It's six o'clock Arizona time, but it's seven o'clock, and I know that we are now starting our WNS webinar, Changes to Coding Evaluation and Management. On the line, we have, first of all, welcome to our Zoom meeting. John Ratliff and I will be taking you through these changes to evaluation and management that happened 11 days ago. I'd like to welcome everyone to yet another Zoom meeting. I'm sure that we've all had our fill of those. I hope everyone is well and safe and thriving as best as can be expected. We here in Arizona are not number one in the country. We're number one in the world with per capita positive COVID infections. We seem to be setting records every day. But as I was driving home from just doing an emergent case, the bars all seemed open to me. So here we are. John and I are gonna be taking you through this. So thanks everyone for joining us. We appreciate you being on. And I unfortunately have, or actually Lou and I both have a Rook call one hour from now. So we'll try to do about 45 minutes for the presentation and allow hopefully at least 10 or 15 minutes for questions at the end. But thanks to everyone for joining us this evening. These are our disclosures, which have absolutely nothing to do with the topic we're covering. If there's any question of those, please forward those to the WNS office. What we're gonna be covering today are the changes to the coding and evaluation management. It's always good to know where, the first question that many people are having, especially when I talk to some of my partners about this, is like, why are we doing this? What's the point of this? What's the point of yet another change? And so I think it's important to go through some of the rationale behind that, because there is method to the madness. Then we're gonna go through the summary of the revisions themselves, so that you get a sense of how these codes, it's not a seismic shift. It's not an ICD-9 to ICD-10 type of change. It's more of a logical step forward to make hopefully all of our lives better and easier with regards to documentation. We'll go through the code descriptors with a very granular detail, and especially John's gonna be spending some time on the medical decision-making, which is really the emphasis of these new codes. The benefits of this new coding scheme, which I can just say in one, in a nutshell, it's gonna be the auditing. You're not gonna be having to scrub through whether or not you did an ophthalmologic exam, whether or not you reviewed all 10 systems, whether you asked someone whether or not there's easy bruising. This is the, it's gonna be a more, it's a cleaner way of doing things. It makes more sense. We'll cover the RVUs. There's gonna be some detail, especially with some late-breaking legislation that has passed regarding the conversion factor. Of course, we all wanna know how to prepare our practice. We'll go over all of this, and we'll make it all very digestible for it. This is a CME activity. As such, we wanna make sure that the learning objectives for your CME with the AANS is clear. What we want everyone to walk away with from this webinar is understanding why we made these changes, because once you understand why we make these changes, it's gonna be more understandable how to apply these codes. We want you to identify why these new CPT, E&M revisions are needed and what the benefits are. Gonna summarize the key changes that took place already January 1st. And then we'll go through some coding examples so that you can achieve a facility with the application of these new codes. Now, this has already happened. If you've done any clinics, and I've done two, we're already using these new codes that have come into play. So, a quick fact to kind of frame our webinar is despite the fact that the majority of our revenue is coming from what we do in the operating room, up to 25%, and in some cases higher. I went back and looked at how much E&M impacts my practice, and actually greater than 25%. And this is, so this is very relevant. 25% of our revenue annually comes from what we do in clinic, comes from what we do in consults in the hospital, comes from what we do in taking care of patients. And so it's very relevant, very important, and important to get right. So, we got a letter from Medicare. This was way back in November of 2018. CMS Administrator, Sema Verma, she's not a physician, but her husband is. And if I remember correctly, and John, you can correct me if I'm wrong, but he is a critical care doctor or pulmonologist, I think. He is of the cognitive specialties. But she reached out to physicians regarding E&M coding, and the comments that she made resonated with them. Here are some of the comments in the letter. Current E&M coding scheme was developed in the 1990s. True. The nature of clinical work in medicine has evolved and is incongruent with that approach. We certainly can agree with that. Practice of medicine is now more patient-centric. That's very well demonstrated by the way we approach our neuro-oncology patients and the tumor boards that we do, the collaborative relationships that we have with our radiation oncology planning, the radiation treatments. That is a very germane comment that is made. Physicians use collaborative models in clinical work in teams in unison. Again, pain management, working in collaboration with pain management for interventions in spine, and working with our neuroendovascular colleagues for vascular surgery. This is all very germane. A major source of physician burnout is the documentation and burden associated with E&M coding. It's overwhelming. And so a change is, I think we can all agree, a change is long overdue. And as neurosurgeons, E&M coding is complex, out of proportion for the dollar value, even though it's 25%. I mean, the amount of times that I have gone and said, I don't think I have what I need to capture the work that I've done, and I don't wanna get audited. I've been audited in my E&M codes by United for level fours. They went through all of my level fours, and we've all been through something like that. Is it worth all the anxiety? Is there a better way to do this? And again, these code sets have been developed when I was still in medical school, and they are not really congruent with what we have in our changing healthcare system. Many of us have gone through focusing on the technicalities as opposed to focusing on the patient. And how do I, this is a lot of time and energy expended, but I can't code that because I didn't do an ophthalmologic exam. I didn't have a complete review of systems. We find ourselves trying to make sure that we take out our coding sheet on how we code. Did I get there? Or perhaps we have coders that say, hey, you missed this, you missed that. So I can't code that level that you have recommended. We think, and we all agree, that time would be better spent focusing on the patient, actually providing the care and not filling in the fields in our electronic health record. So we know that the current E&M codes were established. The basis of them were back in 1992. There's 1995, 1997 criteria. The choice of the E&M code is based on three key components, history, exam, and medical decision-making. Time is used as a key component when we are spending greater than 50% of the visit counseling and or coordinating of care. So 50% of that time is face-to-face time. 50% of the time is spent talking to the neuro-oncologist, talking to the radiation oncologist, talking to the other elements that may be involved in the care. And that's the only time we're using time. We've all seen this. We've all seen these images where we're trying to make sure that we are reaching all of the elements that we need in order to be able to get a level five, a comprehensive physical examination, which has several criteria, complexity of high medical decision-making, presenting of the problem, moderate to high, and being able to hit all of those boxes. And so these are the elements that I think that we should leave this back to 1995 and 1997. None of us have a cell phone from that era. Why do we have this coding scheme? And so patients over paperwork, the initial proposal was to say, hey, we don't want you guys to be focusing as much on attempting to code in a manner that is arcane, is Byzantine. We want you to focus on the patient. And so CMS actually, they came with their own proposal. Keep in mind, this is back in 2018. And their proposal said, hey, look, we're gonna take these five levels that you have, and we're gonna squash them all down into two. You're gonna get straightforward, and then you're gonna get complex. And so exist in binary. The documentation required for payment is only what you need for a level two visit for the straightforward, non-complex, and then a separate payment would remain for the most complex patients in whom they would get a level five. And so, again, the five levels collapse into two, simple and complex. It's like coding an aneurysm. There's only two categories. Patients' visits can even fall into routine or complex, and that was supposed to have started in January of 2019. So we listened to that, but we understand that that, number one, establishes a very dangerous precedent. Number two, it creates a system where the codes in the manner that we have valued them as a due process has not been employed. And so the AMA, the WNS and the CNS strongly objected to CMS just coming in and doing an end-around to a new coding scheme. Again, more than anything, this is a very alarming precedent to establish. CPT and the RUC establishes codes, values codes. That is how it's done. It cannot be done by CMS doing an end-around and arbitrarily deciding, hey, we wanna help you. Go ahead and let us give you this coding scheme. That's simply not, it's how it's done. And so how, what is due process to change a CPT code? Well, we all, if you remember the Schoolhouse Rock video or cartoons when we were kids on how a bill becomes a law, we could do something similar to that for how a CPT code actually becomes a CPT code. And the first step is that the AMA, which is the representative body of all physicians, comes in and gets input from all of the stakeholders. Then with multidisciplinary representation of all of medicine, internal medicine, specialty medicine, there's various specialties of the cognitive specialties as well as the surgical specialties. The CPT editorial panel comes together. Then the RUC creates surveys based on the recommendations from the CPT editorial panel. Valuations are established. Then the committee meets again. The new E&M codes are agreed upon, again, in a multidisciplinary manner. An RVU assignment is made. And that is how we have new E&M codes. And that is how the new E&M codes were established in this process, not an end around by a federal government agency, which would fall outside what we would consider as due process. So we, January 1st, 2019, came and went, and we did what we should do when we don't feel due process has been observed, and we kicked the can. So the chairs of the CPT committee, the AMA specialty RUC created a CPT work group on E&M in order to solicit feedback on the best coding structure to decrease, to accomplish those goals of decreasing the burden of documentation while ensuring proper valuation. A code application, what we call the CCA, was submitted through the appropriate channels. Again, this is due process. Consideration by the CPT editorial panel. And in February, 2019, they presented it and it passed. At that point, the AMA CPT developed a new set of E&M code descriptors focused on medical decision making or total time. Physicians can continue, and it's important that you can continue to use the current descriptors in the E&M code. So if you say, look, I got three years to retirement, as someone had mentioned to me on our earlier webinar. Yeah, look, if you've got something that works, you can continue to use them. Again, this is supposed to make your life easy, not hard. The descriptors allow for some time, both in before and after. For example, hey, look, I've got a patient with a recurrent GBM who's been treated at two different places. I'm looking at several studies. I'm looking at several treatment plans. I've been reviewing all of their clinical notes, previous MRIs. That's, this allows for, the descriptors allow for some time before and after. After a clinic visit, whether you are reviewing all of the interventions that have been done by a pain management physician before considering spinal cord stimulation. So all of these E&M codes have a pre-service and post-service time that's included. Again, the primary objective of the CPT editorial panel revision was to improve documentation. And improving documentation means that we need less of it. So it's reducing the burden on physicians for documenting. In the end, in the final analysis, I would have to say that these are improvements. And again, I emphasize the, when you don't have that much documentation, you don't have that much of a need for audit. I'd like to think that I'm audit proof, but I'm not. And a level four versus a level three is a, it can be a difficult, difficult to hit every time, every single point. And again, decreasing the unnecessary documentation, having to document the fact that the tetanus is up to date. How is that relevant for what it is that we do in the treatment of our patients? So the primary objective of the CPT editorial panel revision, once again, not to, oh, so we did not want to change the fee schedule. We did not want to direct more funds to outpatient. We wanted to keep the valuations the same. There's no direct goal for payment redistribution between the specialties. But we'll go more into that later because that was one of the, I would say, ideals that we wanted to adhere to. And we'll discuss that later. So now I think I'm handing it over, John, to you. We hit slide 26. Thanks, Lou. I'm gonna stop share, John. Yep. Everybody see my screen okay? So again, the key was no direct goal for payment redistribution. The AMA was quite happy with this work product. We centered our new E&M documentation and our E&M definitions around how physicians think, how they care for patients, and not on check boxes, not on copy and paste, but on the patient side of things. Not on check boxes, not on copy and paste, not on the work that was kind of built into EPIC with regards to filling out kind of meaningless, and again, clinically irrelevant documentation requirements for E&M. So these revisions only applied to outpatient services, the 201 through 215 family. Some of the key changes were that the history and physical was eliminated as a requirement for code choice. Now it's still expected that you're going to document a history and physical. That needs to be part of your medical documentation, but there's not a set number of elements or a set standard here. You're going to document what is clinically appropriate for a given patient's clinical setting. Providers will choose for picking code level, medical decision making, MDM, you're going to see it a bunch of times in this presentation, or total time. While the new definitions maintain the general criteria for medical decision making, there were some changes, and we're going to spend a few minutes kind of talking about that, like a little bit of time in the weeds going over what medical decision making means. 99201 was deleted. There's a prolonged services code that was created for people that are doing time-based coding and you need prolonged services. And even today, like Kathy Hill was sending us an email saying that there's a new work group at CPT looking at other E&M services that may be added to this effort, meaning that ER services, consultation codes, inpatient services, other aspects of E&M may eventually fall under the same general rubric. So we eliminate the history and physical. Your physician's work should still be documented, but those elements are not gonna determine your code level. So the new definition just notes a medically appropriate history and or examination, meaning that it's left up to the treating physician. You can now choose the value and the level of the code that you use based on either medical decision-making or total time. So medical decision-making. With the work group, we didn't really change the medical decision-making components, but there was a lot of edits applied to medical decision-making, and they really kind of completely rewrote this aspect of CPT. So again, we'll spend a little bit of time talking about that. They created a lot of clarifying definitions for the E&M guidelines in and around medical decision-making. Now, your other option is to code by time. And here, the definition of time for your E&M valuation is your minimum time, not your typical time. And also, this is a big difference. It represents the total physician or qualified health professional time on the date of service, meaning that it can include time you spend looking at the patient's MRI before or after you see the patient. It can include chasing down an EMG result and reviewing that EMG. It's not face-to-face time. So your definition of time was relaxed for these new E&M criteria. So again, not just face-to-face. Review a test, obtaining a history, performing your exam, counseling and education, ordering medication, et cetera, et cetera. Your EHR documentation. All of that stuff goes in to time-based recording. So it's not just face-to-face time. The total time for the new codes are listed here. The idea here was recognizing that the work involved in clinical medicine is not just face-to-face time. There's care coordination. There's review a test. There's other things that are involved in providing healthcare. Now, these definitions and the total times that you're seeing here on the slide, they only apply when the code selection is primarily based on time and not medical decision-making. Stanford, where I work, has recently done a HealthStream module that they've gotten all my faculty to take that really push using time-based recording and time-based coding in this new system. I'm not sure it's such a good thing. The main thing to remember if you're doing time-based E&M recording is that there are 24 hours in the day and you can't work more than 24 hours in one given period. A level five new patient, 99205, about an hour and a half. There's only a few of those you're gonna jam into an eight-hour-long clinic. So what are the medical decision-making criteria and how do we use that for our definition for E&M? So again, in building the new code definitions, the CPT panel used the basic CMS table of risks as a foundation, but then they added a lot. And the idea with doing this was to kind of maintain the audit tools and a lot of stuff that subcontractors use. You wanna be able to maintain that and not totally revamp the system, but speech definitions within the system to hopefully make it a little bit cleaner. Remember, everything you touch is... Somebody needs to mute. What comes to mind if I was to wash your hands right now? Well, medical decision-making is key. There are three categories to look at in medical decision-making and then four levels of complexity within each of these categories. And then you base your level of an E&M code on two of these three elements. So I just spent a few minutes going over this because again, I think this is the key element. Oh, excuse me. This is a key element and the key difference in how we code today as opposed to how we coded back in 2020. So there are number of diagnoses or management options and that's quantified minimal, limited, multiple or extensive, amount and or complexity of data, risk of complications and or morbidity or mortality. And then from those three categories, based on two out of the three elements, two out of three of those categories, you pick your type of medical decision-making. And then there are four. There's straightforward, low complexity, moderate complexity and high complexity. And digging through that in a little bit of detail, 99211 was eliminated. So you're straightforward or level two, 99202 for a new patient, 212 for a follow-up, straightforward medical decision-making, meaning two out of three of these, minimal problem. So it's gotta be one self-limited problem or something minor. Complexity of data is minimal or none. The risk of complications, minimal or none. So I did not just describe a neurosurgical patient. Let's go right to a level three. Here, your medical decision-making is low, meaning two out of three of either number and complexity of problems being low. So two minor problems or two self-limited problems or one chronic problem or one uncomplicated illness. And then a limited amount of data. Any combination of two from the following. And again, two categories here where you pick one out of the two. So one is tests. One is assessment requiring independent historian. So the test would be review an external note, look at unique tests, ordering unique tests. That's pretty much every day. And risk of complications, low. Again, not common for neurosurgical patients. Then you get into level four and level five. Moderate medical decision-making in a level four, meaning two out of three of these. One chronic illness with an exacerbation. Two stable chronics. Or one undiagnosed new problem. A moderate degree of information that you review, meaning one out of three categories. One being tests. And again, looking at external notes. Reviewing results. Category two, independent interpretation of tests. So that's your neurosurgeon looking at an MRI. You pretty much automatically get a category two on every single patient that you see. And category three, discussion or management. So that's calling your referring doc. But looking at tests, doing that independent interpretation of tests, that's almost every single patient that we see. And then for risk, moderate risk of morbidity from additional diagnostic testing or treatment. So what does that mean? That's prescription drugs. Minor surgery with identified risk factors. Major surgery without risk factors. How many of our surgeries don't have risk factors? Then you get to level five. So that's a high intensity of medical decision making. So chronic illness with a severe exacerbation or one acute or chronic injury that poses a threat to life or bodily function. And then two out of three categories for your data interpretation. Same definitions that we use for the level four. And here it's test documents, meaning checking labs, independent interpretation of tests, that's looking at an MRI, or calling a referring doctor for decision of management or test interpretation. And then high risk, morbidity or mortality for diagnostic testing or treatment. So elective major surgery with risk factors, any emergency surgery, having to hospitalize a patient, that's a high risk. That puts you to a level five for your new patient and your follow up visits. So just to belabor this a little bit, a level four new patient visit, two out of three of the following. A moderate number of diagnoses or management options. One acute illness or one acute complicated injury. Two stable illnesses or one chronic illness with exacerbation. A moderate complexity of data. Looking at lab results. Looking at imaging. Discussing a management. Looking at the patient's outside notes or the patient's referral note from their primary care doc. Or ordering tests. Each of those actions gets you points towards that moderate complexity of data. And a moderate risk of morbidity. That could be prescribing a drug, a decision requiring minor surgery, or major surgery without risk factors. So there's also a shorter, prolonged services code that was created. And that was to capture your physician or health professional time in 15 minute increments. That's reported in addition when you're doing time-based recording to 99205 and 99215. And that's only done when you're doing your time-based recording. So again, just going through how these definitions are a little bit different. Your new patient codes in 21. Levels two through five. Medical decision making straightforward through high. And your total time is recorded here. With a level three being a minimum 30 minutes. A level four being a minimum 45 minutes for total time. Now, how does that change these descriptors? So back in 2020, our previous definition in 203, three key components which are bolded here. Detailed history, detailed examination, and medical decision making of low complexity. So you needed all of those back in 2020. With typically 30 minutes spent face-to-face. So our new definition in 21, we've changed all that. So now, medically appropriate history and or examination and a low level of medical decision making for a level three new patient visit. When using time, typical time is 30 to 44 minutes. So for an established patient, that's a 212 through 215 levels. Very similar architecture. You progress from straightforward to high. And your total times increase from a minimum of like 10 minutes for a level two up to a minimum of 40 minutes for a level five if you're doing time-based recording. 99211 is a level one established E&M that's still available, but the code descriptor doesn't include a time reference. So I guess presumably if you're doing less than 10 minutes or if it's a nurse visit, 211 is gonna be the code that you use. So your 212 and 215 look a lot like the new patient codes in 2021. So for the established level three in the new definitions for 2021, medically appropriate history and examination and a low level of medical decision making. This established patient's code, 20 to 29 minutes of total time is spent on the date of the encounter. And Lou, I will stop sharing and turn it back over to you to pick up for the next set of slides. Okay. All right. So, hopefully everyone can see my screen now. We're gonna transition to application of these codes with a knowledge assessment and just take a situation that very common for those of us who see patients with spinal conditions in our clinics, which by our count is probably 60 to 70%, probably most of the people on the call. I see that Kathy Mazzola is in there. So her follow-ups will be very different with her pediatric practice, but you have a 42 year old woman, established patient returns to the clinic for follow-up over improving lumbar radiculopathy after undergoing injection. So you meet with her, you perform a medically appropriate examination, say it's an L3-4 disc herniation. So you're going to do an examination, which makes sense. You're not gonna be checking her, I wouldn't, I'd be bicep or tricep, but you already have examined those. So you're getting a, you're gonna check the patellar tendon reflex, check the quadriceps strength, do a sensory examination. You'll go over a, her MRI again with her. She's getting better. You talk about the natural history of lumbar radiculopathy. Talk to her about her options if symptoms come back, but if she's doing better, you're gonna recommend continued non-operative measures. The whole, you're not doing this by time and you're doing this by the fact that you've seen her, examined her, discussed natural history, reviewed the injection notes, make sure that they injected her at the right level and talk to her about her various options afterwards. So the most appropriate code for this encounter that captures all of this is actually gonna be the 99213. Based on everything that John has gone through, you've covered all of that. Discussing the patient, discussing the outcome from a intervention you recommended, reviewing her MRI once again, and talking about the natural history and intervention for follow-up. If you're doing it purely on time, you'd have to document that you did all of that in 20 minutes, 20 to 29 minutes. So again, level three follow-up requires a low level of medical decision-making. According to new documentation rules, history and physical are no longer required, but only to be performed if medically necessary. Basically, that means that you don't have to go through the entire, your subjective as the patient is returning for follow-up after injection therapy, where they injected, dates of injection, things like that, things that are relevant. So now let's discuss some of the benefits because these may not be immediately apparent at first glance. And so again, what are the benefits to us? All of a sudden, instead of going through and saying, did I do an ophthalmologic exam? Did I go and auscultate the heart and lungs? Did I do all the things that I need to for my physical examination? We can focus on taking care of patients, doing what makes sense for our practice instead of performing unnecessary documentation just to meet these outdated requirements from 95 to 97. We have an appropriate coding and payment pathway based on a clinical decision. We can either use medical decision-making or total time. I think that time is very valuable so that you, especially in those circumstances, I think of, when am I gonna use time in a level five? I can tell you exactly, it's the patient that I have to bring in at the end of clinic who a referring doctor says, I've got a guy with metastatic lung cancer that's impinging on his cord, his ambulatory, can you see him? That's a patient who I'm gonna bring into clinic, sit down, have a long conversation about the panoramic view of what we're gonna do, likely be admitting the patient from my clinic. And that's gonna be a level five. And I can now just say, okay, I'm gonna code this on time and I'm going to, that is a clinic appointment that just, it takes the time it takes because of the circumstance that the patient is in. There's a greater clarity in the definitions and it is my belief that this will certainly decrease our risk of being audited because it's just that much more straightforward. Payers are gonna like this because of the greater clarity in the definition, may need also lower degree of audits, it's streamlined for time reporting, medical decision-making, and should be, from an administrative standpoint, more straightforward. Healthcare systems and hospitals will, again, see it at decreased administrative burden. Physicians will focus more on the patient, less on the Byzantine system of documenting everything that needs to be for the various codes. And again, greater clarity in definitions should lower that audit risk. So let's go now into the valuations. Now that we have these new codes, what do these new codes translate into? So it is important, again, I talked about the due process of why we did not allow CMS or why we were much against and were successful in our effort to not allow CMS to do the end around, but rather to have this evaluated through due process. So 52 specialty societies participated in the RUC surveys. To include 1,000 neurosurgeons were selected to evaluate these codes. Maybe some of the people on this Zoom call were asked. The survey asked in particular questions about physician work, practice expense. And from all of that, we are able to get these RVUs actually increased so that the two has not changed. The three did bump up. And while these look like modest bumps, after a year of work, and certainly after five years of work, all of this adds up. And so the level five code got the greatest bump, everything else got a modest bump, at least it's going the right direction. These are going to be the established work codes. And again, not as significant of a bump, but nevertheless, a positive trajectory and positive trajectory in this day and age, I feel is a win. So with the new valuation, all of these codes go up except for the level one, obviously, the five is one that increases the most. A .33 increase doesn't sound like a lot. But keep in mind 2.8 million 99205s are recorded in the CMS database for 2017. So it's, it's quite a few and it adds up quickly. Conversion factor, we all are familiar and those of us who are not, the conversion factor is how we get paid, you multiply the conversion factor that Congress agrees upon by the RVU. And there you have how we get paid. So the problem here is that we have to have a budget neutrality. So CMS will need to decrease the conversion factor they base payments on to cover the expense of the new E&M valuations. Again, conversion factor is how we get paid, which turns RVUs into dollars and determines the value of the services that we have. Shout out to Katie Eureka, who has actually gone through and has taken the various common codes that John and I kind of sent her way that cover bread and butter. And she has these available from the Washington office. And I thought it was incredibly insightful. But at the end of the day, the, the E&M services. So keep in mind that when we, when we have an RVU assigned for say a microdisc, the 63030, 40% of that entire physician fee is going to be part of the E&M code for that. So that it's the work that we don't do while in the operator group. So this is from the CMS website and it's how we get our payment. So the payment is going to be the work RVU, the practice expense, meaning that it's more expensive to practice in Manhattan than it is in Columbia, Missouri. And so that practice expense has to be incorporated because the, the, the cost of rent, the cost of hiring an MA is all much more expensive than the malpractice, which has to be incorporated into the equation. So all of those are generated into the, all of those are added up and then multiplied by the conversion factor. Again, the conversion factor is decided by Congress. There is some initially alarming news, which becomes less alarming, which we're going to cover. And this is all late breaking that Katie from the Washington, Katie Rico from the Washington office was able to hand us just a nick of time for us to get these slides right. So the conversion factor translates RVUs into dollars to create, to create a fiscal balance. When E&M values goes up, something else has to go down with a decrease in the conversion factor. Everything else in the fee schedule goes down because we multiply it by that conversion factor. And that's what allows us to maintain budget neutrality. Now, private insurance contracts negotiate on a percentage of Medicare tied to the CMS conversion factor can be potentially affected. It all depends on how you negotiate our contracts. Our contracts, my shop are not necessarily tethered to that, but some are. And so all of this has ramifications because it will affect our entire flow of revenue into our practice. So John is going to update us more, but right now this is what our reality was initially. So CMS released its Medicare fee, a physician fee schedule proposal for August or for 2021 in August 3rd of 2020, the conversion factor dropped $3 and 83 cents. That was a significant amount. Today, prior to, or not today in 2020, it was $36 and nine cents. That's what we multiply our RVUs and it dropped to 3226. That's before more recent legislation came through. And so for that, that would have translated to us as a 7% cut on, on all of our Medicare billings. So the, the problem with that is that what became as a documentation and burden reduction project has led to a significant payment redistributions. Why? Because we are taking a hit with RVUs. One more step to this, this equation, the E and M component of an RVU code for a surgical procedure did not increase commensurate with the other increases that we've seen in the, in the E and M codes, meaning that the increases in those codes did not get brought into the E and M component of a surgical code. And so that creates a disparity. The WNS, CNS Washington office has now been working on this. There's significant advocacy to remedy that. Again, the increases in the E and M codes that we're seeing when we see patients in clinic are not translating into the E and M component of our surgical codes. So this is a slide from the surgical care coalition, which we're participating in the WNS, CNS, spine section, CS and S are all involved in, in contributing to this because in the end, this is what is going to be unfavorable to surgeons. And I think John, this is where I hand it off to you, or do I go one more slide? I think you're taking over from here to kind of address all that. Sure. So I think the key would be in terms of, let me go back one slide. So the surgical care coalition is a group that came together of multiple surgical societies. The college kind of championed this. We were some of the initial surgical subspecialties to sign onto it, both WNS and CNS, the spine section and the CS and S, the councils of state neurosurgical societies, all made significant financial contributions and even greater contributions of our time in this effort. But the idea being that by pulling together, by doing focal marketing and by kind of getting the story out, that we could illustrate how these cuts are going to be very deleterious in the middle of a pandemic to surgical practices. And for some practices, I'm sure it would have been absolutely devastating to take a 7% cut on top of having all of your elective surgeries canceled for a period of months, and on top of patients being scared to come into your clinic. So there were the Barron-Bouchon Bill 8702 that was proposed and moved forward and developed a number of co-sponsors also came up in the Senate, and we ended up with a Consolidated Appropriations Act of 2021. That's an omnibus spending package that funds the government through 2021. There was a very sizable section, which we don't have time for here, going over surprise medical billing. We will go over that in future presentations. There's a provision and a fix for surprise medical billing that I think we and most organized medicine we're pretty happy with. But the key in terms of the framing for today's conversation is that we reduce the budget neutrality impact of these new E&M valuations through modification of the conversion factor. So if you have to wonder why you're a member of ANS and CNS and why you hopefully give money to the neurosurgical PAC, or should start giving money to your neurosurgical PAC, it's because of things like this. So the fee schedule payments increased by 3.75% for 2021. The 2% sequestration was suspended through the end of March. The complexity add-on code that we mentioned way back at the beginning of this presentation, which independently was going to add about $3 billion to E&M from Medicare was delayed with regards to its implementation through 2024. These changes led to a revision of the conversion factor, where the conversion factor came up to $34.8931. So it's still down, but it came up significantly from what budget neutrality would have necessitated. So the projected change now, if you look kind of two up from the bottom, neurosurgery, oops, $811 million of Medicare charges projected for 2021, our projected cut with the previous final rule was going to be a drop of about 6% with regards to our Medicare reimbursement. And that came up to us being about neutral. There is zero on the final rule. And if anything, the internal medicine and our internal medicine colleagues that saw increases will see even greater increases with this new approach and these new definitions in this new omnibus bill. So what's the impact on neurosurgery? If you kind of break it down into codes, Katie was coming up to put this together for us. 22551, anterior cervical discectomy infusion. In 2020, we were paid $1,782.10 by Medicare, that was going to decrease to $1,637.28. The new value came back up. So a projected change simply with the new bill was adopted to fund the government for 2021. That's $115 for every single ACDF that you do. It is still slightly down from 2020. 1% down. And if we look at each of our codes, there's a small decrease in each of these procedural codes. But remember, there's a substantial increase in the E&M codes. So the projection from the AMA and from excuse me, the projection from CMS in this space, is that neurosurgery will end up at about the same point at about 0% change with the new fee schedule conversion factor implemented. So what's not affected by these new codes, Lou kind of touched on this. These changes don't affect all of E&M, hospital admissions, consultations, emergency department, any other E&M remains the same. The only thing that's being changed is a new patient outpatient visits. 99201 was eliminated, and your established patient outpatient visits. Now, will CPTs within a global increase, and Lou had touched on this before, like how we value procedural codes is predicated both by the amount of time and the intensity of the procedure itself, but also evaluating the patient preoperatively and seeing the patient back in clinic postoperatively during the 90 days of their global. Generally, if we increase or decrease or in any way change E&M, we also change the value of the procedures that have E&M visits built into them. But here, we didn't change anything. No, we left the global values the same. So the value for our procedure is not going to change, meaning their surveys for the RUC in the future are going to get much more confusing. So it's really the first time since we started the RBRVS system that we're kind of paying different positions differently for the same work. So it's unusual. It's something we pushed against substantially. We do worry that this may compromise relativity within the fee schedule. Now, we'll continue to work on this and advocate. So how do you prepare your practice? Hopefully, you've already prepared your practice since these changes already took place. But one of the keys is education. Surgeons need to understand these changes and make sure you're documenting your encounters. Your practice manager needs to make sure your EMR is ready for these changes and your coders know these new definitions to select the correct E&M visit. And of course, with your payers, making sure that those changes are incorporated as well. Your various commercial payers, you have to consider for your, if you're RVU-based, like a hospital-based position, the RVUs here are probably going to go up because your E&M is going to go up. The conversion factor doesn't change RVUs. It just changes how Medicare converts an RVU to an actual payment that it makes to a physician's practice or to a physician's employer, if you like subcontract, say for me to Stanford. So that's something to look at. And then your vendor or practice contract, your software may need to be changed and updated to make sure that you're ready for these new documentation requirements. So a quick summary. So we'll have a few minutes for questions. So we went through some of the background of how we ended up with these new definitions of this new system, reviewed kind of a summary of the revisions in CPT regarding new patient and follow-up patient evaluation and management codes. We talked through the new code descriptors and what this new coding scheme looks like. We kind of went over what work RVUs are and the new conversion factor and how that changed with the legislation that just came out at the very beginning of 2021. And hopefully we gave you a little bit of insight in how to help prepare your practice. So in terms of meeting our learning objectives, hopefully we went through and explained to our attendees what this rationale was, why these CPT revisions are needed and the potential benefit that these revisions provide. We summarized some of the key changes and brought you up to date with legislation that just came out like a couple weeks ago. So now you are up to date and where we are with regards to physician reimbursement for 2021. And hopefully we help you develop a facility in application of these new codes to your patients. And with that, these changes took place on January 1st, 2021. Hopefully with this webinar, you're better prepared for coding going forth for the rest of the year. Thank you very much for your attention this evening. Good luck. And we will open the text box and open the floor for any questions that attendees may have. And again, thank you very much for your attention. So one of the questions I see that Katie put up, are private payers still using the consult codes, even though Medicare no longer uses them? And I would say, yes, they are. Even at our house, we will still bill out like consult codes. And we are about the most conservative entity imaginable. We will still use consult codes for our private payers. Lou, what do you do at B&I with consult codes? We've shut them down and most of our payers are not paying those. So they've followed Medicare. So I wonder if that's going to go to the way of the dodo bird. So going back to a previous question, does time spent researching patient's problem to make a decision outside clinic setting count towards the time? I'm actually not sure if that's a good question. Towards the time? I mean, I would say yes, it does. If it's the same day. I mean, the entire point is that it's got to be the kind of the same calendar date. So if you're looking up something, doing research on a condition, and then educating the patient about what you've learned, then I think that's a valid application of time-based billing. If anybody else would like to tap a question or type a question into the chat box, we'll be happy to field them. Shannon, is there a capacity for anyone to raise their hand to verbalize a question, or they don't feel like typing, or if someone's calling in? I can look to see that, but we did just get another question in the chat. Ooh, I don't have that. Let's see. Oh, maybe that was the one you were just talking about. I apologize. We have just the Q&A, if they want to put anything in there. Corinne put something in the chat. If you see a patient with a nurse practitioner or a PA, am I confirming that you can add the time together for time-based billing? Is the PA working for... So that's a really good question, and I don't know the answer to. See, if it says yes, I don't know that Medicare is going to say yes, but I think by CPT definition, that's legal. Now, I am not sure, nor would I definitively state that Medicare is going to agree with that. Again, my personal bias, I still think medical decision-making is much easier to use than a time-based billing, especially if you're seeing 20 or 25 patients in a clinic doing time-based billing. And if you get audited with time-based billing, I mean, I feel I can document my medical decision-making in a pretty time-effective fashion. And in my hands, at least, I think it's a little bit safer to do that than to do it purely time-based. How do you feel? Hungry? Hey, John, it's Kathy Mazzola. Hey, Kathy. Thanks for joining us. You're very welcome, and thank you guys for doing this for us. I have a quick question for you. Very often, if a patient calls to schedule an appointment, my MA and my nurses may spend literally hours hunting down the child's MRIs, getting the images, getting the discs, things like that. And so that may involve hours before the day of the appointment. On the day of the appointment, because all these things are now available, I'm able to review all of these things. How do you build in the time spent by your nurses and MPs and clinical assistants in retrieving the endocrinologist notes, the MRIs, and all of these things? How do you incorporate that time spent into the day of visit? That's a good question. For the new E&M definitions, the practice expense that rolls into those definitions actually was structured to capture just what you're saying, because it's not just our practices that have to deal with chasing down medical records and talking to EHRs that won't talk to each other, et cetera. So a lot of our primary care physicians and a lot of our cognitive colleagues, for lack of a better term, do this same crap all the time. So as we value these new codes, the practice expense portion of that supposedly encapsulated and captures some of that work. Now, it's not gonna capture hours of work by your medical assistant. There's really no way to capture that or build that in. The MA's not gonna be able to build for that time. But the practice expense for these new codes and the increase in value of these new codes, part of the argument was exactly that, just the increased complexity and the amount of work that has to be done prior to the patient being seen in clinic. So that is built into the value of the code, but as a physician, you don't build that out. You just build out the time, if you're doing time-based billing, the time that you're gonna spend on that patient on that single calendar day or whatever day you're billing it. Now, if the patient has that many records and that much data that you have to pull up, then that's automatically gonna push you more into a level four or level five if you do a medical decision-making-based billing. So you'll capture some of the billing there, but there's no direct way to capture what your extenders, what your medical assistants are doing on the days before you're seeing the patient. And I'll see if Lou wants to add anything to that. No, I think you've covered it all there, John. The question in the chat box, will this PowerPoint be emailed to all that attended this webinar? Sharon, can we share like a PDF or share a deck? Absolutely, they'll be in my courses and I can also email them to them for the slides as well. Very good. And I think you're at the eight o'clock mark. We're gonna go advocate for greater reimbursement for decompressions with fusions now. So our work is never done. Lou and I get to leave this webinar and go directly to a RUC call to talk about the RUC meeting, which is gonna be later on this week. And again, thank you guys so much for joining us. We really appreciate you taking an hour out of your life to learn more about E&M coding and to prepare for these changes that just came through on January 1st. And we're happy to have been able to update you with some of the positive changes we are able to affect with our Washington office and with a joint advocacy effort led by WNS and CNS with the assistance of the CSNS and the spine section, along with the American College of Surgeons and a number of other surgical specialty organizations. And it's always good to be able to give positive news and kind of good feedback to our members. So again, thank you for joining us. We really appreciate you taking the time. Have a good evening. And thank you very much, Lou. Thanks for your help with this. Yep, stay safe everyone. Thanks guys.

coding changes

evaluation management

E&M

January 1st 2021

coding system revisions

new code descriptors

physician reimbursement impact

conversion factor

RVUs

practice preparation