Lori: Hi everybody and welcome to "Audit with An Expert Series," where we are going to take you through five different specialties, one on each one of our series. We're gonna do primary care. We're gonna talk about pediatrics and a few others. So make sure that you tune in to this one as well as the future ones that will all be posted on our website. And I'll talk about that here in just a little bit. Thank you for joining us. My name is Lori Cox. I am one of the regional directors here at AAPC Services, and I have two of my favorite people to do presentations with. I have Charla Prillaman and Elizabeth Hylton. Thank you guys for joining me again. I'm so excited about these webinars.

We are going to briefly on this first webinar...this is series one in our series of five. We're gonna start with an overview of the changes. We're gonna talk about the time requirements, the medical decision-making. And we're just gonna do that on this first one. And then, we're gonna get into three case examples, and we're gonna dissect those for you. And we're gonna kind of give you a look into our thought process when we're auditing these, and hopefully, that'll help you as we move into 2021, what you're gonna need to be thinking about as you start auditing some of your cases for 2021. And then in the rest of our series of presentations, we're just gonna jump right into those case examples. Now, I do wanna say that these webinars were written for coders, auditors, or physicians that have a basic understanding of what those changes are going to be.

So you should know by now a few of the elements that are required, but let's go through some of those just really briefly here. So effective January 1st of 2021, we are going to select our level of E&M visit based on MDM or time only. Now, it's very super important to remember, if you don't take anything else away from this webinar, it's that you know that these changes that we are talking about only affect 99202 through 99215. So these are your new and established office patient visits. These changes do not affect consultations or ed or hospital visits, nothing else except for 202 through 215. So please keep that in mind as we go through. And then 99201 was deleted just because it had the same MDM as 99202, so we really didn't need that anymore.

Let's look at time briefly. These are the new time guidelines that will be published in the CPT book. They are a little bit different from what we're used to, so make sure that you're familiar with these time guidelines, and as we go through and dissect our cases, you'll see, well, how we use these. It's important to remember that you don't have to worry about the counseling and coordination of care anymore, it's just the total time spent on that day. And then the medical decision-making, it has changed. There are still three parts as we had before, but they have been redefined, that you're going to still be looking at the number and complexity of problems addressed. So we'll kind of discuss that a little bit. The data has undergone a significant overhaul, and then the risk of complications. So it's important to...like I said, if you don't have that basic knowledge already of what these changes are going to be, definitely, go to our website, go to the AAPC website and make sure you get that education on those basic elements.

So now that we've gotten through just that brief overview, let's start with a case example. Now, these cases are all primary care cases. So you're looking at it from a primary care perspective. And to kind of save some busyness on some of the times, I didn't always include the full family, social history, and that kind of thing, because there's simply...it won't matter anymore really when we're looking at these cases. Now, it's important to know they still have to be documented because in some cases they will help us decipher what our MDM is saying. But in the ones that we're using an example, sometimes we just simply didn't need it.

So we're gonna start with Case 1. So, Charla, Elizabeth, we're just gonna keep a really open dialog here. And as you can see in this one, I really just kind of put a brief HPI and then an assessment and plan. So who wants to kind of take a stab at this?

Charla: Well, the first thing that I see is we've got a lot of lines with type 2 diabetes as part of the descriptions. Do we count each of those as a separate problem?

Lori: That's a good question. Elizabeth, what are your thoughts on that?

Elizabeth: I would say that the diabetes itself would be counted as one condition, and then we would also count the individual manifestations, especially if the provider's looking at those and treating them.

Lori: I agree. Right? So we're just gonna count the type 2 diabetes once, but then what is he...? He's got hyperglycemia, CKD. We've got... What else do I see here? Hyperlipidemia. Right? So we would count those manifestations, and then we also need to be counting the CAD, right? The sclerotic heart disease. He does say suspect obesity, but we don't use those, right? As suspected. Hypertension, hyperlipidemia. What else do you guys notice about this note?

Charla: We wanna be careful not to capture the CKD twice because it's listed by itself as separate on number five, and as a manifestation on number two. So, I think we have to be careful that we see what he's addressing and what he's not addressing in order to capture our Chart A information. So I see that he's addressing the diabetes. He is...Is he addressing the CAD? I don't see it on line 3 unless it's somewhere else.

Lori: He only says that it's clinically asymptomatic, right? Under, like, where it says Patient Plan.

Elizabeth: Bare minimum.

Lori: Right.

Charla: And we have those definitions that really talk about what does addressed mean, so maybe we have to answer that when we look at the chart.

Lori: I agree with that.

Charla: Same with the kidney disease. He's saying he has it, we don't... Now, we see with the hypertension, he's referring us to some scanned blood pressures. We see that he's ordering a CBC and a CMP. And with the hyperlipidemia, he says it's stable. He's gonna get a lipid panel.

Charla: I think we have at least three things that are addressed because I think the request for those labs are addressing the problem.

Elizabeth: Absolutely. And some of those lab values technically could be used to monitor the CKD, but I feel like a best-practice perspective would be to explicitly state it.

Charla: And they probably...you know, some of those big panels give so much information. They probably give information about more than one condition.

Elizabeth: Correct.

Lori: So, I noticed here that he says total time spent with the patient is 15 minutes. Why can't I just say, "Oh, there's my total time," and move on?

Elizabeth: I was just about to say something about that, Lori, because it would be so easy to level based on time, it's right there, but that only gets us to a 99212. My auditor sense is tingling when I look at eight different diagnoses and the amount of data that's gonna be mined here, the amount of management that's taking place. All of these conditions have the potential to play off one another and create a real perfect storm of issues chronically. So I don't think it would be fair to the provider as a capture of his cognitive work put on paper, which is what the definition of an E&M service is, to download code it in such a manner. I really do feel like the component of medical decision-making should rule in this case.

Charla: I agree, Elizabeth, and the rules or the new guidance very clearly says either/or.

Elizabeth: Correct. I feel like it's really gonna be a trap that some providers could fall into, especially when time is so explicitly stated. "Oh, that's all I need." And then they're short-changing themselves if they follow only that.

Charla: Right. And if you think that an established patient 99213 historically could be supported in a 15-minute time slot, that's a Level 2 now. So, you know, I think the services remain the same, how we capture them is what is different. And this patient, to me, needs a lot higher care than what is represented by a Level 2 service.

Elizabeth: I agree.

Lori: So, Charla brought up...we talk about Chart A, B and C. So I have some of those laid out here. So let's look at Chart A. Now, for our listeners, if you're looking for an audit tool, there is one on our website. It's www.aapc.com/business. You can go and download a free audit tool. I know there's several out there that have been created, but this is the one that we are using. So based on the note that we just looked at, what are you guys thinking? This is definitely not one self-limited or minor problem. Right? We know that. But where does it fall here?

Elizabeth: I definitely would put it in the moderate category. Charla was very succinct with going through and specifying this one, this one, this one, and we were two-plus easily with this.

Lori: Oh. And they seemed to be all stable. I didn't see anywhere that said anything had any severe exacerbation or was life-threatening or, you know, an acute life threat. Right?

Elizabeth: Correct.

Lori: So I think moderate. And if I click, hopefully, my little box comes up. Yes. So my little X is there. So that's where, I think, we all felt, like, really comfortable with. So you can see how we fill out Chart A. Now, let's go to Chart B. Now, Chart B is where things can get a little confusing because we have all of our wonderful tests and documents, then we have our independent historian, interpretation of tests, and discussion or management, which all I really saw, I believe, was tests and documents. Do you guys agree?

Charla: I agree. And, you know, what might fool our people, particularly our physicians who have been taught over the last 20 years with a chart that looks almost like this but a little bit different, that you can only count each kind of test once. So remember...I can't tell you the number of times I've said whether it's one lab code or all the lab codes known to CPT, you only get one point. Now, a point is afforded for every single unique test.

Lori: Absolutely. I'm gonna back up to that slide so we can see how many tests do we count. So we have an A1c, microalbumin, I'm assuming.

Charla: You think that's creatinine?

Lori: Yes. So three. I thought I saw another one.

Elizabeth: CBC.

Together: CBC.

Charla: And CPK and lipids.

Lori: And lipids. So I'm getting six, and there might even be more buried in there somewhere. The good thing is we don't need quite that many. So we'll show you that here in just a second, but we know that he ordered several tests. So then on our audit tool, what we would do is we would say that he ordered six tests, or whatever the number might be... And now it's gonna stop working. Oh, I know. I think I have to click down here. There we go. Okay. So that gives us six here. Gotta put the wonderful math skills on, but thankfully it's only times one, right?

And then, so we wind up with a six total, and that gives us a data level of moderate. So let me show you where I got that from. This is from our Chart B calculations for data. And I know it looks a lot busy, but once...it's just like any audit tool, once you get the hang of it, you're gonna be able to figure this out. We had at least three-plus tests and document. We didn't have anything else. We didn't have any interp, no discussion, nothing else. So moderate is where we end up with. And that's where I ended up with the moderate here.

Charla: So, if you have just three tests, then you have moderate?

Lori: Mm-hmm. Yeah. So three is the most, really, that you need to count. Right. So think of that as a time saver when you're looking through your audits, how quickly...how many tests was there? Once you get to three, that's great. And then look for your other items. So that would be our Chart B, and then chart C is our new risk table. So remember that busy risk table that we had that was like, "Ugh, it's hard to read." Now, we've got this one risk table. Now we have to figure out, how much of a risk is this patient? And we have some examples that are given to us that kind of still reflect what was on the old risk table, but where would you guys...I think we can rule out minimal. I mean, she was not minimal risk, she had tons of stuff going on.

Charla: And I think we can rule out low risk for the very same reason.

Lori: Yeah, because she wasn't given any over-the-counter drugs or just PT and OT, right? She at least had prescription drug management. They did talk, I believe, about prescription drug management. Is she a high risk?

Elizabeth: I would say no, simply because the provider does take great pains in his assessment to let us know the patient's asymptomatic or they're stable. That type of language really does steer me away from thinking, "This is a worrisome patient."

Lori: Right.

Charla: Right. And I always think about, when are they having the patient come back? You know, if it's six months out, or a year, or tomorrow, or even next week, in some cases, might qualify in the high risk. You know, I wonder if morbidity is a word that we should talk about a little bit. You know, high risk of morbidity doesn't mean the patient's gonna die.

Lori: Right.

Charla: And, I mean, you know, ultimately, we're all going to die, but in this context, it's when, you know. And how is the physician thinking? I think Elizabeth said it best. She said... What did you call it? Cognitive...

Elizabeth: Cognitive effort.

Charla: Cognitive effort. You know, we're almost reading his mind or her mind, "How sick is my patient, and what must I do for them to prevent deterioration and to, you know, optimize their health?" So, in this case, I would've expected to see language that said, "I need to get a stat test to evaluate, I need to get 'em over for a heart cath. I've gotta do, you know, something kind of immediate." And as I read that note, it seemed like the physician very clearly identified, while the woman has a lot of things going on, nothing's acting up at the moment, we'll maintain, you know, our pathway, you know, towards optimizing her health. So I would agree that we're at moderate risk.

Lori: I agree, too. And that's a good definition of morbidity. And that's something which I can't seem to get the definitions page to pull up, but that's part of what our audit tool is about. These new definitions that the AMA has tried very hard to create for us to define morbidity and mortality and things like that so that we as coders and auditors have a little bit better determination of what that means.

Elizabeth: I really appreciate the definitions...

Lori. I do.

Elizabeth: Because this really does represent a mindset shift for us as auditors and coders, I feel. We've tended to shy away from clinical definitions or anything toeing the line of clinical because that's just not our role. We have to think like that now. We have to understand the provider's language a little bit more and put it into terms that we can justify without stepping over into that medical practice, if you will.

Charla: Right. Right. I think we coders and auditors are set to learn some new information that we maybe didn't use in the past.

Lori: Right. I agree.

Elizabeth: Absolutely.

Lori: So when we bring this all together, this is what we come up with. Right? We had a moderate number of complexity of problems, and moderate data, moderate risk. So moderate.

Charla: Well, that was pretty straightforward. Moderate, moderate, moderate.

Lori: Yeah. That was easy.

Charla: Because you need two, right?

Lori: Yeah, absolutely. So if we'd had... And we'll have some examples, I think, in this one and in our future series that we will be talking about where they won't be. So, we kind of try hard here to put, you know, if you have two or three circles, that's where you're gonna draw your line and that's where you end up with your MDM. Or if you have all three different columns, you go with the one down the center, because you've got to have two of the three to meet your criteria. So this one then ends up being a 99214, right?

Charla: Right.

Elizabeth: Yeah.

Lori: Or an 04, if it was a new patient. I don't think it was, I think it was established.

Elizabeth: Yeah.

Lori: All right. Let's do our next case.

Charla: Oh, you know what I just thought of?

Lori: What?

Charla: As you said, a 14 or an 04, that in itself is a big change. Because in the past, when we had to count the three key elements, either two of three or three of three, Level-4 established patients were very much like a Level-3 new patient. Now, the four will match a four, a four will be a four. That's great.

Lori: Isn't that nice? So much easier.

Charla: Yeah. And it'll make sense to our doctors.

Elizabeth: Yes.

Lori: Yes. So much easier to explain.

Charla: Right. You're right. It's hard to say, well, a four is only a four in one way, and in other cases, this same work would be a three. And so yeah, this is gonna be good. Yeah.

Elizabeth: Yeah. Much more logical. And if there's one thing I know about providers, it's, "Just the facts, ma'am, let's get to it."

Charla: Right, right. Do we have another one, Lori?

Lori: Yeah. One more. Well, actually we have three, but I don't know if we'll get through 'em all. We'll just see how our...I mean, we're doing pretty good on time. So, on this case, we have a patient that's presenting to his primary care. So we can assume from that, right, that it's established, he's presenting to his primary care doctor.

Elizabeth: For follow-up. Right. I would call that established.

Lori: Yeah. Patient is experiencing pain. Daily pain is 3 [inaudible 00:21:02], some improvement. After discussion, we will change current treatment plan. Patient's BP is controlled. Patient needs blood work. Lab req written.

Elizabeth: Nice job, tongue twister.

Charla: Nice job, documenting doctor.

Lori: Yeah.

Elizabeth: Very much so.

Charla: You know, I can kind of...how many times have those of us who do education said, "Please paint the picture, so a reader who's removed in time and space can tell what's going on." I feel like I know what went on in this visit.

Lori: Yep. So it looks like he ends up with cervical radiculopathy, primary hypertension, and mixed hyperlipidemia. Now, I've stumbled...the first time I looked at this, I stumbled a bit over the hypertension and the hyperlipidemia because one of our definitions states that the provider must address those issues in order for us to count 'em. So if the provider is merely stating chronic conditions and he's not addressing or managing them, we can't count them anymore. So how do I know from looking at this note that he is addressing hypertension and hyperlipidemia?

Elizabeth: We have to look at the big picture here. We can pull some information from the HPI. The patient's blood pressure is controlled. We can assume a stable status from that. Patient needs blood work. If we get into the plan there from number one, there's more than just radiculopathy being listed there for management. You've got a diabetes panel, CPK, FLP is the fasting lipid profile. So there's our management of the hyperlipidemia. We've also got the TSH, the UA, the vitamin D. So even though it only looks like we're managing one condition, it's actually a much more comprehensive picture of the patient's overall health.

Lori: Yes. Be careful.

Charla: And notice that he's also suggesting weight loss, portion control, and daily exercise. Those healthy dietary choices will impact, in fact, treatment options for the hypertension and the lipids. And, you know, as I look at this, this kind of comes to one of the coder traps that I've seen and auditor traps, is we often get...we notice the labels of things, and sometimes we don't get all the information. There's nothing in any regulation that I've ever read that says that information has to be labeled a certain way. This patient plan, like you said, Elizabeth, is way more comprehensive than the number one problem, cervical radiculopathy. You know, it includes it, but he doesn't have to separate it out. Now, if we auditors wrote the note, we would lift some of that plan information and put part of it under Assessment 2, and part of it under Assessment 3, wouldn't we?

Lori: Mm-hmm.

Elizabeth: Mm-hmm, absolutely.

Charla: But there's no rule that says you must. So it's important that we read everything thoroughly. You know, one of the things as I was glancing at this because the CPAP is written capital letters, I wondered if he was treating...

Lori: Sleep apnea. Yeah.

Charla: But all I see is that the patient uses it. I don't see anything more about it to make me think that it should be counted. But we have three things to count, so it's just like the other one, three is what takes you to moderate. It doesn't look like this patient is at a high category. So, I probably wouldn't spend a whole heck of a lot of time trying to figure out if any or some of these words following assessment belong in a different category. I would take the three together and say moderate and move on.

Lori: I think I did. And I think I would, too. So just like the last one. Oh, that little X is supposed to be right there. Move, little X. I hope I clicked forward. Okay. Well, we need to move that little X down, but...

Charla: Can you control Z and back up? Will it work in this program?

Lori: I don't know.

Elizabeth: No, I don't think it will.

Lori: Okay. So we wound up with... Oh, I'm sorry. I think I just lost my screen share, one second. Oh goodness. Here we go. Let's try that again. Sorry about that. Let's try that again. So yes. Our little X needs to be here. We definitely had to... Oh, I know why, because... Hold on, this isn't right. So let me back up. I mean, it is right. The symptoms are getting better. I think...

Charla: Hey, Lori. I'm not seeing the screen.

Lori: Really? Don't you love technology? I mean...

Charla: Only when it works.

Elizabeth: When it works. I was just about to say.

Lori: I clicked share. I mean...

Charla: There we go.

Elizabeth: Perfect.

Lori: Good thing there wasn't any HPI or anything. That's on my... I mean, PHI, not H...well, that, too. It's a good thing, there wasn't anything, like, my passwords and stuff up on that screen. Okay. So if we look at this, I think the reason I wrote that was because he said that his symptoms were getting better but not that they were stable, they were still acute. So what I did on this one is I marked this one and this one. So this one for the hypertension and the hyperlipidemia, and this one...I guess it's really not exacerbation, though. So maybe I'm wrong on that. So, you...

Charla: No, I think you're right. And the reason you’re right we have to go back to those materials that we've been provided by the AMA, where it defines a stable chronic condition and tells us that if a condition is not at goal, it is not stable. And in this note, we see that the patient is still experiencing daily pain, and currently, it's at a level 3 out of 10. So I think that that clearly takes it out of the stable chronic condition place and puts it into the exacerbation progression or treatment of side effects.

Elizabeth: I would definitely agree with that. Also, to add to that definition, we've got progressing with an intent of controlling progression and requiring additional supportive care. So we're definitely still there, getting this patient to be the best they can possibly be in the context that he's gonna have this probably for the rest of his life.

Charla: Sure.

Lori: Right. Okay. Good. Well, I'm glad my little X was on this... X marks the spot on that one. Now, let's talk about data, but before I go...so I'll pull up the data table real briefly, but I think we need to go back and look at the note because we need to look at what he said. One of the points that we're hearing is that if the provider's going to be billing for the labs, or whatever the CPT codes are, that he may not be able to get points also for the MDM, it's considered double-dipping. So he does say here, he is ordering several...he's ordering that panel, the CPK, all of that, but up at the top, he just says, "Lab req written." So I'm thinking I kind of need some more information to know 100% for sure. But what do you guys think about that? Would you give them credit for the data?

Charla: I would, I think he's sending that patient out to whoever their local lab company is to get that blood drawn.

Elizabeth: Mm-hmm. I agree.

Lori: I agree. So how many...I mean, we know we all only need three and we definitely have that here, right?

Charla: Right.

Lori: So we can go forward to...

Charla: He's probably doing the UA in office, so that is probably on the bill sheet.

Lori: Probably, probably.

Charla: Because there's still three or more left over.

Lori: Yeah. I think I had counted six again, like we did our last time, but as we know, we only need three. We definitely had that. So that gives us six here. And once again, we get moderate. I didn't see any of this unless you guys saw history interpretation of test. I didn't see any of that in the notes.

Charla: I did not, no.

Lori: So, we know, again, with our data table that we've shown before, we're at a moderate here with the calculations. So what about our risk? Again, I think we're kind of the same as the last one. We can rule out the minimal and the low, right?

Elizabeth: And the high.

Lori: And the high because they're definitely not in any high risk, so right. I think we're back on to our moderate. And so we wind up with the same thing we did on our last one, but see, this is good. Now we know we're going...we're on the right track here. So, again, we wind up with a four. All right. Perfect.

Charla: That makes sense.

Lori: One more quick little case here. I think we can get through it in the time that we have. So we have a patient coming in, we know it's established, they're having an allergic reaction. And so, as I read through this, a couple of things stand out to me. They have no dysphasia or shortness of breath. They have a throbbing headache, but they finished a course of Sulfa for UTI recently. "Hmm," that makes my brain think. Right? Allergies, none known. There are some more on the next slide. Oh, this is just a very simple exam. Respiratory is normal, has a rash all over. That would be horrible.

And here's our assessment and plan. So, he does say the patient has severe hives and a headache, call if symptoms persist, medications prescribed. He starts with over-the-counter Benadryl. And then I think he goes on and says, "Injection today and a prescription for prednisone." All right. So what do you guys think about this one as far as our Chart A? So, we have severe hives, which we know could be an allergic reaction. Right?

Charla: Right. And it's described as an allergic reaction in the HPI section. So yeah.

Elizabeth: It would be so easy to look at this and go, "Oh, it's just hives." But according to this assessment and plan, it looks like it's far from it.

Lori: Yeah. But have you ever had hives?

Elizabeth: Right. You're miserable. You can think of nothing else, especially when we're not just stopping at an over-the-counter. We are giving a steroid injection today. We've got the prescription for yet another steroid, even the dosage of the Depo-Medrol, we don't stop with the 40-milligram dose. We're going to the 80-milligram dose.

Charla: Well, and allergic reactions. I mean, we don't see here that this patient is anaphylactic, but he did talk about swallowing and shortness of breath ruling out that level of intensity before he went ahead with the prescription drug management. So I think this is more severe than one might think at first glance. I don't think it meets the criteria for the high risk, though.

Lori: Right. I think I would be looking for something along the lines of respiratory distress or, "Hey, I think we need to send you over to the hospital for, you know..."

Charla: Or some difficulty swallowing.

Lori: Right. Right.

Elizabeth: Yes. Swelling of the tongue, anything like that.

Charla: Right.

Lori: So on here, it's definitely not minimal nor is it really low. And I think we've kind of ruled ourselves out of high. But the patient has systemic symptoms. And I think we should just kind of focus on that for a minute because auditors get kind of confused, and our definition on that has changed this year. So make sure, again, that you get those definitions out and you're looking at them. But systemic symptoms are that it's affecting some other part of the body, right, Charla and Elizabeth? I mean, what are your...how do you define systemic symptoms?

Elizabeth: Well, I think you summed it up beautifully. We're talking about that headache as well. That could be a manifestation of the allergic reaction. And if he's saying that the patient has hives all over...

Charla: Now, we're talking about, you know, a full impact to the whole patient, not just, you know, their...I don't know, their arm is swollen, or they got poison ivy on their elbow or something like that.

Lori: But at the same time, it's also not just that I have a cold and I'm running a low-grade fever. I think the definitions were clear that, like, a general symptom and the setting of a self-limited or minor problem, if I remember correctly, can just make it moderate. Right. It needs to be a little bit more acute than something simple, which we know, especially in today's day and age, that cold could really be COVID, right? So you have to look at the big picture of that patient, what are they really there for? But as far as this patient, I agree. And I think I marked that as an acute illness with systemic symptoms as well, just because of the headache. And it is acute. I mean, he said right in his note, it was severe, but I just don't see anything to support this being severely life-threatening.

Charla: No, I don't think we see that information. Even though patients like this could be, this patient isn't described that way.

Lori: So if we were educating the doctor, what we might wanna say to him...let's say he did code this as a high, a 99215. What we might have to say to the doctor is, "You know, I really need to see why this is severe." Severe hives doesn't scream life-threatening to me, but it very well could be. So we would wanna educate him. This is why it's a four instead of a five, if that's what we come out to be. But I think as we flip through these tables, I don't think we have any data.

Charla: I didn't see any.

Elizabeth: Yeah. I didn't see any either.

Lori: So then when we go to our overall risk, again, I think we kind of ruled out minimal and high, didn't we? But this is definitely not just over the counter, you know?

Charla: Right. And, you know, he gave the steroid in office, but he's also sending the patient home with the steroid prescription. So I think we're clearly at moderate.

Elizabeth: I like how it changed a little bit, we're no longer just checking off boxes. We're being given examples of where things should fall. And I think that's gonna allow us for maybe a broader interpretation, one that lines up more with the clinical language, once again, that our providers are using.

Charla: Right. And in broadening that category, it's gonna require us to learn more. You know, we're just gonna have to know what certain things mean in order to evaluate it correctly. Google's my best friend.

Elizabeth: I was just about to say, "Take the initiative and learn something new via our friend, Google."

Lori: Right. Because this isn't going away. If nothing else, these guidelines are going to expand into other categories. Right. That's what we're hearing anyway.

Charla: Right. We don't know when, though. And sometimes things move slowly. You know, with my 30 years in the business, I wouldn't anticipate a rapid change. I've read that the office-based codes, 992, well, what used to be 01 through 15 now will be, 02 through 15, account for something like a quarter of Medicare, Part B spending.

Lori: I agree. Wow.

Charla: Wow. That's high when you think how low...you know, if you think about the difference in reimbursement between say a Level 3 office visit and a multilevel, very complex back surgery, and the office visit still come out almost a quarter of the expenditure, there must be a whole lot of them being billed.

Elizabeth: Because that population is so chronically ill and there're so many different comorbidities that need to be managed. Absolutely.

Charla: Yeah.

Lori: Great. Now, we have a lot to look forward to, don't we?

Charla: We do.

Lori: The only thing constant in healthcare is change.

Charla: Amen...

Lori: So on this one, then, we ended up with moderate again, but we didn't have any data, but we still end up with moderate because we only need two of the three. So since we had...Chart A and Chart C were both moderate, that we're billing in 99214 or 04, depending again on if that was. And I feel comfortable. I feel comfortable with all of these being...I guess I always kind of go to my instinct, and maybe that's my 20-plus years of doing this, is what does my instinct tell me? Is this patient here for a bug bite, or are they here because they can't breathe? You know, where am I falling in that category? So I feel good about these.

Charla: And I think what we've talked about will really line up with, you know, if you have a conversation with physicians about their audit findings, you know, and let's pretend word that we were auditing these, if they had selected something different than we did, I think they would clinically see our rationale and it would make sense to them.

Elizabeth: I think it's gonna go a long way towards building the rapport that we really do want with our physicians because they're going to see that we are making an effort to understand them and we will be able to more succinctly explain our position, I feel like now that we've got the definitions and the guidelines to do so.

Charla: Agreed.

Lori: I like it. So hopefully, this webinar has helped everyone kind of learn. You can see how we work through things and sometimes we have to bounce ideas off of each other. And hopefully, you all have someone that you can bounce ideas off of. I did put a couple of references here. The AMA guidelines can be found here. And that link will also take you to the definitions that we talked about. You're definitely gonna want to familiarize yourself with those because they're really important. And then I did put the 2020 proposed rule link on here. This is where CMS is telling us that they're pretty much going to follow AMA guidelines. And then we, of course, await the final rule to come out sometime in November. We cross our fingers. This has been really great. Charla and Elizabeth, thank you once again for joining me.

As I said, this is series one of five, our next presentation series two will be on pediatrics, followed, I believe by surgery specialties, then gynecology, and then followed up at the end by hematology and oncology. So you can find all of these and all of the audit tools and even more information on our website. Again, that website is www.aapc.com/business. And out there, you can also contact us if you would like us to take a look at your charts now and see if you're prepared and ready to go for 2021. We'd be absolutely happy to do that. Thanks, everybody, and we will talk to you again soon.