We're running a little bit behind, but I'll try to hit some of the high points and some of the key things that you need to get as graduating and senior residents as you start moving out and looking at jobs and looking at positions. Just some basic questions. How are you going to determine your value when you go into a negotiation with any entity, whether it be a hospital, a practice, an academic environment? What's an RVU? Can anybody answer that question for me? What's an RVU? What's it mean? What's the RVU mean and what's the RVRVS? This is probably like the key things and things that will like influence all of your like, there are not a lot of like 40-year-old neurosurgeons who are white guys that can put 50 cent on the second slide of like a presentation like this and I think I'm going to pull it off. I think the key is this, like you're in your early 30s and you're probably looking to get in your first real job, so you probably need to have some kind of knowledge base in terms of understanding what your value is, what are you going to ask for, what are you going to bring to a practice. A lot of these slides I took from the physician's breakout section that Joe Chang and I developed as part of the coding and reimbursement course. I want to go over some of the faculty that we have for the coding courses just so you understand the kind of people that are involved in this nationally in the AANS and in CNS. Joe Chang put up to this group, he did just a phenomenal job, I'm fortunate enough to work with him. Peter Angivine, I'm going to go over some of his slides in a minute, he's a spine guy at Columbia. Pat Jacob has been doing this and just got named to the CPT editorial panel, so he's on the group that develops and determines the nomenclature, the numbers, the very foundational elements of how we describe procedures. It's an extremely important position. Robert Johnson teaches our coding courses also, has been doing it for many, many years. Alex Mason is the CNS rep to the RUC, that's the RBRVS update committee. Just briefly, they're the guys and girls who determine what people get paid. They determine what codes are valued by. He's our representative there. Clemmons does cerebrovascular, Scott Simon I think does some functional and vascular, David Sunda does epilepsy, Karen Schwartz is the rep representative for the North American Spine Society. Lou is kind of moving up in running these courses and is a spine guy. Ed Bates is our alternate at the RUC, meaning he also sits on the table to determine code valuation with Greg Zubilski being our normal person for the RUC. What does that mean? All of the faculty that teach these courses for the WNS are influencers, they're heavy hitters, they're people that are doing things in terms of developing code valuation, in terms of determining codes. It's a really solid group. You really are going to have to take a coding course. You're not going to be able to get this information from a little 20-minute session here. I want to give you a taste of it, but again, you're going to have to take a two-day long coding course to really get some concept and some depth of understanding of what coding actually means and what it entails. Now, if you have like the mental age of like a 15-year-old boy, it's probably being like exciting to be able to say you've been arrested for like felony speeding if you're like a neurosurgeon because you were driving a like A8 at 118 and you got pulled over and you had to do time for it. Ten years ago, he will probably joke about that as being like kind of a cool thing that he did when he was like 42. Now, if you get sentenced to prison time for defrauding Medicare or defrauding an insurer, it's probably not the kind of thing you're going to be joking about or not the kind of thing that you're going to be making fun of ten years from now because you may still be in prison ten years from now for like Medicare fraud. OIG audits we mentioned before, I mean, it's a reasonable thing to point out. It's probably a good thing to point out that there's a dollar value to these audits. They don't just come in and say like you did a bad job. This Blue Cross and Blue Shield audit was forwarded to our Washington Committee a little while ago where the practice was asked to write a check for $197,000, $190,000 based on one audit of one set of claims from one payer. So not Medicare, not their entire practice, but one payer auditing them and coming back and asking for a little bit less than $200,000 like now because we've been overpaying you for the last like 6 to 12 months. So real money, real concerns, most practices, that's going to be a pretty significant hit. But you shouldn't be afraid because this is probably not going to happen. The percentage of neurosurgeons actually facing prison time for fraud is thankfully quite low. So it's probably not the kind of thing that you're going to be hit with. It's not really a realistic worry. But you just think like why is that? Why is it not a realistic worry? Because most of the groups you join, and chances are with how our graduating residents have been doing, a lot of you guys are going to be going into employee practices or joining large practices or joining academic entities, you're probably not going to be going out and hanging out a shingle and going into practice on your own. The coding that you're going to be going into or the situational practice you'll be in, you're probably going to have a professional coder. You're going to have someone who's certified and someone whose job it is to try to get this right and make sure your coding's accurate. So no problem, right? You don't really need to know it yourself. But those coders are on the hook essentially for nothing. They don't do better if you get reimbursed more and you capture all of your reviews. They don't do worse if you leave some money on the table. They're not at all incentivized to maximize your value. And if anything, if you're at a major tertiary referral academic center or some of the other larger entities, if anything, they're incentivized to be very, very strict and perhaps a touch too conservative with how they code, meaning that a large institution may be perfectly happy to leave like a few million dollars on the table, just not have to worry about potential risks of an audit in the future. That may be a ton of money to an individual practice. So you've got to really understand this. You've got to understand this language. And again, that's really the only way you can represent yourself and have the conversations that Dr. Binzel was talking about earlier. Essentially, anybody who hires you is going to be able to project from MGMA and NERSC data what your value to a practice is going to be over the first two to three years that you get out. They have that number already. Your ability to negotiate when you're kind of first coming out is somewhat limited because you're not really a known entity. People will know your training. People will know your reputation. You can do things that kind of hurt your value. But in terms of being able to negotiate, it may be kind of challenging. But when you become a known entity or become embroiled, when you get a foundation in a practice, that's when this becomes extremely valuable. You've got to know kind of the language of the realm. You've got to understand the same kind of coding that administrators, that practice management, personnel, that coders use. Like, you've got to understand this. Or you don't have to understand it. But by choosing not to understand it, by leaving this kind of in a black box, you may be missing out on a lot of potential revenue. You may be leaving, again, a lot of money on the table. So I want to go over some slides that Peter and Angie put together just for the AANS coding course that we did, like, last year. So you'll have some idea in a case-based format when we talk about coding what we mean. And these are all Peter's slides, which I have stolen from him. So as opposed to the War College guy I'm saying that I'm plagiarizing somebody else's stuff. So this is case one, 60-year-old guy, back and leg pain, right L5 radiculopathy, not a great position, not a great presentation from the side. He's got a herniated disc. So you've got to know your ICD-9, and you will soon need to know your ICD-10 code for what that diagnosis is. A little more herniated disc, so 722.1. You'll get to the point where you fire off these numbers, and it means nothing to you. 722.1 is like a herniated disc, or you have spinal stenosis with neurogenic claudication. We're transitioning to ICD-10, supposedly, probably next year, maybe, maybe not. But that'll be an entirely new nomenclature for diagnoses. And again, just things that you have to learn. And then you have a set of particular codes for what was done here. A bilateral L4-L5 partial laminectomy with medial fascitectomy for decompression, with a right-sided microdisc, with your diagnosis being a herniated disc. So it's a 63030.50. You use the microscope, so you use microscope with microdissection. This is why I said this is a really bad topic to have at the end of the day, because we start getting a little bit into the weeds, and everybody's kind of like glasses over, because it's pretty dense content to go through. There's a whole family of different codes that we use for laminectomies, 63020 and 30 or doing a laminectomy for a disc, open or endoscopic, the disc or legal codes, and it's a 90-day global. We'll talk about that in a second, too. There's a separate set of codes that we use for a laminectomy for stenosis, 63045, 4.6, and 4.7, meaning you're doing a decompression for stenosis as opposed to a herniated disc. Again, a 90-day global. There's a separate set of procedures that we do for a re-operation outside of the 90-day global. There's a modifier that you use at 78 if you're doing that re-operation within the 90-day global. Have I lost everyone yet? Because if I haven't, I'll keep going. In case two, classic grade one spondylolisthesis in an architect, bilateral leg pain, unresponsive to multimodality conservative therapy, you're taking them to surgery. We have these nice kind of catch-all diagnoses, like degenerative disc disease, which is 722.52. Now, can you use that for this patient with a spondylolisthesis? Well, you can, but you'll get denied, because no one does fusion for degenerative disc disease anymore. So, you want to know that the correct code for this patient with a grade one slip is stenosis with claudication, and preferably the spondylolisthesis code, the 738.4, which is letting the payer know the patient's got a slip. That's why you're going to do the stabilization, or that's why you're doing the fusion along with the decompression. And again, there's separate codes that will have an ICD-10. So what do you do? You decompress them. That's a laminectomy with a facetectomy. You do pedicle screw instrumentation at that level. You do a transforaminal lumbar interbody fusion. You put in a peak spacer. You do a posterior lateral fusion as well, and you use some local autograft and more sized allograft. How many residents have done this exact procedure? Like over a hundred times, probably. So everybody's like done this. How many people know the core CPT code for this procedure that you've all done? So, the family of codes that you would use for this single-level TLIF with non-segmental instrumentation, the key code is going to be your interbody fusion with a posterior lateral fusion, which is a 22633. There are a number of other codes that you use. The idea with approaching spine coding is that you try to break it into like parts. So you code your decompression. You code any stabilization or fusion that you do. You code your instrumentation. You code your bone graft, your intervertebral body device, your spacer, whatever other stuff you're putting in. But you kind of break it into kind of a step-by-step fashion. So with each code, you kind of have like the same basic set of questions that you ask and answer, and then put that into a CPT framework or kind of a CPT language that an insurer is going to understand. And here you're using 63047, Peter, saying because you're not doing a gill laminectomy. A gill laminectomy, you're taking off all the posterior elements, which is 630.12. I don't want to get too much into the weeds going through these with the different kinds of laminectomies. If you're doing a patient with a dysplastic spondy, where you're doing a total posterior decompression, meaning taking off all the posterior elements, that's a gill procedure. There's a separate code for that. And of course, there's a whole other family of codes for instrumentation, which you use as additional codes or in addition to your like base code. And again, there's just absolutely no way in 30 minutes we can go through this in any detail at all, except to say there's segmental, there's non-segmental, meaning multiple points of fixation versus two points of fixation. There's a lot of depth and a lot of insight that you have to develop if you want to start thinking with regards to this nomenclature. And it's something that I didn't get at all in Resonance. I had to pick all of this up as I got out. And again, by not knowing this nomenclature and not being able to think and interact in terms of this, you're at a disadvantage talking with a coder who maybe has done a week-long course learning this, but then knows it better than you do. They may have a high school education. They may have like just done basic stuff, knowing coding. But if they know coding, they're going to be able to go through this talking to an insurer much more effectively than you, which means you have to learn this. You have to go through and put in the time and put in the effort to actually pick up this basic nomenclature, at least for what you do and at least the practice that you're participating in. So the coding courses are vital. You don't have to take the AANS course. I think the AANS course is great. That's why I went through kind of the faculty before, because we've just got fantastic faculty teaching that course. The North American Spine Society has a really good spine coding course too. There are other opportunities that are out there. I would probably steer you away from doing industry-sponsored coding courses. No disrespect to my industry friends that are here, but you kind of want to get your coding information from surgeons, from people who are doing procedures, from people who are doing coding, not from industry representatives, not from other entities. There are plenty of people who will give you advice about coding. It probably should be a surgeon or a respected consultant like KZA or another group that, say, we work with, as opposed to an entity. But again, you've got to learn this language and master this language. It's the language of the realm. It's what everyone works with, and we have a bunch of different opportunities for doing these courses. We'll get just slightly into the weeds in terms of understanding RUC coding. RUC 101 is how we value codes or how we describe what a code is valued. Why is a lumbar discectomy worth X? Why is a lumbar laminectomy worth 110, 120 percent of X? That's what the RVRVS or the RUC RVRVS update committee does. So it's a group of physicians, slight preponderance of primary care and medical specialties and subspecialties who determine what CPT codes are going to be valued. Now, what do all these words mean? The whole alphabet soup, these, like, terminology certainly doesn't help at all in terms of developing an understanding of this. Relatively straightforward practice is kind of determined by, like, two different committees. So just to basically go over that, we came up with this idea back in 92 of the resource-based relative value scale, which the idea was we're going to try to determine what the value of a physician's work is and how you're going to value an ophthalmologist versus a dermatologist versus a neurosurgeon, all using the same basic language, the same basic numbers, and put it into a framework that Medicare could then use to set reimbursement rates for physicians. So this started many, many years ago, and we have gradually refined this over time to get to the system that we have today. It's how we value procedures, clinic visits, essentially anything we do that is valued by the RUC is anything that we do that has value with regards to reimbursement is valued through the RUC. It does physician work, practice expense, and malpractice, or your liability exposure. Physician work is about 52 percent of, like, an individual either E&M or procedure's value. Initially all of this was done by Harvard, so we talk about Harvard value with our codes, meaning codes that were valued back in the early 90s. When we sat down, came up with a CPT nomenclature, but then valued the CPT nomenclature, again, just based on a committee at Harvard that went through and kind of assigned values to everything, and then we worked with those numbers. So we started now where we mandate reviewing the entire code set. So that's the CPT, or the Common Procedural Terminology. That's a product that the AMA owns, publishes, and maintains copyright on. It's developed by the CPT editorial panel. And again, it's owned by the AMA, but it's how we define and describe procedures. It's how we put a number on a lumbar disc and say that it's 63030. It's how we put a number on a posterior lateral cervical fusion and say it's 22600. Developing that numerical set, but more importantly, the definitions or the language that's entailed in each of those procedures is what CPT does. So the CPT editorial panel, which is appointed by the AMA, does that. They set this language, and they set what the procedure descriptors are. And again, there are about 8,700 of them. So once everything's kind of defined by the CPT editorial panel, then it goes to the RUC, which is the RVRVS, or the Resource-Based Relative Value Scale Update Committee, or the RUC. What they do is go through each of those codes, debate them, usually have an advocate for the code present survey results, present whatever compelling arguments they have for the value that they believe the code should have, and then the panel votes on what that code is, and the panel makes a recommendation, it's a CMS, as to what the code should be valued, so it's kind of step one, step two, step three. CPT defines the code, puts a number on the code, says this is a procedure, it's going to be assigned this tracking code, and eventually this category one, or full code, then the RUC goes through and values it. The people who make the final decision is CMS, CMS is the one who assigns the final RVU valuation to the code. Most of the time, we used to be able to say they agreed with the RUC panel, a lot of the times now they do not. We should be mandating all the codes every five years, some of that doesn't, there's been a lot of interest in bundling codes, and the surveys are one of the things I will bring out here. The surveys we email out, as soon as you get out and you join the spine section, the cerebrovascular section, any section you join, you're going to end up getting tagged with surveys at some point, which are going to come from myself, or come from Joe, there will be this kind of boilerplate thing that CMS has us send out, via AMA, that's a survey that helps us determine code value. It's really helpful if you fill these out. And the whole point is, it's how we're getting paid. It's how CMS assigns value, what CMS assigns becomes adopted, but essentially all other payers in CMS is a 900 pound gorilla, so having CMS get it wrong is potentially disastrous for us, having them get it right helps us a lot. So filling out the surveys helps a lot, our response rate is usually around 10%, but it's the foundation of our recommendations to the RUC. So just be honest, do it on a routine patient if you're doing it, and do it quickly. Normally we give about a week's turnaround to do these. Now, briefly, going deeper into the weeds, practitioners, our PAs, nurse practitioners, not just physicians, ultimately our views are set by CMS, and that's set by, like, the CMS Act. So CMS.gov are the people who eventually sign and really determine what these, our views are. They're kind of three things that the Medicare fee schedule uses to determine the valuation for a given procedure, or a given CPT. The work RVUs, which is what the RUC decides on, the practice expense, meaning the amount of money that takes you to run your practice and maintain your practice to provide this service, and then your malpractice liability, meaning is this a super risky surgery, is this a very straightforward surgery, is this an E&M, whatever. That adds up to being your total RVU. And then after you get that, your RVU value, then you have to apply your conversion factor, which varies every year, which takes the RVU value and then converts it into what you're actually getting paid by, like, Medicare. The conversion factor is what normally changes the most. I'm going to try to back out of the weeds. And there are gypsies involved in there, too, which are the geographic practice. We're backing out of the weeds. I'm going to give less detail now. The conversion factor is what takes those RVUs and puts it into a dollar value. For 2014, it's $35.82. Conversion factors per RVU are sometimes what hospital-based practices will kind of bandy around in terms of what your reimbursement is, and one way you can kind of compare between, like, systems. It creates annual fluxes in reimbursements. When we talk about the physician fegs, if you've heard anything about the SGR, the sustainable growth rate, the kind of headaches that come through Congress all the time, that's this stuff, and how the conversion factor has to keep bouncing around. I'll just quickly move through some of these slides. We, from the SGR, faced a 27% cut. This is still going on now. It's been kicked down the can to, like, 2015, but it's still floating around. Right now for 2015, our proposed from the Medicare physician fee schedule for neurosurgery is an increase of about 1%, and you can tell we're a relatively small hitter for CMS. Neurosurgery looks like about $730 million allowed charges, and you can see where cardiac surgery is less, cardiology $6 billion. So some of our medical, if you wonder about CHF readmissions or why there's such focus on cardiology, it's because they're a much bigger fish for Medicare than we are, which is a good thing. Bundle codes. So once you learn this, don't think you're done, because there's a reason there's like a 2014 CPT, and there's going to be a 2015 CPT, and a 2016 CPT, because once we get everything kind of straightened out, then we change it all. Bundle codes are one of the ways that we've, like, changed it all, because CMS had the bright idea that, oh gosh, all these surgeons are reporting a decompression in the anterior cervical space, and then a fusion in the anterior cervical space, and they're always doing those two procedures at the same time. So if we put those together in one code, that would give us an excuse to, like, chop maybe 15 or 20% of the value out of that combined code, because there's probably duplication of work between these two codes that are being done all the time on the same patient at the same time, which is exactly what happened. We went from having decompression and fusion, 63075 and 22254, to our new combined code, which is a decompression and fusion together, 22551. And the valuation of that went down by, I think, between 15 and 20%, and it's because 95% of the time, people were doing a decompression and a fusion at the same time, so we came up with a new code. This is going back to, like, I think 2011 that we brought out that code. In 2012, we saw the same thing happen with the lumbar fusions, or the interbody fusion combined with a posterolateral fusion. The point is, not so much to understand the valuations here, but more to understand that this is an ongoing sort of moving target, and that list of people we went through before who are participating in this are constantly having to advocate and constantly having to go back through CPT and through the RUC to make sure that we maintain the valuation of the codes and the valuations of what we do. With these new kind of lumbar fusion bundles being the most recent significant combination in code that we've had in spine, at least, meaning putting your interbody fusion and your posterolateral fusion in one code. I think we had right at a 10 percent decrease in value, like, as that code came out. And it just changes completely the nomenclature that you have to use, and changes completely what your coders have to do in describing basic cases, like that single-level T-lift that we described earlier. So if that was bad, it actually gets much worse, and it probably will get much worse for you during your practice career. E&M, or Evaluation and Management, being seeing a patient in clinic, there are five codes for a new patient visit to a physician's office. And the degree of complexity in correctly doing E&M coding is horrific. It is amazing the amount of documentation and amount of information you really need. The definitions are kind of ungainly, and previously, frankly, when I would teach the coding courses, I would almost steer physicians away from correctly coding their E&Ms to make sure they got a lot of level fives, which are valued very high. I more kind of teach guys and girls, okay, stick it like maybe a level three. Don't try to be really aggressive with doing your E&M coding. Do a nice basic E&M, document to a level three at least. If you do a few level fours and level fives, and you leave that money on the table, it's okay. See a few more patients, because you're a proceduralist. So if you get one more patient, by seeing one more patient in clinic, you get one more procedure that more than offsets any money you're leaving on the table from the evaluation and management coding maybe being a little bit too conservative. What's a 90-day global? Please, come on. Is it a 90-day trip around the world? No. It's not an insurance policy for a surgery. Is it a bundle of payment for post-op procedures, or a bundle for post-op care? Any guesses? So it's D. It's kind of your post-op care. So seeing a patient, when you do a procedure on a patient, and there's a 90-day global, what you're saying is that for the 90 days after you've done that procedure, you're going to take care of that patient, you're going to see them in clinic, you're going to see them in the emergency room if you need to. If they need basic procedures that go back to that original diagnosis, it's all going to be bundled in. So you get paid of that bundle. That covers 90 days after the procedure. Now we are probably bringing an end to that, or at least CMS is discussing now kind of stopping all that and eliminating 10 and 90-day globals and going to where you just get paid for your procedure. That is a terrible thing for neurosurgery, because a number of our codes say craniotomy for a subdural hematoma. It's a very well-valued code, because it builds in a number of ICU days, it builds in a lot of critical care, it builds in a lot of outpatient, excuse me, inpatient hospital care, and then outpatient care. Because a patient who has a subdural is sick for the 90 days after you do their craniotomy for the subdural, it's assumed you're going to be taking care of them. So that's built into the code. Now in most facilities, you're also going to have maybe a surgical intensivist taking care of them, and maybe a neurointensivist taking care of them, and maybe your hospital is taking care of them out on the ward, and each of those physicians is submitting their own bill to CMS, which is okay, that's fine. Some of you may know orthopedic surgeons who do hips and knees and operations like that. How many people know, say, one of our colleagues in orthopedics who does sliding saline and so on for their post-op patients? Yeah, so we chuckle, because they don't really do that, because they kind of rely on hospitalists to take care of that, which is perfectly fine. But that in-hospital management for, say, a total hip arthroplasty, is built into the valuation of a total hip arthroplasty. And Medicare has kind of figured out, gosh, we're paying twice for the same thing. We're paying this E&M in the original CPT, and then we're paying this hospitalist to see the patient for the two days they're in the hospital, or the three days they're in the hospital. So we're kind of double-dipping. So how do we fix that? Well, let's eliminate GOBLs. So then we'll slash the procedure reimbursement by 50 percent, 55 percent maybe, and make you bill individually each time you see the patient in the ICU afterwards, each time you see the patient on the ward afterwards, and each time you see the patient in clinic afterwards. So as long as the original valuation is correct, and you're actually providing this degree of critical care and postoperative care, then you should be fine. It should be a wash. But if you have maybe two or three intensivists all sending critical care bills on the same patient with the same Social Security number on the same date, one of those is going to get paid, and two of them won't. So you're going to see, again, very, very bright on Medicare's part to be putting a ceiling on this, and again, to be driving down this valuation. It's not something that's happened yet, but it may be something where you have to learn even more in terms of coding by learning evaluation and management thoroughly, by learning how to do critical care coding, by making sure that you're able to capture that as well. Since, again, this is truly a moving target. Just as we think we have a good handle on it, things kind of shift again because we're dealing with many, many moving parts. Now, we haven't talked a lot about quality evaluation, PQRS, quality indicators, stuff like that. I haven't even heard that mentioned in this session. And yet for you guys, at your stage in your career, it's going to have so much more impact going forward than what it has had in mind up until now, but will have in mind in the future. The idea is there are payers, these are slides that United shared with us earlier, that are trying to break down, here cardiologists in Atlanta, into high-quality low-cost, high-quality high-cost, low-quality high-cost, and low-quality low-cost. And you can tell where they're going to want everyone. And as we look at value-based payment modifiers and a value-based approach to purchasing health care, there's going to be more pressure on facilities that are low-quality, high-cost or not, but also on facilities that are high-cost, and that they're going to figure out kind of an average number for how much it should cost, or how much they, how much it should require to provide a set of services, say cardiology care over a one-month period for a patient with CHF in metro Atlanta, and then figure out where you break in that group. And then figure out where your readmission rates are, where your ER visits are for CHF exacerbation, stuff like that, the kind of stuff you can extract from an administrative database, but then develop like a numerical model for a physician's performance. And then based on that model, either reward that physician or more likely penalize that physician if they're not reaching the quality and efficiency marks that are being set by the outside entity. Here, United, more likely CMS. Another thing you guys are going to get to experience in your careers is probably an absolute frame shift in how we approach reimbursements for procedures. We'll probably see within the 20 to 25 years that each of you are in practice a move from like basic fee-for-service to episodes of care and procedure episode groups, or an idea that you're going to get a bundled payment for a procedure, for your preoperative evaluation, your procedure, your postoperative evaluation, anesthesia, labs, radiology, inpatient hospital stay, ICU stay. Most of these are going to include your postoperative rehab and your postoperative physical therapy, all that put into like one payment. So Medicare writes one check and then has to cover all that, which means you're going to be able to have to advocate within that system for what slice of that pie should go to you, the surgeon, as opposed to the hospital, or to the rehab physician, or the anesthesiologist, et cetera. It's a whole set of considerations that we haven't even, we began working on, but certainly we don't have an answer yet. There are many different approaches to measuring physician quality. I don't want to go through this in any detail. This would be just a simple example of what was done with like lumbar surgery here on a pilot project that was ran by United, where they looked at a set of surgeons. None of these numbers and names are correct, this is just model data. Looking at different diagnoses, looking at how many patients ended up having a fusion, looking at what kind of fusion rates would be appropriate within a population, then comparing the surgeons in that population, and again, determining like how many fusions should be done for a set of diagnoses, and then defining who's doing too many fusions, or who's doing too few fusions, with about 2,000 physicians they're modeling from. The point I would offer, again, and kind of wrapping this up, is that the amount of data that's being collected on your practice is phenomenal. And it behooves payers, it behooves Medicare to understand that data, and manipulate that data, and from that data, to be able to predict your behavior as a practitioner. And if you fall away from those predicted values, or out of that like safe zone or whatever, then it becomes something where you may face scrutiny, or may face more issues in the future. So wrapping this up, and I've only gone like, oh, 15 minutes over. It's important to learn the language, and learn the language that's used in these procedures. There's no way I can cover that now, but it is something in the first couple of years of your practice that is probably going to be a wonderful return on investment, for you to learn the CPT, and learn the coding that applies to your particular subspecialty within neurosurgery. The impact on your career as someone getting started is going to be absolutely fundamental. Quality metrics and tracking physicians is going to become bigger and bigger, as we go into the next probably five to 10 years of reforming our healthcare system. Our transition to probably a bundle payment architecture, and away from simple fee-for-service, and more fee-for-service that's put in, the nomenclature and the structure of a bundle payment, again, is going to be a frame shift in how we approach reimbursement. And I'd also say you need to get involved. Quality Improvement Work Group always has opportunity for young surgeons to be involved. Coding and reimbursement always has room. We're happy to have young people, and kind of bring them up, kind of teach them coding and reimbursement, get them involved. Your state neurosurgical society and the CSNS is a great opportunity for you to meet other neurosurgeons, and again, be involved so that you can try to influence this process, and make sure that you're we, AANS, CNS, that you're leading organizations are able to advocate for your interests, and really be there to represent you nationally. And again, the AMA, for all the people kick it, Peter Carmel would always say, is the only doctor's organization that's in the crossword. So being a member of the AMA has, like, impact. And again, it's one opportunity where we have to make our voices heard, and to try to advocate for what we do. And more importantly, just to maintain the access for our patients to the care that we provide. Thank you for your interest.

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