Hey, everybody. I am Michael Johnson. I'm here to present some reimbursement basics for the Neurosurgical APP. Thanks a lot for having me. Thanks to Laura and the course directors and the AANS education staff for having us back again this year. So I'm going to get started here. Introduction, I'm Mike Johnson. I've been in neurosurgery for about 12 years. I am full-time faculty at the GWPA program and I'm an assistant professor there and I hold a secondary appointment as assistant professor in the department of neurosurgery. I have no financial relevant relationships to disclose and I am an employee of the George Washington University and I don't speak for them in the views and opinions in this presentation. We're going to shut off the camera. No reason to look at me this whole time. So jumping into some content here, some more disclosures. All content references are for educational purposes only. I am not here giving you coding, medical, legal, clinical advice in any way, shape, or form. Every effort has been made by me to ensure the information I give you is up-to-date and accurate. But at the end of the day, appropriate claim submission is the responsibility of the billing provider. I am not a coder. This is not coding advice. Medicare commercial policies change regularly. You should be talking to your coders to make sure that you're up to date with the newest information. This is just here to give you some context and you should know that the American Medical Association has copyright and trademark of the CPT, which we were talking about quite a bit today. Learning objectives for us today at the end of this session. I hope you, the advanced neurosurgical, excuse me, the neurosurgical advanced practice provider should be to demonstrate appropriate code selection inpatient outpatient E&M codes. We are going to talk about the role of the APP in the global surgery package. And I hope, my biggest hope, is that you can identify opportunities to improve your value to your organization. All right. PAs and NPs, we are the APPs of the neurosurgery world here for the AANS. We are classified by Medicare as APPs. Nearly all of Medicare's coverage reimbursement policies are the same for both professions. If you want some more information on any of this stuff, we have terrific organizations that generally work well together on issues related to reimbursement and Medicare issues. Please get involved with your organizations and please seek these resources for further information. But for all intents and purposes, we are in the same boat. And I really like this thing, that boat screaming, because that's sometimes how it feels. So CPT, what is it? It's the current procedural terminology. And this is a, this is all our codes that we use to describe what we did. It was first published by the American Medical Association in 1966. And they used it for many years. And then CMS adopted it in 1983 as kind of the official way to seek reimbursement from CMS. This relationship has developed while the main AMA has maintained control over it and the content. They made the content and the releases of new updates that they make each October. There's three bodies of codes. Category one is really the only ones that we needed to concern ourselves with. This is just kind of FYI. It's most of the codes that which are commonly used by APPs. There are such things as category two supplemental tracking codes. Say if we want to put it together and do want to do a new surgery that doesn't have a list of code, they may give us a category two, a tracking code. And then there were some category three codes out there during COVID when we were doing kind of emergency and emerging stuff. But by and large, category one is where we live. The category one codes are all these five-digit codes. And these are the ones that primarily relate to neurosurgery. So anywhere from zero to 99,000 is where the codes are. So specifically, the ones are we going to talk about today are the evaluation and management codes, the 99 codes. You may also use some codes that have to do with anesthesia. The codes below 10,000 codes below 10,000, below 2000, I guess. Surgery has the largest body there in between 10,000 and 70,000. And they're further broken down. So to the right are also surgery. So the general surgeries are the 10,000. The musculoskeletal surgeries are the 20,000. And surgery of the nervous systems are the 61 to 65,000. So you'll notice that most of what we do in neurosurgery is either 20,000 or 60,000. Interestingly, if you're doing bone work fusion screws, that's going to end up in the 20,000, the MSK body of codes. And if you're doing things to decompress nerves, or you're doing things specifically on nerves, you're going to be in the 6,000. So if you are doing a LAMY with a fusion, your LAMY is going to be the decompression of the nerves. And then your fusion is going to be a 60,000 code. And then your fusion is going to be in the 20,000. And that's why that is that way. If you're doing some shunts or anything like that, you may end up in the 10,000 as well. But by and large, neurosurgery codes are in these two bodies on the right. Radiology, some people are doing radiology stuff, or angiograms, or reading their own films. And there's a bunch of other stuff there too. But this is primarily where we live. Okay, so that's the background on CPT. Why is it important to us? Because this is our value. This is how we get paid. Every CPT code has a value. And that's called the relative value unit. Okay, so every CPT code is assigned a value. How much is it worth? Every CPT code has three components. There's a work component. And that is the most important to us as providers. That is the value of our time and the physician time. It has to do with our training and our experience and our time. And that's generally the largest percentage of the code. 40, 50, even 60% of that goes into the work RVU. That's why most contracts are laid out by the amount of work RVU and code. Medicare also knows it costs some money to maintain a practice. You got to pay the rent, you got to pay the staff, you got to keep the lights on, you got to pay for the EMR. So they give us some money for that. Usually 40, 50% of the total RVU goes to practice expense as well. Medicare also knows that there's some costs associated with risk and malpractice insurance premiums. And so they give us some money for that. Usually between five and 10% of the total RVU goes to malpractice. So when you sum all those up, you get the total RVU. But the one you'll see that providers care the most about is the work RVU. So as an example, you see a new patient and an outpatient visit. We're going to go through all of this here shortly. You would bill a 99203 if it was low or medium complexity. And so that code, you look that up, has a total value of 3.35. And the breakdown of it is the work RVU is 1.6, the practice expense is also 1.6, and the malpractice it's pretty low. It's closer to 5% for this code, it's 0.16. So that is how the code is breaking down. That's how it's valued. And if that procedure was formed facility, so in a facility, say your hospital system owned the office that you were working, which happens a lot in neurosurgery and big academic practices, there would be a decrease in the practice expense RVU because the facility is also going to submit its own charge. But it means our total RVU is a little lower, but the work RVU doesn't change. The work that the provider puts into it doesn't change. The important question is, how do we turn that in the dollars? First thing you have to do is think about where the service takes place. And Medicare realizes that it's a little more expensive to take care of patients in DC, where I live and practice, than it is maybe in Oklahoma, not to pick on any of my colleagues from Oklahoma, it's just a lower cost of doing business there. So what they have is something called a geographic price cost index, by which we multiply the individual components of the RVU by a multiplier to give us an adjusted RVU based on where we are. And some places have higher malpractice, but lower physician payment. So these vary per code. So the gypsy for DC and all of these different things is there. So the work RVU would get multiplied by 1.057. The practice expense, it's very expensive to work here in DC. So the practice expense RVU would get multiplied by 1.192. And then the malpractice, there's a little bit of higher malpractice premiums, but you go to different places that maybe have different rules about court reform and medical malpractice limits. And the malpractice rates might be different. So the reimbursement, excuse me, the reimbursement gypsy on that might be different as well. So if you multiply all those specific components, what we'll get for that here is 3.72, where the unadjusted on the previous page was 3.35. So we're getting paid a little bit more for that code here in DC, because the cost of doing business is much higher. And how do we turn it into dollars? You've probably heard of Medicare's conversion factor, which as of right now, today, I think I've got changed April 1st of this year, we got a little bit of a bump, which means basically it just didn't go down, which it generally goes down a little bit each year. Right now it's $33.28 per RVU. That's what it's worth to Medicare. So we would multiply that 3.72, the total adjusted by $33.28. And if a physician did this, they would expect to get paid $125.46 for this service. It was performed in an office in DC. And so there's a lot of variability. We could be in a facility, this could be performed by an APP, and we're going to talk about some of these distinct things. But in general, that is how this works. That's how we turn CPTs into dollars. APP reimbursement, it's quite similar, but there are some differences. So we're going to talk today primarily about CMS and what CMS is the Center for Medicare and Medicaid Studies. They kind of lead the way and a lot of private carriers follow. Medicare covers care provided by APPs, nurse practitioners, and physician assistants in all practice settings at a uniform rate of 85% of the physician fee schedule. Now, what we just talked about on the previous slide was what the physician would get. So if we did that, if an APP billed that, they would expect to get 85% of that. APPs are to bill to Medicare at full charge under their NPI. And there are a few special cases that exist. We're going to talk about them. Medicare is no longer in the level of supervision or co-signing business anymore. They leave it to the states. As long as your licenses do so, Medicare doesn't have an opinion on your specific level of supervision or collaboration. It is left to the states. There's a little bit of variability in the way Medicaid covers and credentials. APPs varies by state. I won't talk about it today. You should know the rules where you work and practice. Commercial health insurances, all major health insurances, all of them, cover the services of APPs in some way or another. But I would say there's a wide variety and variation in how we are credentialed, how claims are submitted, how they're supposed to be submitted, and how they get paid. So when you're looking at a contract, the things you should know is, what rate are we being reimbursed? 85% is what Medicare, so is it any different there? How do claims get submitted? Do they get submitted under the APP or do they get submitted under the position with a modifier? Do they cover the same scope or practice? Medicare doesn't have an opinion. As long as it's something that you are credentialed and legally allowed to do, Medicare does not have an opinion here. Some insurances do. They just won't pay for an APP to do certain things. Will they pay for you to be an assistant at surgery? Just because Medicare does, doesn't mean a private insurance will. Do they support incident two and split shared billing, which we're going to talk about here in a minute? And do they pay, if you're operating at a surgery center, do they pay for the coverage of an APP at a surgery center? Not all do. Okay. We're going to jump right into evaluation and management. So what is evaluation management? It is non-procedural medical services provided to a beneficiary, right? So it's not a procedure. This is different. This is E&M, seeing the patient, doing physical, making a plan, doing patient care, not procedural. So these codes all start with 992, followed by two variables. What those variables What those variables describe to Medicare is if this is a new or established patient, where the service took place. Did it take place in the hospital or did it take place in an outpatient setting or a nursing facility? And it also includes the complexity of the care, all three things that those two variables. So the codes that we're going to talk about today are inpatient and outpatient. So the inpatient codes are the 9922 codes and 9923 codes, and then outpatient 9920 and 9921. Pretty simple. You remember four families of codes, you can get to most of where you need to be. These are the ones we're going to talk about today. So the first thing we're going to do is talk about outpatient evaluation and management. For those who have been in practice for a little while, these should sound fairly familiar. These are professional services provided in an outpatient setting. And for those who have been in practice for a minute, remember how this used to be before 2021 when these codes were updated. And this has been a big improvement. We are no longer counting components of HPI or review a system or the amount of past family, medical and social history that is gone. We are no longer counting the number of body systems that we're touching. We're no longer giving ourselves credit for doing components of physical exams or counting the 95 versus 97 version. Those days are gone. For those of you who started practice since 2021, consider yourselves lucky from a coding perspective. Code assignment is now based only on either the complexity of your medical decision making or the total time you spend on the day. So this still very much requires a medically appropriate history and physical exam, but neither contributes specifically to the code selection. I say medically appropriate. That's what CPT says. And also that is what you will want to have in case you're ever trying to get any procedure surgery or radiology prior authorized. They are still going to look for the appropriate level of surgery to describe the complexity of this complaint. So if you are talking about new patients in an outpatient center, that's the 9920s. It could be 22, 202, 203, 204, 205. We don't, the 201 code is gone. If it's an established patient, 211, although that code is very sparsely used, it actually doesn't even require the presence of provider. So that's not used very often where we in neurosurgery live most of the time are the three fours and fives with most of these codes. But again, not coding advice here today. When you're seeing a patient in the outpatient clinic, one thing, you know, sometimes coders have trouble with and providers have to do as well is whether your person, your patient is new or established. Here's what CPT says. A new patient is one who has not received any professional services from the physician or other qualified health professional or physician or qualified professional, exact same specialty or subspecialty who belongs to the same group or practice within three years. And a reminder that APPs are considered to work in the exact same specialty as their collaborating position. You may have a different taxonomy number and theirs may be neurosurgery or neurovascular and yours may be physician assistant or nurse practitioner. And that creates its own set of complications. But from a billing perspective, you are considered to work in exact same specialty as your collaborating physician. So don't get cute with this. There's opportunities for misuse here. I am of the mind that if my spine surgeon sees someone and then I see them and then I see them on a tumor for a tumor or something like that, I'm still probably going to lean towards this being a follow up because I'm trying to get in trouble for this. But there are ways to to work with this. So here are some examples. Your surgeon that you work with sees a patient for a consult is an inpatient for back pain. They follow up with you three weeks later to talk about surgery. When you see this patient, it is an established patient. And sometimes, particularly my coders may not have access to our hospital records. So they cue me and say, Mike, this patient hasn't been seen in the clinic before. I'd like to change this to a new. And I have to say, no, they were seen by a physician in the hospital. This is a follow up. So what I've got in the habit of doing is very, very clear about this in my history, that this is a 34 year old patient who was seen by my physician, Dr. So and so three weeks ago when they were inpatient at XY Hospital, and they present today for a follow up visit that gets rid of any conversation about that. So again, it doesn't matter where the care took place. It matters that they have been seen by someone who build a new patient visit within three years in your practice. What if the pain doctor in your practice sends a patient to your spine surgeon to talk about a new surgical option? That's a new, even though you all have the same employer, they all have the same employer, because they're different specialties and even subspecialties could get away with this. This is a new patient. A patient you saw 30 months ago for back pain returns, and they're going to get updated imaging. 30 months is within three years. That is an established patient. So you can, we talked about, select a code based on total time, and you use the total time that you spend on the day of the encounter, and it's pretty generous, really. It includes all of these things, preparing to see the patient. They bring a stack of films and CDs in a shoebox or the dreaded pile of films that you have to hang up and look at, you have to look at all those, that counts. Seeing the patient, taking the history, doing the physical, your counseling patient, family, caregivers, if you're ordering tests and medications, if you are coordinating care, if you're referring and communicating with their health care providers, and those two have asterisks, we're going to talk about. Your documentation in the medical record, reviewing results, they get x-rays on the way out the door. You review them after clinic, and you call them. Both of those things count into the total time that you spent with the patient on the day of the encounter. Let's say there are some things that you should not contribute, the time of the clinical staff or the time of your collaborating physician, doesn't count. This is your code. This is your time. If you are teaching, if you are precepting, and I hope you do, and I hope you listen to my talk on precepting, that does not count, though it is valuable. And this is important when the performance of services that may be billed separately, so back to some of the asterisks that we had on the prior page, there is a CPT code for counseling. There is a special CPT code for care coordination. So if you're going to add on the care coordination CPT code procedure, basically, for care coordination, you cannot count care coordination into either the complexity or the time that you spend on that. Additionally, if your company owns the machine, and you are going to bill out a radiology code for the interpretation of the radiographs that you took, you cannot factor that in either to the time nor complexity of this code selection. So again, it's kind of an unusual situation for an APP to be in, to be dictating out and charging the radiographs, but if you do, you cannot count that into the time and the complexity of the care that you're using to pay select a code. You should have a chart like this somewhere above your computer. I mean, your EMR probably has recommendations on this as well, but here is the kind of the ranges for the different codes, the time, and that's total time. Again, total time on the day of service. Okay, so that is time. So we said you could bill based on time or medical decision making. And here is medical decision making. So it has three components, the number and complexity of problems addressed at the encounter, the amount and complexity of data to review and analyze, and your plan and the risks of complications and or morbidity, mortality, patient management. So how complex is your plan, and what risk does it pose to the patient? This is a nice little chart that summarizes the different levels and components of medical decision making. You should have something, again, like this hung up against, hung above your computer. And you should be able to find out where your, what you're doing lands here. So again, I'm not here to give coding advice, but think about the levels of MDM. And in neurosurgery, we mostly live here. Very few of our things are straightforward and have no involvement of complexity and minimal risk for mortality. So we don't live in this level very often. These are most of the codes we use. And this equates to a level three, a level four, or a level five outpatient note. So say your patient with lumbar stenosis is getting worse. They're not walking quite as well. So that puts them at maybe a acute illness with systemic systems because they can't walk or chronic with progression of side effects. And then they come in, and you independently interpret their MRI. And then you talk to them about a surgery, and they've got some risk factors. So they're going to end up one here, one here, and one here. And this says you have to have two out of the three to get the code. So with two at level at moderate and one at high, this is going to be a moderate patient. So that is basically how you apply this. Again, I'm not here to give coding advice because I'm not a coder. You should be able to apply this chart to your practice. Go over it with your coders if you're not familiar with it. And please don't rely overly on your EMR to select your code for you. So kind of distilling down again, I want to dispel myths. And I love to do this. There are still myths that persist that APPs can't see new Medicare patients. This is factually inaccurate. There's still also persistent myths that a physician must see or be on site anytime an APP sees a Medicare payment. Again, this is a myth. What Medicare says about it is it's authorized under state law and not otherwise excluded from coverage, APP may furnish services billed under all levels of evaluation and management and diagnostic tests. There is nothing here that says Medicare has an opinion. If your practice has an opinion and they're pointing at Medicare, have them look this up. The reference is on the bottom. We want APPs to be practicing at the top of their level with appropriate supervision. We don't want necessarily them stifled by out-of-date and misunderstood regulation. So Medicare does not have an opinion on that. Other options for outpatient reimbursement. Outpatient counters for Medicare beneficiaries performed by an APP should be billed under the APP's NPI number. And you should expect 85% of the physician fee schedule in return, right? So you can see, Medicare says you can see outpatient visits and you should get 85% billed under your NPI number, pretty straightforward. We don't share visits in the outpatient setting if this is site of service 11. Again, this may be a little bit different if your clinic is owned and managed as a hospital, by a hospital, so there are some nuances there that you should go over with your administration folks. APP should not act as a scribe. We know that it's not good for APP's job satisfaction. It is kind of misrepresents what we're doing if you're acting as a scribe. If you say you act as a scribe and you're putting something in your note that says this was under the direction of so-and-so, what you're basically telling Medicare is that your involvement in patient care had nothing to do with patient care. You didn't ask any questions. You didn't do any physical exam. You were just merely there scribing. We are not scribes, so we should be, again, working towards the top of our license in a way that is appropriate with the level of supervision required on our license and our individual state, but you should not be scribing. There is one reimbursement option that we should talk about. It is an option. It is a Medicare convention whereby an APP can see a patient in follow-up, and if they have been previously seen by a physician and the physician wrote a careful plan, a treatment plan, you can see the patient in follow-up and bill it under a supervising physician's NPI number and expect 100% of the fee schedule. So that's, you know, it's nice to get a little more revenue, but there are some issues with it. So there are some compliance problems with this. Important things you need to know in case anybody ever pressures you to inappropriately bill something as an incident to so that we can get an extra 15% reimbursement. Incident to cannot be for an initial visit, cannot be an initial visit because it's incident to the initial visit. You and the person, the physician must have the same employer or you must be a contractor or have some kind of leasing agreement with that provider. There must be a financial relationship. A physician, and it doesn't have to be the one who wrote the note, a physician must be physically present in the clinic, in the clinic, same clinic, not upstairs, not down the hall, no, across the hospital. They have to be physically present in the clinic when the service was provided. The physician who saw them first must remain engaged in the care of the patient. Somehow, you have to be able to prove the Medicare if you're called for an audit that the physician continue to be engaged, that you've documented somewhere in the note at subsequent visits, I talked to Dr. So-and-so about this plan and they continue to agree with it, or they should be seen by the physician periodically. Can't be for a new problem. If the physician saw them for lumbar stenosis and you're following their treatment plan for lumbar stenosis and they come in with a complaining of hand pain and you think it's carpal tunnel, that's a new problem. They don't have a plan for that, so you can't bill that as incident two. Outpatient private clinic only, not for inpatient things. It cannot be for a worsening problem. So if the patient's getting worse and how they're worsening is not really described in the initial treatment plan, yeah, that's not covered by incident two billing. It's not so we can act as a scribe. You know how I feel about this. It can be for procedures if noted in the initial treatment plan, and I think a nice example of this is if you're seeing someone with a shunt for NPH and they show up and the doc does the initial visit and assesses their shunt and says, oh, you know, they're having symptoms and they're currently set at 1.5 and I'm going to send it for a CT and if the vents are bigger, we're going to dial them back and I want the APP to change them to 1.0, they show up, vents are bigger. You can change it to 1.0 and that procedure and the E&M can be billed under the physician provided all of the other things. A physician is in the building, area in the clinic and so forth. So that is a way procedures can be billed and I would say that this has a risk for fraud and abuse, you just Google fraud and abuse incident two and you'll get all kinds of people who have been brought to bear consequences for inappropriately applying these and having to pay back thousands and hundreds of thousands if not millions of ill-gotten reimbursement for Medicare for inappropriately applying this. So if you're doing this, if your clinic is doing this, please make sure you understand the rules because you are responsible as well. Please don't end up getting in trouble for this. So other rules and compliance. The public health emergency gave us some flexibility on the supervision for incident two. That is gone. It's a thing of the past. It ended a year and a half ago. So supervision has to be now in person in clinic. I would also note that private payers may have different rules and languages. So check your contract if they have it at all. Pros, nice. 15% extra is nice to get, you know, with Medicare reimbursement rates flat or going down, it's nice to be able to recover 100% instead of 85%. Don't get me wrong. The cons are there's some risk for fraud and abuse. This can be applied inappropriately and lead to issues with inappropriate Medicare reimbursement. Another thing it does is it fails to track our productivity and our value to the organization. So if you're someone who they're going to pull out your RVU tracking over a period of time and say, look how productive you were, we want you to be more productive. But if you're doing a percentage of your work as incident two, that doesn't get billed under your NPI number. So it doesn't track APP productivity. So if they're using RVUs as a way to track your productivity, you're not getting any for this. I would also say there's a bit of an unclear future for incident two, as I think there's going to be more movement towards ACOs and bundled payments. And, you know, incident two and billing in general may become less of a thing when we're looking at outcomes and quality. So whether or not this continues to be a thing as more people move towards bundled payment, I'm not sure. That is it for outpatient. I'm going to pivot now to how we bill in the hospital. So we are covered under Medicare Part B, and we can provide care in a hospital. So it should, again, all care billed by us should be billed for E&M under our NPI, your NPI number. And again, you should expect 85% of the physician fee schedule. It includes all evaluation and management that would be in a hospital and appropriate procedures. Very important, you must act within your scope of practice, that which you are credentialed and supervised in accordance with local regulations, 100%. Don't do things you're not allowed to do. Maintain your level of supervision. Just because Medicare doesn't have an opinion doesn't mean that we do not need to have supervision and collaboration, and that can be different from state to state, facility to facility. So don't do things and bill just because you can doesn't mean you should. So, again, keeping very close eye on your credentialing. Hospital E&M, and this is service provided in a hospital, whether it's observation inpatient, and luckily these codes were updated in 2023, and again, similarly updated, now only based on medical decision making or total time, still, of course, requiring that medically appropriate history and physical exam, neither contributing to the code selection anymore. We only have three levels of code which correlate to that low, medium, and high on that sheet. There's nothing straightforward about being in the hospital. If it's straightforward in E&M, it's time to go home from the hospital. So we've got low, we've got medium, and we've got high corresponding with one, two, and three for these different families of code, whether it's inpatient or subsequent. So, and interesting, there's a little difference here, whether you are inpatient or, excuse me, initial or subsequent on an inpatient basis. So, CPT says initial service, when the patient has not received any professional services, blah, blah, blah, during that specific inpatient observation or nursing facility admission or stay. So it has to do with the particular episode with which they're hospitalized. If they were hospitalized two weeks ago, and for finding they're not in the global period, they were discharged two weeks ago, and they're back, and you see them again, that is a initial encounter, an initial inpatient encounter. So that three-year thing doesn't really count for this. It has to do with that particular facility stay. Again, you're considered to work in the exact same specialty as your collaborating physician. I would, my advice, don't get kicked here. All right. So, another convention, similar kind of to how incident two is managed on the outpatient side, there is a convention that accounts for kind of a collaborative approach to care in the hospital, where an APP and physician work together to see a patient in the hospital. The physician may bill under the physician NPI, you know, therefore getting the full 100%, if these conditions are met, and there's some nuance and some complication here. It has to occur on the same calendar day, period, and that goes the same for inpatient or outpatient. You have to work for the same group. There's a big asterisk there, and we're going to talk about it on the next slide. Here's where it gets a little confusing. Physician performs what is described as a substantive portion of the MDM service, and that is currently defined as either MDM or time. So, you can split the note, and you can either bill it on time or MDM. And if you're going to bill it on MDM, what CPT and Medicare are kind of saying right now is you have to have, basically, be responsible for two of the three elements used in the selection of the code. So, and again, there's a little, CPT and Medicare have a little different language here. So, the substantive portion of the MDM requires, according to CPT, requires the billing provider, and in most cases, this means the physician, has performed two of the three elements used in the selection of the code-level-based MDM. And how this can usually be satisfied, and again, you're using language out of CPT, when the billing provider can say they, quote, made or approved the management plan and, quote, takes responsibility for that plan with its inherent risks, complications, and morbidity, mortality of the patient management. So, again, there's a nuance here, and there's some complications, and there's a skosh of a different language between CMS and CPT. Work with your coders to make sure that you're staying on the right side of this, and know that there's kind of a target on this. There's, you know, been a movement for Medicare to change this to a time-based only. I think that's not really good for us, and it's certainly not good for our practices going to just time-based. And it would be, if you're doing a time, it'd be more than half the total combined time of the encounter. So if the physician spends 45 minutes working on that patient for the day and the mid APP spends 30 minutes, you could say the total time of 70 minutes, the physician spent 40 minutes and therefore bill it out under the physician for that. So there is a movement that the transition to that has been delayed a couple times. It was supposed to happen in 24, it did not. So we're still left with this, this kind of MDM or time to kind of stay tuned and stay in touch with your billing folks to make sure that you're on the right side of all of these regulations. Back to the asterisks, in split-share billing, the APP and the physician should work for the same group. So if there's a case where you are a hospital-employed APP and a private practice surgeon, there has to be some kind of lease agreement or financial agreement between the hospital and the private practice group. Otherwise, this could be a kickback. This could be the hospital giving free services to the private practice surgeons in exchange for them coming there. That would be a kickback and that would be a problem. So if that is the case for you, it might be just worth asking, what's the financial agreement here that protects everybody here? You don't want to be involved in that. It does apply to basically that which we do in the hospital. Split-share works for initial encounters, subsequent encounters, critical care services as of 2022, and it does not apply to procedures. It is an E&M, it's an evaluation and management convention. So it does not apply to procedures. You're doing procedures in the hospital, not surgeries. If you're doing procedures in the hospital, you should be billing for those procedures. Okay, so that's the end of what we're going to talk about in terms of E&M billing in the hospital and we're going to move on to surgery and the global surgery package. So payments for surgery, a little different than how we do E&M. So payment for surgery to a physician group is a standard package, right, that includes all of the work that goes on to it, including preoperative work, interoperative work, and post operative services. So the global period can be either zero days, that means only on the day of service, it can be 10 days, or it can be 90 days. And again, that includes all of the preoperative visits after the decision for surgery has been made, and so your morning of H&P, your consent, and your counseling, and all that stuff after you've decided to do surgery, all of that is included. You can't bill separately for your H&P that you do on the morning of. It includes all the standard intra-op services, you know, just because infiltration of local anesthetic has its own CPT code, it doesn't mean that you can bill for it outside of that. So the positioning, the local, the skin prep, the approach, the closure, the dressings, the drain, the takedown from positioning, all of the things are included in a normal scope of the work of that case are included in the intra-operative services. And again, standard post-operative care, all the wound care, the drains, your pain management, your surgeon's pain management, and your complications if they don't require a return to the OR, that all goes into standard post-op care. So you bill one code and you get paid for all of the work that you do on for that patient. So it can have a zero day global. So things that have zero day global, and again, it's just the day of the procedure. So if you place an EVD, an endocrinial pressure monitor, you do an angiogram. Interestingly, our coiling, our embos, our stroke thrombectomies, those all have a zero day global, and pain injections as well. So the things you do on the day of should be included, but the day before, day after, not so much. So what has a 10 day global? Things like kyphoplasty, pump placement, replacement spinal cord stimulators, those kinds of things, those are considered, quote, minor procedures. I'm not sure if I agree with that terminology, but considered minor procedures are considered 10 day global, and it starts, again, the day of the procedure, not the day before. Going on to 90, these are what Medicare describes as little major procedures, and the global period starts the day before the procedure. So if you're doing any work the day before the procedure on this patient, it is certainly included in the global period. All, just about all other, except for your EVDs, your pressure monitors, all your craniotomy, cranioplasty, all of that stuff is included. Most all of your spine cases, and for whatever reason, carotid stents live here, as opposed to the thrombectomies, which we saw on the prior page. What's not included? So your initial consultation to determine the need for surgery is not included, it can be billed separately. Visits unrelated to the surgical procedure or the diagnosis. So a great example of this is you do an ACDF on a patient, and they come in and their hand still, their hand is bothering them now, and you do an assessment, you think they have carpal tunnel, you can, if you see them, it's day 75, you can bill a visit for that patient outside of the global period, because it's a different problem, it is a different diagnosis, it's unrelated to the procedure and the diagnosis for the procedure. They are clearly distinct procedure, surgical procedures, and it's like a planned procedure, or a failure of a less invasive procedure, we're gonna try to do an ACDF, but we may have to come back and back it up with a posterior fusion. You can bill for both of those surgeries within the global period, that's not a complication or anything like that, so you can get paid outside of the global period for that. Some modifiers that you would use to tell Medicare that you're trying to show an exception to the global period, if you have a planned return to the EOR on a different day, so we're gonna do the front today, and tomorrow we're gonna do the back, you would put a 58 modifier on all of the second day codes. If you have an unplanned return to the EOR, you can still get paid for that, but it's considered a complication, you would put your 78 modifier on that, and if you have an unrelated procedure within the global period for another, so you do a again maybe a ACDF, and then two months later they get a carpal tunnel release, the carpal tunnel release is unrelated, you would want to get paid for that, it's not a complication, it's got a different diagnosis, so you would append the 79 modifier to some of that to get paid. Again, this is again just for example, I'm not giving billing or coding advice. And again, these are things that surgeons and coders need to worry more about. So how do we demonstrate our value? So I'm going to start talking about surgical codes. Surgical codes are valued by the complexity of care and when the care is typically provided in the global period. And it makes sense that the majority of work has to do with the intraoperative phase of care. So this is what an ACDF gets paid, how the breakdown of the components of the ACDF. So Medicare and CPT think that about 10% of the work that go into this code has to do with the three operatives, seeing the patient, reviewing the labs, doing all the things, calling the patient, the H&P, all of that stuff. 70%, 69% to be exact, is the intraoperative work. It is all the things I talked about, the procedure, the positioning, the coordinating with anesthesia, the doing the thing, the incision, the going down and doing the fusion and closing and all of that work. And when they get to the PACU, that's when the post-op work starts. And so 20% of the work and expertise goes into the post-operative phase of care. If you do E&M related to the procedure, your post-op notes and your clinic notes for post-op ACDF, those all get billed with a global period code, the 99024. Some states require it to be done. They're being tracked because Medicare is keenly interested to make sure they're getting their money's worth and they're concerned that they're not. So some states, you're required to put this code in because Medicare is counting the number of post-op visits their patients are getting. They assume how much work they're paying for is the amount of work you're doing, but it should be noted there is zero RVU. So if you're doing a lot of post-op care in your clinic, you should know that it has a zero RVU. So when it comes again time to calculate your contributions to the group, if you're doing a lot of post-operative care, that's a zero RVU. Again, going back to this, and we're going to break it down in terms of dollars. So if this single level ACDF, and this doesn't include anything else like extra levels of plating or anything like that, you just do a single level ACDF, the value of that, if it's done in DC and I've gone through and done the geographic price cost index, the total value is about $1,924.45. And so doing the math off the previous, off the pie chart there, the intraoperative work is $1,300, the post-operative care is $404, and the preoperative care is $1,902. So if you're doing a bunch of the preoperative and post-operative care and has a zero RVU, the contribution to this work, this value with zero RVU can be up to $600. So the pre-op care and the post-op care don't get paid separately, doesn't mean it doesn't have value. It's got a dollar value of almost $600. Another thing to think about is an assistant at surgery. So I'm sure a lot of you were doing some of this. An assistant at surgery is a provider who actively insists the physician in charge of a case performing the surgical procedure. So we are not ever in charge of a case, we should not be building the surgical codes, but we can certainly assist actively in that care. It can be a physician, it can be a nurse practitioner, it can be a physician assistant, clinical nurse specialist, whoever is authorized to provide that under state law and is credentialed to do so can serve an assistant at surgery. Again, Medicare doesn't have strong feelings. Some states do and some facilities have opinions on this. The assistant at surgery provides more than just ancillary services. It's tough to have an extra scrub tech to hand instruments. They should do more. And the operative note should clearly document the role, what they did and why they were there and why it was medically necessary. It's a little tricky if you were working at a teaching hospital to get paid for this. We all know that Medicare largely funds the GME process, so residents are paid to be assistants at surgery. So when I was coming up, it was considered to be an audit risk if you were operating at a teaching facility. The way around that is if there is no training program in that specialty. If you're a teaching hospital, but you don't have neurosurgery, you don't have any neurosurgery resident coverage, it seems reasonable that you could charge and expect to be reimbursed for that. If there's a specific surgeon that has a policy of never working with residents, you could expect to get funding for that. And again, it is organized at the administration level that they get probably a pay cut for that. If there is no qualified resident available, for some reason, your chief is off doing something else and it's only the intern and an AVM comes in and you've got to help with the AVM and the intern doesn't know how to do the certain things for the AVM, and you're going to be an assistant, that's fine. You may get paid for that. If there's emergencies, multiple patients, if you're covering cranies because everybody else is operating as well, you may think about billing for that as well. But in general, it should be considered kind of a question mark or an audit risk to bill an assistant at surgery at a teaching hospital. So question or not, is an assistant going to be paid for this procedure? Not every procedure allows for an assistant at surgery. So the American College of Surgeons maintains a list, and this is from the 2023 update, of the appropriateness, and this is ACS, this is not required, Medicare doesn't have to think the same thing, of if it's reasonable to bill an assistant at surgery. So going here, 22551 is the ACDF code. Almost always, the X means that a first assistant will almost always get paid. What the zero means here is that a second assistant could sometimes get paid. I'm not sure what a second assistant would do in a single level ACDF, but it's not my job. But you could even think about billing to assistants, though I probably would not do that, but it could possibly get paid based on this. Medicare also has some opinions about this, and this is from Novitas, who is the fee servicer for my area. You can look up any of this stuff. This stuff is all quite, you know, publicly available, and this is where I pulled some of my data from, including the number 194727 up a little higher. So whether or not Medicare is going to pay for it, you can look it up. The assistant surgery at the big positive orange arrow sign, if it's a two, it may get paid. They never say always, because it's always based on medical necessity. And one is it might get paid, and if it's a zero, it's unlikely to be paid for this. So again, depending on medical necessity and appropriate documentation. So to bill this, the surgeon dictates the operative report. They should describe either probably in the introduction why an assistant was medically necessary. And then in the body, they should specifically drive what the assistant did, and they can't just put the assistant on top. They should be specific. If you want to get paid and not be an onerous, they should describe what you were doing. They, you know, they opened the retractors, they held the retractor, they held the screws, they did whatever it is they do. That was more than just being a surgical technologist. If you're doing this at a teaching hospital, it needs to be in the notes specifically why the resident was not available to act as an assistant. How does it get billed? Again, this is for your billing folks, but you should have a little background on it. So APP builds the code under their NPI. So you, you bill it out and you put an AS modifier to the code to say you're an assistant at surgery. So 22551.AS, your modifier. And so the reimbursement for an assistant at surgery is 16% of the fee scheduled for that code. Because again, remember a physician can be in the assistant. So it's 16% of the code. So for an APP, it's 85% of that 16. So effectively it's 13.6%. So 13.6% of 1900 24 and 45 cents is $261 and 72 cents, which is not terrible for an hour or so of work. So how is our value? What's our value overall? So say that you did 90% that you thought you did 90%. And I would never say a hundred, but there's always a collaboration that has to happen with a physician, 100%. But say you did 90% of the pre-op work, which I think is not unreasonable because we want to keep our surgeons operating and us practicing at the highest level of our license. So we reviewed the labs. We called the patient that before we got there early, we did the preoperative HMP. We went in and did their consent. And then the physician started up and signed the consent. 90% of the pre-op work would be valued. Going back to one of our other slides, we had 90% pre-op, $173. We did 90% of post-op work, which again, I don't think is unreasonable. I would never say it's a hundred percent because there has to be an acknowledgement of the collaborative relationship, but patient rolls the PACU. We did the post-op note. We did their post-op check. We ran on them day one where we pulled their drain. We did their discharge. They came in and see us in the clinic, their wound check. We did their six-week post-op visit. We ordered their therapy. We did a two-month visit. We ordered films. We reviewed their films. We called the doc. We talked to them about it. We collaborated. That's a lot of work. That would be where 90% of that work, $363. You were an assistant at surgery and you billed for Medicare. You could expect to maybe get $261 and that would be due since. So our total contribution to what started out as a $1,900 enterprise is up to $800. So we did some work here and we contributed value to our organization, none of which is really recognized through our views, but we certainly have financial value. We have value to the patient because patients appreciate all of those things that we do before and after the surgery. So we do have value. All right. So in summary, I would just like to remind you that misconceptions persist. There are still some people out there that think Medicare patients can't be seen on new visits by APPs. That is inaccurate. We have to be educated about reimbursement so that we can work at the top of our license and to maximize our contributions and so that we don't get tied up with the risk of fraud. For as many people as there are who think we can't see new patients, there are just as many who don't understand the components of incident to billing that must be met, setting us up again for fraud and so forth. We should know our value to the organization. Just because they print off an RVU sheet once every three months and tell us how we're doing doesn't mean that's our total contribution to the organization. And just because the RVU is zero does not mean it's worth zero dollars to the organization. So I hope that you have enjoyed your time with me. I've sure enjoyed talking about this. It means a lot to me that we are involved in these sort of discussions and that we have a seat at the table because it's an important seat and it's good for patient care and it's good for us to understand our value. So that's all I have. I thank you for your time.

Neurosurgical APPs

reimbursement processes

Medicare coverage

CPT codes

billing conventions

global surgery package

RVUs

surgical assistants

compliance regulations