing that wasn't necessary, that the dentist was arguing that wasn't necessary, that the dentist evaluate that. Cardiovascular, again, these are the bullets that exist. Palpation of the heart, or I'm sorry, palpation of the heart, auscultation or listening to the heart, edema and or varicocities. These are looking full body edema or varicocities, not necessarily chest. Again, the edema varicocities, we may evaluate on a pain patient if I'm concerned about like a connective tissue or autoimmune disorder, but these are going to be reaching. Chest, listen, inspection of breasts and the palpation of the breast and excellae. I'm not going to go down those routes. I don't think that's appropriate, medically necessary for us in any way. GI, looking at massive tenderness in the abdomen, liver exam, hernias. Again, I don't think we're doing any rectal exams on our patient or doing a call test on them. So, GI is going to be pretty much useless for us. Genital urinary, again, I'd see no way this is involved in any patient that we're touching. Lymph, absolutely, this is a great spot for us to look. Neck, other is not well defined, and in my mind, these are the defined areas. Neck, excellae and groin. Neck, easy. If I'm looking at, you know, lymph nodes, pre-auricular, post-auricular lymph nodes, that's not in the neck. So, to me, that falls under other. So, you can get two bullets under there, in other words. Musculoskeletal, average sleep patient, probably not as important to look at digits and nails, but if I'm examining a patient or we're examining a patient, I mean, again, sleep world, we're going to involve pain. You can't separate these two. So, if you're concerned for arthritis, I would highly suggest you'd be looking at digits, right? Are we looking for rheumatoid arthritis? Do they have swelling, you know, in their digits or not? So, that's well within our scope. While we might be limited to treatment in the oral cavity, that doesn't mean we can't look at a patient, right? Looking for clubbing on their fingernails, all well within the scope of dentistry. Now, we aren't going to treat it, but it might lead us to suspect different conditions. And then muscles and joints in one area is one bullet. If you want to get more technical, you can get different areas and whatnot. We aren't going to be examining muscles in the leg, for example. So, muscles and joint in the head needs to be a comprehensive evaluation of that system. So, you can't palpate one masseter and say, okay, I did muscles and joints. You didn't. You got to look at all the masseters or all the masters, both masseters, both temporalis muscles, and and pterygoids generally. Those are harder to argue about palpation on, and no one's going to argue with you if you didn't palpate. And then the joint as well has to be examined. It can't just be muscles, and it can't just be joint. Has to be the musculoskeletal system. Rounding it out here. Skin. General inspection of palpation. Again, easy for us to look at. You know, is the patient jaundiced? You know, is there something going on there? Is their skin, you know, sloughing in areas? Perfectly fine for us to evaluate. Neuro exam. Cranial nerve exam, in my opinion, should be something that we do regularly. I certainly forgot it from dental school, picked it back up in residency and now it's general, every patient's gonna get one. Takes a couple minutes and you'll be amazed how many times you find a deficit. Just like we're screening for blood pressure, we should be screening for cranial nerve deficits. Sensation, if I touch you with a Q-tip on the soft end, is it soft? If I touch you Q-tip on the hard end, does it feel hard or sharp? If one of those is messed up, comment. If they're correct, comment. So an exam does not need to be a negative or a problem. You can also have exam findings that are normal and that should be noted. And lastly, psychological. I don't want you to think this is a psych eval of the patient. Does their judgment seem intact? You know, judgment insight, do they seem intact? Are they oriented? Does the patient know where they are? Do they know what time it is? Do they know who they are? Is their memory generally good and is their mood affect appropriate? You know, are they coming in for their sleep delivery appliance giggling and just absolutely giggling left and right? You know, we might have a little affect issue there. Again, I wouldn't suggest you comment necessarily on that without a psyche eval at that point when you're gonna try and say it's a deficit. But if they come in and generally their mood and affect is appropriate for the time, place and circumstance, comment on it. And then this is the, I would say, what determines your coding the most and that's medical decision-making. So while the history of the patient and their exam are elements of our coding, this is the biggest limiting factor to what you can do. And this is what's gonna be that medical necessity argument too. Is the medical decision-making that we have to go through difficult or is it not? So again, using that hangnail example, medical decision-making on a hangnail is pretty easy. So we'll break that down. Let's look at a hangnail really quickly and then we'll look at a sleep. So problems, it's a self-limited problem and it's minor. So hangnail is gonna go away, right? It's generally speaking self-limited. So you'll get one point and then I'll show you the point breakdowns in a second. And then the next thing is kind of, if let's say hangnail is not perfect for this example, but let's say it's a new patient, but there's no workup necessary, that honestly probably are sleep patients. We don't have to do additional workup most of the time. You're gonna get three points for that problem. So definitely more, and it's not a self-limited problem, but if it's something simple, that's gonna go away, really doesn't matter if it's a new problem. For the most part, it's gonna be one point. Data, so what data are we using? Again, on my hangnail example, we're not gonna be doing testing. We're not gonna be talking with another physician or there's no need to. We're not gonna be viewing images. We're not gonna get old records. So we're not gonna get points on any of the data. So that patient, we have one, so our one medical decision-making point. Now let's look at our sleep patients. New sleep patient, let's do a simple one. They come in and they have sleep apnea, but also occasional soreness in their jaw. So we have two new problems, and new is new to us. So we have two new problems. One is the apnea. There's no workup necessary for that. Realistically, they're gonna come with their workup. Let's assume that we're following a good model and it's physicians referring to us. And then the second one is the muscle pain. I would argue most of the time, but they're not gonna need a workup on that. Usually that's gonna be, our exam is gonna handle that. Now, if you're suspicious for something autoimmune and you're gonna send for lab testing, okay, maybe we do need an additional workup. And you'll notice that with the new problems with no workup, we can only use one problem from there. So in this case, in that example of the patient with apnea, but with slight muscle soreness, we're only gonna get three problem points. So even though there's a second new problem, we don't get any points for it, because again, we're saying there's no workup. If there was workup needed, now we'd add both together, we get seven points. As far as data, again, look at our sleep patient. Are we reviewing or ordering testing? Not just ordering, are we reviewing? Absolutely we are. So reviewing a sleep study is perfectly within our scope. Ordering is the questionable side, but reviewing it, not reading it, reviewing it is absolutely something we should be doing with our patients. Now, did we call, if there's a question on it, okay, that's weird. Why was their, their AHI was one, but their average, their average O2 sat was 70. So are we gonna call the sleep physician and say, hey, what's going on here? Sure, then we'll get a point for that. Patient comes in, joint condition, and you're looking at images another provider took. That's two points. So it, the same side of that is this is in the medical world this is assuming that a radiologist read your study. So if you, as the dentist, order the image and read and interpret it, you get one point for ordering. And that's not reviewing at that point. You are independently reviewing of the image. So it's not just a simple review of it. You're actually looking at it and writing your own review and evaluation of it. So you'll get multiple points there. And then are you reviewing in some summarizing other and old records? Generally, no. So what that really means is if you, let's say you have this extensive patient history of your patient, and you're trying to summarize it all together in your summary to make this clearer, or you were asked to write up this review for the patient, or you're reviewing multiple providers notes and putting them together. But it's a very rare occurrence that we're gonna actually get points for that. So I wouldn't count on those. The last part of medical decision-making, and again, we're gonna tie this all together in a second, is the risk level. What is the risk of your procedure? And what is the risk of the diagnosis? So in this case, let's look at the hangnail, the risk of the diagnosis, it's a self-limiting problem. So it's gonna go away. If you do nothing, it'll go away, right? Almost no risk. And your treatment, basically nothing, maybe a Band-Aid. So rest, wait, that's gonna be your minimal straightforward risk. Low level risk, you're gonna see some, this was like having dirty, when I learned this thing, this was like having the dirty tricks of medicine aired for me. Pulling the wool off my eyes to see, okay, that's why physicians do what they do. So if you do over-the-counter meds or refer for physical therapy, that's a low-risk treatment. And if the morbidity risk of the condition is pretty low without treatment, again, it's gonna be on the low. Now, if I treat with prescription medication, now it's a moderate risk. So if I tell a patient to take four Motrin every three times a day, right? 800 milligrams of Motrin three times a day, that's OTC med, low risk. If I tell them I'm going to prescribe you 800 milligrams of Motrin to take 300 times a day, now it's a moderate risk. This is why you never leave a physician without a prescription for the most part. This is what gets them up to the next level of exam. And this is very similar for us in sleep too. I mean, we're gonna look and are there risks associated with our treatment? Yes. Are there risks of not treating the condition? Absolutely. So a lot of times we can be justified saying we're at a moderate risk. High risk, and remember, these are relative risks to other medical conditions. So while we may view it and go, okay, obstructive sleep apnea, we absolutely need to treat that. Severe apnea can take 20 years off your life. That is a huge mortality risk. Insurances are not gonna agree with that because they're comparing it to things like cancer. They're comparing it to things that require major surgeries, gunshot wounds, right? And so remember it's a relative risk still. So in the high category, we will almost never get to high. The most, I'll be honest, just personally where I get, the only times I get high into high risk is on my patients where I'm gonna prescribe something like carbamazepine where I need quarterly blood testing to make sure their liver function is still adequate. So in those patients, when you need to do required monitoring, high risk. But usually for what we're treating sleep, we're gonna be low to moderate. All right, so let's put all of these slides together. Feel free, you're gonna wanna go back and forth. I promise you, cause I know I have to, but the lowest two out of three is what determines our medical decision or medical complexity. So again, if you look at our problem points where we had different numbers, our data points where we had different numbers and that risk, whatever's lowest is automatically the floor or I should say, I'm sorry, the ceiling, as long as you've got two or three that are that low. So if we're at a low risk, then pretty much that's the highest we can get to. So if our data points, don't shoot for four data points in your note, don't waste your time writing up four data points. If your risk is low, just get two data points and you're done or just get something for two problem points and you're done. I'm not saying you don't do other things, but I'm saying don't spend time writing your note, covering all of these extra things when it's not gonna get you anywhere more on your exam. So realistically that risk is almost always the limiting factor and most insurances have a policy that states the risk level determines the maximum of your medical decision-making. So you might say lowest two out of three, but asterisk risk needs to be one of those three that you count or one of those two that you count. So that's how I start every single exam is I'm gonna look at what is the risk level of the treatment where I'm gonna get to most likely and that's gonna determine then pretty much the rest of my exam. So here's our average sleep patient, right? New problem, no workup. So three points there. So you'll see I highlighted the three problem points. Now we reviewed the study, we ordered radiographs, we summarized their records. Again, I'm giving myself a little extra credit here on the summarizing. That's if we're gonna write it down and we're gonna summarize, okay, physician said X, Y, and Z. Let's say we're doing that. A lot of our softwares have us do that. So it's there. Insurance is gonna be iffy on it, but let's just count it because I wanted to prove a point on this slide. And the morbidity risk without treatment is low to moderate. So we're gonna kind of be in that low to moderate zone as far as risk. So let's, again, I'm overachieving on data points. So I got four data points. It doesn't matter because my risk was moderate. My problem points were at the three level. You'll see on that little chart, it puts me at a moderate level of decision-making. Again, decision-making is one of the three elements to your overall exam. Now the established patient, the average established sleep patient, we've got their OSA, we're gonna comment. Is it getting better, worse, stable? So let's say we're doing our job great, it's stable, but they're snoring too. So we've got two things we're looking at. We've got their apnea, which is still there, right? We're managing their apnea. We didn't cure it, so we still code for it. And they still have snoring. Apnea does not mean snoring. So you can certainly manage the apnea and still have snoring. So we've got two points. Data points, I didn't have anything to review. So either a zero if I have nothing, or let's say they had efficacy study and we reviewed it. So we've got one point there. And then our risk though is still the same because it's still the OSA that's determining the risk. So we still need to treat this patient. They're still low to moderate. So in this patient, we're at a moderate, or I'm sorry, low level of medical decision-making. So here's the chart. Here's how we put it all together. If you wanna print this off, go back and restart the other section, feel free to, where we went through each of these. But I'll be honest, in my office, I've got like five different posters of all of this trying to keep it straight. It's incredibly confusing and you only need to worry about till 2021, hopefully. So let's put it together again. I highlighted the medical decision-making process is the key. It is what is gonna determine the medical need for your exam level. So if you don't have a medical decision-making process of high risk or high level, don't waste your time on a comprehensive exam and fighting for those extra bullets unless it's necessary for your patient to manage their care. I'm not saying again, I'm not saying don't look at them. I'm just saying, don't waste your time commenting on it in your exam because it's not gonna get you there coding. Same thing on the history. If we're at a low to moderate risk, don't waste your time getting every single history element. Just do what you need to do. Maximize your time. The first kind of section of that chart are gonna be your new patient exams. Again, the 9920 is new patient, 9921 is established. You're gonna see on a new patient, you need all three areas. You can only take the lowest of the three areas. So in other words, if you have low medical decision-making, but high complexities, you're only gonna get a 203 because your lowest level was that medical decision-making. On an established patient, you only need two out of the three elements, first of all. And then the other thing is that there are no requirements for level one new patient or established patient, I'm sorry. In other words, don't ever bill it. I would argue that it is definitely fraudulent to bill a level one. Those are designed for nurse visits. So if you were billing a 99211 and I was the insurance company, I would audit you. At the same token, don't bill a level five for apnea. It is not appropriate ever for apnea alone. You need additional codes to support that. It needs to be reasonable what you're billing. Most apnea patients are gonna be around 99203 for new patient and 99212 or 99213 for established if they're just simple, straightforward apnea. You'll see I listed the times there, but I wanna split those out here. Remember, you can bill by element, which you just saw was incredibly complex, or you can bill by time. When you're looking at billing by time, there are two things. You need to look at only time face-to-face with the doctor. That's requirement one. Requirement two is 50% of the time spent needs to be counseling coordination of care. Think of it this way. If you spend 90 minutes with your patient and 20 minutes on coordination of care, figure that's a 40 minute exam, right? Because the 20 minutes, half of it has to be the coordination of care. 20 leads us to a 40 minute exam. Even though you spent 90 minutes with a patient, that shortest requirement that was fulfilled was the 20 minutes that was spent counseling. Counseling coordination of care, not something we really look at in dentistry or think about too much as to what are we doing where, but the big idea here is if you're talking to the patient about their condition, what's going on, relating it to them, that's counseling. Not history-taking. History-taking is not counseling. Counseling is when you're talking to them about here's how your appliance is gonna work. Here's what we're going to do. We're gonna do these things. Here are the risks, the benefits, all of, again, kind of this doctoring that we do. That's counseling. Or saying we're gonna get you back with your sleep physician, or we need to call the sleep physician to schedule. That's all coordination of care as long as you're the one doing it. In your note, here are the key elements in the bottom three here. Your note has to include the start and stop time if you wanna be very safe on audit. Include both. If you say 60 minutes, you might get away, but include both, start and stop. You need to also say in general what you're doing, so generalized specifics. What I mean by that is don't just say I spent 60 minutes, 30 minutes of which, or a majority of which was spent counseling coordination of care, period. What was the medical need for that counseling coordination of care? I spent 60 minutes face-to-face with the patient with at least 51%, or the majority of the time spent related to counseling coordination of care. Specifically, we discussed the risk benefits and alternatives to oral appliance therapy, reviewed their sleep study, and recommended follow-up with their physician. Okay, now we were specific in a general way. And the last, again, medical necessity does apply. Seeing a patient and billing a level one, or a level, I'm sorry, a level five exam by time, so implying you spent 60 minutes with the patient, 30 minutes of which you spent coordinating their care, or counseling, for a hangnail makes no sense. For sleep, it might. So again, I would be careful there, though, because most likely, insurance is gonna kick back and audit. You might prevail, but I just wouldn't do it. I would stick with the two, level two or level four, I'm sorry, level three or level four for a new patient. Four is a reach. Three is probably more appropriate. And again, on follow-up right around there, you'll see the times. Those are the time sets. So those are the written down what to do. I have this chart literally on my wall, because I bill by time most of the time on sleep. Paying, I usually bill on elements, because it's a little easier to hit those. Last slide, what's coming. So we spent the last hour and a half, hour and 50 minutes going over what it is now, which is important until the end of the year. This will all change in 2021, most likely. So what happened is Medicare submitted a proposal in 2019, I'm sorry, 2018, saying that, you know what? We're tired of all these different levels of exams. Just like we got rid of consults by saying, hey, we're just gonna pay you the same, whether you do a consult or not. Now we're gonna get rid of the levels. And we're gonna force that by saying, exams levels two through four, same price. You know, we're just gonna pay you the same no matter what. And if you do level five, yeah, you'll get some brownie points and we'll pay a little more. So that was basically what Medicare said. Obviously, everyone in the physician community had quite the objection to that. The AMA, let's say politely got off their bottom and said, okay, we're gonna just change CPT. We're gonna change the codes themselves because of course that's where Medicare sets their guidelines is what the code describes. So CPT committee got together in a year and came up with new guidelines and published them. Lots of letters were written to Medicare. And Medicare said, okay, we'll relook at that. And then they said, fine, we will take the, we won't combine the fees. They determined this in 2019 and Medicare writes the standards for the following year. So in 2019, when they're writing the 2020 rules, they said, okay, we aren't going to combine the fees like we said we were. And we're not going to, or we're going to accept CPT changes that the AMA has done, but we don't have enough time to incorporate those yet. So Medicare is currently writing the standards for what they're gonna require. Almost universally, insurances are gonna follow, commercial insurance are gonna follow Medicare guidelines. So just know that when Medicare changes the guideline, usually insurances follow suit, but not always. So you certainly, insurance, you gotta look up what their policies are, but they're gonna generally follow suit. The standards are not published yet. That's as of July 23rd. I checked, realistically, I actually checked this morning and they weren't published, but I didn't do a thorough check this morning. So the last thorough check where I went to federalregister.gov to look them up was July 23rd. So no changes yet. Now we're recording on the 31st of July. So by the time this comes out, hopefully, we'll have some changes and we'll have an addendum already posted and I'll have hopped in my time capsule. But here are the general broad ideas of what is coming. How Medicare interprets these is what's up for question, but here's what the CPT committee said. History requirements are gone. They're not saying don't take a history, still take a history, but the history no longer determines your level of exam. Your physical exam, gone. Again, still take it, still do it, still record it. But if you only do two bullet points, but it's medically appropriate to build a higher level, you as the doctor get to decide what level of exam you need. So it's a big shift where it was, fit your exam to your patient's decision-making process. Now it's, listen, let's just let medical decision-making determine everything. And then you, doctor with a degree and a license, determine what you need to examine and what's appropriate to examine. So this is fantastic for us because we were already kind of struggling because all of the mouth is included in one bullet. So this is fantastic. We can do our exams however is appropriate for the patient and the medical decision-making will determine everything. Now, the other big change is time will include all time of the appointment and all time with your staff and all time at your office. So if you have your patient go from one room to another, or you do your, for example, impressions or scans first, that time is all included in the time value. So, and you aren't limited to just 50% of coordination and counseling. So if they spend 90 minutes with you, you might be able to build 90 minutes if it's medically necessary. I will argue this, this is gonna be where the details of Medicare's determination is gonna be key. So I wouldn't just jump ahead there. The other thing that will change is the time. So those times on the other screen were related to times on the current coding standards. These new times are gonna be a little different, similar, and they're gonna be ranges. I should mention that, yeah, I apologize. When I'm looking at the times, those were the minimums, if you will. So if you spend 15 minutes with a patient that was one time bracket, the next was 30. So if you spend 29 minutes with that patient, the question is, where does that fall? And generally they're gonna say it falls to the closer of those two, but I always build down to be safe. In the new system, it's gonna say 20 to 29 minutes is this level, 30 to 39, or 30 to 34. It's gonna clarify that a little better. But again, medical necessity is king. It determines everything. So there will still be issues where we run into, okay, yeah, you might've spent 90 minutes with a patient, but that's not a level five for apnea. There's no reason to, and I agree with that again. I think that's appropriate. But the big thing is our coding and our note requirements are gonna get drastically easier come January 1, 2021, assuming Medicare published the standards. They're a month late already publishing them. I'm one to always get concerned that late means unfortunate or something we aren't gonna want, and they had to clarify why, but we'll see. Again, hopefully by the time this comes out, I've already gotten a time capsule and we've fixed that. Lastly, really quickly, just a nice video of my family. We enjoy, we're in Richmond, Virginia. We enjoy going out and trying to hike as much as we can. Nothing crazy, but just out in the woods, we've got a beautiful son who sadly got cut off in this photo, but he is four now and my lovely wife behind him and me. And that is the sum total of the Vaughn plan in Richmond, Virginia. And thank you all for your time.

evaluation and management coding guidelines

2021 coding guideline changes

medical necessity in coding exams

coding exams based on elements

coding exams based on time spent

different requirements for new and established patient exams

levels of exams and coding requirements

changes in coding guidelines in 2021