Welcome everyone thanks for joining today we will get started at 11 a.m. central we just ask that you stay muted today and if you have any questions feel free to share them in the chat box. And Jeanne, I'll keep letting people in. Okay. Thanks, Dr. Jones. I'm just having some tech issues. We will get started in a minute, everyone. Thank you for joining today. Welcome everyone. Thank you for joining the first HMDCB webinar of 2024. Today's session is on hospice coding and billing and will be facilitated by Dr. Christopher Jones. A couple of quick HMDCB updates before we get started today. So first thing is just to remind everyone to please stay on mute during today's presentation. And if you do have a question, we encourage you to put it in the chat box. And we also wanna thank our sponsors for today, Gentiva Hospice and Heartland Hospice. They are generous sponsors for the 2024 webinar series and allow us to produce these webinars for free for all of our certificates. So if you're interested in learning more about these organizations, we encourage you to go ahead and visit their website. And then we have some upcoming HMDCB community events, a coffee chat on March 28th, a webinar we're co-hosting with AHPM on April 18th. And then we'll have a May coffee chat on May 9th that will serve as a follow-up to the April webinar. And then of course, if your credential expires in 2024, you're eligible to renew this year and you can learn more at hmdcb.org slash CCP. And I'll put all of these links in the chat box so you can access them easily, or you can scan the QR code on this screen to access all of the 2024 community events. And I also wanna share that HMDCB has a new learning management system and you can create a free account on here and then you'll be able to access all past webinar and coffee chat recordings and online discussion board. And this is where you will also access the longitudinal assessment to renew your credential. So I'll go ahead and hand it over to Dr. Jones so we can begin today's presentation. Okay. Perfect. Let me just get my screen shared, which is the thing that people say when they're stalling while sharing their screen. Okay. Hopefully folks have a view of some slides. Alan, is that a yes? Okay, perfect. So if folks don't know me, I'm a palliative care doc. I've done kind of 50-50 hospice over the course of my career. And now for the last couple of years have run outpatient palliative care at Duke. People say, oh, if I'm giving a talk, what are you talking on? I literally only know one thing and you guys are getting it. So we're in like the key hole of my knowledge base. What I'm not is a full-time hospice doc. So the Ruth Thompsons of the world are gonna have some knowledge that I don't have here. So if we do get kind of in the wonky, very technical hospice billing questions, I'm gonna crowdsource the answers to some of this stuff. I think probably the best way to do this is going to be to use the chat, like Gina mentioned. And what I'm gonna aim to do, if you were at the CAHPSY webinar, it's similar content. I cut some stuff out that doesn't apply to hospice and then we're gonna spend a bit more time on the complexity table, which we did not do during the hospice, sorry, during the CAHPSY talk. So that's kind of our plan for today. I've decided that I'm never gonna let a disclosure slide go to waste. So there's two things I wanna mention on here. If folks have, especially APPs who are new to palliative care, or if you have assistant medical directors who need some content, the Four Seasons Immersion Course is really good. I've been helping Janet Bull and John Morris with that. The next one of those is actually in the upcoming month. And then Phil Rogers and I do some consulting around billing and coding through Lightning Bolt Partners. Disclaimer slide is sitting here because everything that I tell you is true as of today. This stuff changes. There's actually some stuff cooking that may change over the course of the next couple of weeks around incident two. We're not sure what CMS is gonna do with that, but you've gotta use your local billers and coders. I am not your consultant. I am here for free. So you can't take me to court with you. So use your local folks. I'm gonna try to give you some information though, but I will not join you in the penitentiary. Okay, a wise administrator taught me that if you're gonna tell people, tell adults stuff, tell them what you're gonna tell them, tell them what you're telling them, tell them what you told them. So we're gonna go with the bottom line up front here. We're gonna start with billing time versus complexity. This should be kind of old hat to anybody who's seen me or Phil talk before. We're gonna spend a bit of time on the complexity table because I think there's some meat there that we don't usually have time to do. I'm gonna run through the non-hospice codes that matter for programs that have office-based practices predominantly. I'm gonna mention the prolonged service code and then the advanced care planning. Again, will be not for hospice. We'll do that pretty quickly as well. And then hopefully we'll have some time for questions at the end. So if folks were at the CAHPSI presentation, I guess it was last week, this is not marijuana, this is sage. So we're gonna burn away the bad juju from the 2024 decisions from CMS. So the bad stuff for us is the conversion factor, which is what Medicare, the dollar amount that Medicare multiplies the RVUs by to figure out how much they pay you went down by 3.4%. These G code, the G2211 code that we're gonna talk about is not a hospice code. It's a longitudinal code, but either for primary care or for palliative care. And obviously all other specialties too, but it's not a hospice code. And then principal illness navigation, which is one of the new codes that's out. Same problem, not a hospice code. Any kind of navigation or care coordination goes through the per diem. It's also not a code that's payable if your clinic is set up as a hospital-based outpatient clinic, because you have to have incident to supervision, which I will explain more about shortly. So let's start with some old stuff, although we're gonna burrow in a bit on some hospice specific examples. So remember that if you are billing for a patient visit, you can bill one of two ways. You're getting to the same code, but there's two roads there. One road is on time. The other road is on complexity. If you're billing on time, it used to be unit and floor time on an inpatient facility. It used to be in the room time if you were doing office-based care. That is not true anymore. Now it's all time on day of service doing provider-level tasks. And provider-level tasks in this context is everything that's not driving the car. So your travel time, your windshield time is non-payable. Everything else that you do to coordinate care is payable. Now, this is a challenge in hospice, right? Because what should you be counting as time for your medical care versus what would be paid under the per diem? I cannot delineate that for you. Somebody smarter than me may be able to. The way that I would approach it were I doing a hospice visit is if I'm doing stuff not related to administrative work of hospice, not related to talking to maybe my APP about the face-to-face visit, right? Like that's clearly under the per diem. But if I'm coordinating care with the nurse around the medical problems, coordinating care with the family, I would be very comfortable counting that stuff toward total time. The opposite of time is medical decision-making or complexity. We'll go through the complexity table with a little bit of depth in a minute. This is an example of kind of how the times and the RVUs work. So this is inpatient hospice, which is the same as inpatient hospital care. So if you're doing palliative care in the hospital, all these codes are the same. Remember that you cannot bill advanced care planning under the hospice benefit. Palmetto used to pay for it. And then they realized that that should probably be under the per diem. So they stopped paying for it about 18 months ago is what I think I remember Janet Bull telling me. So the way that it works is on an initial visit in the hospice house, for example. If it takes you 70 minutes to take care of the patient, all in, again, I'll define the time in a minute, then you can bill by time. and lots of people who get admitted to a hospice house because they need to meet GIP criteria, meet high complexity. So it hardly ever takes me 70 minutes. When I did inpatient hospice at Penn, I had a really good template. I could get people admitted in the paperworky side, 15 minutes. And then would obviously spend time with the patient, time with the family, but it hardly ever took 70 minutes. But the complexity was almost always there. And I'll unpack that. This is the initial visits. It went from 70 minutes. Now it's 75 minutes. These are the old times. And then the follow-up visit went up a fair bit. 35 minutes went up to 50 minutes. So if you spend 50 minutes in doing provider level tasks on the day of the visit, then you meet the high level subsequent visit 99233 by time. What if it takes a really long time? If you're not in hospice, I want you to build advanced care planning. If you're in hospice, advanced care planning is not a thing. So that's why I need you guys to know about the prolonged times. We'll reinforce this in one slide a little later, but it's 15 minutes beyond the top code in the series. So the initial visit is 75 minutes. Back when these came out a year and two months ago, CMS and CPT disagreed on the time thresholds. And then God bless them. CMS very quietly put out a transmittal that said, we did our math wrong. And when we added 15, we accidentally added 30. So if you've heard me teach this before, CPT had one group of times, CMS had a different group of times. In March of 23, CMS said, no, no, no, we don't mean our times, we counted wrong. So it is every 15 minutes beyond the longest code in the series, you can build a prolonged code. So this may happen every now and then in the inpatient hospice unit. Again, if you start adding on a bunch of prolonged codes for a home hospice patient, you're gonna be fighting with the per diem. So, and again, I just don't know how to, I just don't know how to fix that for you. Your local coders are gonna have some opinions on that. So these are some key points from the last slide is, again, just repeating stuff for adult learning. If it's time, it's all time on day of service, not just unit and floor time. Your time thresholds are a little bit higher than they were, but that's not terrible because a lot more activities count toward the time. Prolonged codes are no longer 15 or 30 minutes depending on the payer, it's now 15 minutes beyond the longest code in the series. And then if anybody has learners with them, or if you're doing a split shared visit, which I think would be, I think it's not allowed in part A anyway, but if you're doing split shared under Medicare Part B with an APP, you can't bill on the other person's time. You can only bill on the billing person's time. So Christine Swartz-Peterson, I got progressive lenses. I'm like 44 and it's not good for my eyes. So I'm trying to find out where to put the chat that I can actually read it. Is the pay cut universal for part A physician billing as well as part B? Every RVU is now multiplied instead of by 3388, it's multiplied by 32 something lower. So yes, it's every RVU pays less than it used to. Burn the sage. I told you that I was gonna share what activities count toward time. This is it. This comes right out of the final rule from 2024. It's everything we do. It's also everything you do in hospice care. So again, I don't know how to square this circle for you, but it's getting ready to see the patient. It's getting your history. It's examining the patient. It's counseling patient and family. It's ordering meds. It's talking to the referring physician or provider. It's looking at labs and studies. It's writing your note. So I guess what I would say to you is if it's an administrative visit, obviously you're not gonna bill that. That's just gonna go against the per diem. But if you're doing a medically necessary visit for symptom management, and I'm not sure, it sounds like they're cracking down on what defines medical necessity. So be really careful in your note. I am seeing the patient today to manage pain, to manage nausea, to manage dyspnea. Make it clear that you have a medical reason for being there. Then these activities should count toward the time for the visit. I told you I'd put the times up again just so you have them on another slide. So 75 minutes for an initial, 50 for a subsequent, and then just add 15 minutes to those times. That gets you to your prolonged time. If somebody's in the hospice house and they're gonna be discharged, let me change it. If they're in the hospice house and they're gonna be celestially discharged, if they die and you pronounce them, you are able to bill a discharge code. If they died overnight and the nurses pronounce them, you are not allowed to bill the discharge code. So I just want folks to hear that from me. Live discharge, out the door, yep, you get a discharge code. Discharge by death, if you pronounce them, then you are able to bill the discharge code. Let me jump to the two questions in the chat. If a patient's admitted to your hospice house, GIP stabilizes to routine, but remains in the hospice house, then needs to be readmitted GIP, how do you bill that second GIP admission Emily, I love the question because I don't know. So technically, if you made them routine, then they've been discharged from your facility, even if they didn't leave, they come back on, it would be a new, it would be an initial. That would be my answer to that according to the rules. Now, if you made them routine yesterday and then you read GIP them today, at some point you don't wanna antagonize the administrative law judge, right? So in that case, even though technically you could do another GIP, sorry, another initial, I would probably, if it's only been a day, I would probably bill it as subsequent, but that's just me likely being more conservative than the statute requires. Christine Swartz-Peterson, the answer is no. NPs are only able to bill for the medical care that they provide if they're the attending of record. That has not been changed at all. Okay, now I'm gonna ignore the chat for a little bit because I wanna go through and spend some time on complexity. This I think may be new for some people. On the first slide, let me go back to it. I want folks to download the complexity table. So right here, if you're on a phone, you can take a picture. If you have a phone and you're on a computer, you can take a picture of the QR code. If you're on a computer, you can just type this in, HTTPS colon forward slash forward slash bit.ly forward slash 427MFJ8. That is a box account that has five different references for you guys to take with. I redo the WorkRVU table every year, so that's up to date. Thanks, Alan. I do, I have a advanced care planning template for non-hospice. We have an advanced care planning article that we wrote in JPM back in 2016. So, and the thing that I want you to look at is the medical decision-making table because that's what we're gonna go through together. So let me get up to that. Okay, so here's what I want you to think about. I want you to think about when you were taught to build by complexity, it was terrible. It was terrible and awful. It was a lot of box checking. And if you forgot the family history, on the 99-year-old with a prognosis of four hours, you were a level one initial visit instead of a level three. Like it was just bonkers. So mercifully, mercifully, 2023, it all changed. Same in 2024. Your history and your physical exam, if you're building on complexity, your history and your physical exam just have to be medically appropriate because what drives your level, if you're building on complexity, is your medical decision-making. Of course, that's the way it should be. How sick your patient is should drive your level, not whether you put the 10th review of systems item. Now, we're gonna have a moment with you, me, and your general counsel because what I don't want anybody to hear when Uncle Chris teaches about complexity and says, history and physical, take it or leave it. No, that's not what I said. I said medically appropriate. If you start writing nothing in your history and physical, your friendly neighborhood plaintiff's firm is gonna be much more interested in you as a potential contralitigant, if that's a word. So your notes should look like notes. You just don't have to count boxes at the top of the note. There's still a bit of box counting at the bottom of the note. Again, what drives medical decision-making are the three different categories within MDM, which are data, diagnosis, and risk. This is the table that I want you guys to pull out. So I think I called it like MDM table or audit table or something like that in the box link. Now, here's what I wanna orient you to. This is the bottom row. This is the high-level stuff. This gets you level three visits in the hospice house, level three visits in the hospital, level four visits in the SNF, level five visits in the house. And because of course, there should be a different number of levels at each level of care, right? Like when we say level three, that's terrible in the house and it's as sick as you can be in the hospice house. Of course, it should work that way. So there's three columns. The first column is your diagnosis column. Your second column is your data column. Your third column is your risk column. You cannot see this, okay? It is too small. And even when you print it, it is gonna be really small. Like 44-year-old eyes cannot see this without being in the right spot on the glasses. So what I'm gonna do is I'm gonna blow up each of these and I'm gonna really just focus in on hospice care and where the things are that you're doing as part of hospice that meet high complexity. So again, we said diagnosis, data, and risk, and you only need two out of the three columns. So if you get all three, great. If you can only get one of the three columns, then likely you're gonna be at a level two. It is super uncommon, especially in GIP hospice. If you have a patient on GIP and you can only get to a level one, which is like a sniffles and an ice pack visit, you should make them routine. I'm channeling your compliance officer on that one. Okay, so what we're gonna do, we're gonna drill down to each of these columns, and I'm gonna try not to burn all of my time so that I have time to teach you other stuff too. So inpatient hospice, inpatient hospice, the diagnosis column and the risk columns are gonna be your friends. Why is that? To be on the highest level of the complexity table, on the diagnosis side, which is the first column that we're looking at, you need a patient. It's either of these two boxes, but the top box is an easy one, although the bottom box is pretty easy too in inpatient hospice. If you have a patient with a chronic illness, and I'm gonna keep repeating the word severe, with a severe exacerbation, severe progression, or severe side effects of treatment, you don't have to be trying to fix the illness. That person is at a high level for the diagnosis column. So the natural question is, okay, Jones, you're telling me if it's a severe exacerbation, then that'll get me credit. Well, who defines severe? You do, you do. And they've made it, in the CPT book, they've made it really clear that if you have a provider acting in good faith, then the coders and the auditors should not be Monday morning quarterbacking or second guessing the severity of exacerbation. Now, how will the coder or the auditor know that it's a severe exacerbation? You have to tell them. And there's two ways you can tell them. You can either say, patient has CHF on 13 liters of oxygen with crushing substernal chest pain, is blue, O2 sat is 19%, having SVT at a rate of 180, systolic blood pressure is 14. That's one option. And then you hope that your coder and your auditor know what any of those mean. It's one option. Or you can say, severe exacerbation of CHF. Or in the inpatient hospice setting, severe progression of cancer pain, requiring IV opioids. If you put the word severe, then the coder knows what you're intending. So I taught this at Wash U to the hospitalists. And one of the hospitals folds his arms and he goes, oh, I see what we're doing here. This is a game. I'm gonna start writing severe exacerbation of onchomycosis and like, ha, ha, ha, fungal toenails, right? Like that's where the coders, when you're acting in bad faith, they can send you to Medicare jail. But when you're acting in good faith, you define severe exacerbation by telling them that it's a severe exacerbation. And in inpatient hospice, this idea of severe progression, that is like everybody who's GIP has either a severe progression or a severe exacerbation of something. Specific questions about this. And while people think of questions, James's question is the inpatient hospice code for freestanding hospice facilities or just hospital inpatient. You are an inpatient if you're under the GIP benefit or if you're in a hospital. If you're in the hospice house under routine or respite, then you're technically in your home. There used to be these like domiciliary codes and all these other things. They basically folded all of the non-admitted, non-SNF, non-office codes into what they're calling a home or they call it home domiciliary, home community, something like that. So the inpatient hospice is GIP hospice in your facility or GIP hospice in the hospital. Any questions about this severe exacerbation idea? Okay, it's pretty straightforward. Use the word severe. They can't know if you don't tell them. Okay, so let's move on. Data, I'm gonna kind of rush through because it's the one that bogs us down a lot from a time perspective, but I just wanna frame it for you. So there are three categories in the data section. If you get one of the categories, you meet the second highest level, what I'm gonna call level two on the inpatient side. If you get two of the three categories, then you are at level three, okay? So you see here, category one, category two, category three, this is really hard in the community hospice where you don't have a link to the EMR of the health system. Then you're trying to get faxed pages to look at this stuff. And it's really hard. If you have read-only EPIC access, or if you are inside the EMR of the hospital, there's actually more data than we know what to do with. So the common stuff in hospice would be looking at notes from doctors or APPs in oncology, in hospital medicine, in pulmonary, in cardiology. If you look at a lab, you get a point here. If you get three points at all from this top section, you get category one. If you need an independent historian, patients demented, that gets you a point. So any kind of three points from up here, if you yourself look at an EKG or an imaging study, so an X-ray, a CT, an MRI, an ultrasound, and you independently interpret it, not you look at the read of the radiologist, but you look at the tracing or the X-ray, and you say CT abdomen pelvis hyphen, independently reviewed hyphen, moderate stool burden, innumerable liver metastases, that gets you category two. But you've got to read it yourself and tell the auditor or the coder that you did an independent interpretation or a personal read. And then the last one, this one's again challenging if you're trying to navigate the per diem. If you discuss management or test interpretation with a physician or an APP outside of your practice group, then that counts as category three. This is when you call the PCP. This is when you talk to the hospitalist. This is when you talk to the ER doc for the patient who's going in for uncontrolled bleeding. That stuff would all count, but boy, that sure does look like care coordination under the per diem too. So again, I don't know how to tell you how to separate this out. In the inpatient unit, probably for the patients who are not on routine or respite, it's gonna be the diagnosis column, and then we're gonna do the risk column next, and you're gonna see a very obvious one there in a second. Two questions got dropped into the chat. If somebody is in your inpatient unit, but they're not on the, they're not on GIP hospice, they are lodgers in your place, they are not admitted to an inpatient unit, so you would use the home code. So if you have a respite or a routine patient and you're doing a medical visit, you're gonna build that under the home code, not the inpatient code. Okay, questions about data. Though again, it's not a place to sync our time because it's not where inpatient hospice is gonna be super, it's not gonna be super useful. If you're doing home visits, this might be useful if you're kind of chewing through data. Any questions about this? Okay, and I'm just gonna add one more thing just looking at Christine's question a little more carefully. The SNF code, initially I taught this wrong because the way that I thought it was gonna be laid out, it was not. So initially I taught this, you only build a SNF code if the patient is on the skilled benefit. It's not the way that CMS laid it out. The way CMS laid it out is if they are in a skilled nursing facility, i.e. a building that provides skilled nursing care, i.e. a nursing home that's not an assisted living, then you build a SNF code, whether they're a long-term resident or whether they're on the skilled benefit. Initially, the thought was it would only be if you were on the skilled benefit. So the way that I've kind of, I'm a simple man from Scranton, Pennsylvania, so I need like tweets in my head to make things make sense. So the building is a SNF, the person is not on the SNF benefit. So think about it more as the structure in the skilled nursing facility for which code you build. That's the opposite of what happens in your hospice unit. In your hospice unit, it depends what level of care the patient is on. If they're on GIP, you build the inpatient codes. If they're on respite or routine, you build the home codes and just make it really clear that you're providing medically necessary care. Okay, last one, risk column. Remember, we only need two out of three and everybody who comes to your inpatient hospice unit for GIP at least is gonna have a severe exacerbation or a severe progression of the thing trying to kill them. And then lots of people, what is clearly GIPable are IV meds, right? That's the one that's really challenging slash impossible to do in a lower level of care. So in your inpatient hospice unit, if you are adding or managing parenteral controlled substances, remember that's gonna be IV or sub-Q. So if you've got the ends in your facility and you're putting a button in, this will still count in the sub-Q button. And remember it's opioids and benzos. That's most people, at least when I do inpatient hospice, I've got IV stuff available for everybody in case they start spitting or biting. The Haldol doesn't count because it's not controlled, but the benzos and the opioids do. So what I would encourage you to do is each day that you're writing your medical note, have something in there that makes reference to parenteral controlled substances evaluated and will continue them. Something that makes it clear that they're not just sitting on a med list unused. Jim, I love your question and I'm gonna be really technical here. So the Macy catheter, we love the Macy catheter at Duke Hospice. I joke that it's part of the welcome package and it's a very inappropriate handshake, but there are a lot of people who've been able to stay at home because of that. That is the other end of your enteral. So your mouth is one end, your butt is the other end. So it doesn't say non-oral controlled substances, it says parenteral. So around your enter. While that's your exit, it's still your enter from this perspective. So Macy does not count unfortunately, though I know you spend a hundred bucks on it and it feels more complicated. If you have somebody who comes to your unit full code and you make them DNR, that counts as something in the high risk category. And if you're doing EKGs in the hospice unit, I would propose you're doing it wrong, but if you're checking for toxicity in the QT in your inpatient unit with EKGs, that would count. And all this stuff is the same for palliative care too. So in my office practice, all my methadone folks get me to a high level because I review their EKG, I personally read it, I order another one, I'm monitoring for toxicity. So again, hospice probably less, although palliative care, yes. I'm gonna mispronounce your first name, Jigar, about patches. So this one makes me laugh because the rules came out in 1995 when there weren't fentanyl patches, right? So parenteral was IV and sub-Q and then the derogesic patches came out and they redid the complexity table last year and they left it as parenteral controlled substances. So by the letter of the law, that is parenteral, right? You're outside of your enter, you're way over on your shoulder, that's nowhere near your enter. So that would meet this. You decide what your tolerance for orange is. I do not count my fentanyl patches as a parenteral controlled substance, though they are. Again, this is just probably me being a weenie, but I don't do that. So that's the kind of end of complexity. So I'm just gonna repeat a bit of stuff. So three columns, diagnosis, data, and risk. You only need two of the columns. Your diagnosis column is super easy to get in inpatient hospice because they're gonna have a severe exacerbation or severe progression of something. Your risk column is quite easy to get. You just need to show active management of those parenteral controlled substances. And those are your two columns. If you're doing a home visit, if you have access to the EMR, then you can try to get two of the three categories in that middle column, the data column. That is my story on complexity. When Phil and I teach this as consultants, we generally spend about 75 minutes on kind of a smaller bit of content so we can really go through this audit table. But because I cut some stuff out, I wanted you guys to have at least a light version, L-I-T-E, of the audit table. So you know 50% of what I usually teach, but that's maybe more than you came in here knowing. Okay, so now we're gonna go through a bunch of codes that if you only do hospice, you can stick potatoes in your ears because you can't use any of this stuff. If you only do hospice though, partnering with your community oncologist to say, hey, I know you guys have a really good program doing navigation. Have you looked into the principal illness navigation codes or are you doing principal care management? So this may be something that if you know enough to be dangerous, you can help some of your colleagues not be part of what I like to call the Medicare Volunteer Corps where we take care of patients for free. So I'm gonna run through this stuff because these are palliative care things more than hospice things. But again, if you have a non-hospice part of your program, this may be useful to you. So these are office codes. Everything that I'm gonna talk about over the next couple of slides are in the office except for social determinants of health, SDOH assessment, that can be done at the time of a hospital discharge. That's the only thing that we're gonna talk about in the next few slides that is outside of the office setting. So G2211 is for people who are doing office visits and have a longitudinal relationship with a patient. So basically, let me give you the story on this. So this, it's a G code. So it's what we call a HCPCS code. It's not a CPT code. The AMA did not come up with this. In fact, the AMA is probably not super interested in this because the AMA has so many procedural people at their table. So what this is, this was CMS and all the G codes come out of CMS. This was CMS saying, listen, we think that the pendulum may have swung too far toward procedural specialties. Really, you think about that? Indeed, I agree as a cognitive specialist. We're gonna try to swing the pendulum back a little teeny bit within the statutory abilities that we have. So if you have a longitudinal relationship with a patient, you are the continuing focal point for some component of their healthcare. So I do this in my office practice for cancer pain, right? We are the cancer pain people at the Duke Cancer Center. So anybody I'm following for their cancer pain, for their depression, for their nausea, I'm the continuing focal point for that diagnosis. So I can build this complexity add-on because I'm managing a longitudinal problem with this patient. Who cannot build this is if your visit is discrete routine time limited. The examples they give were, if you see somebody for seasonal allergies or GERD, these are not things that require longitudinal care. Importantly, if you're in the office and you see the patient and you also bill something else that has the 25 modifier, so a separately identifiable E&M service, if you already have two codes on the visit, one of which will be your primary, one would require the 25 modifier, then the G2211 gets kicked out. CMS has made it clear, we don't intend this to be the third code for your day. So if you're burning actinic keratosis, you get that $32 and not this $16. But if you only have one code, your level four office follow-up, and it's a longitudinal problem that you're following longitudinally, then you bill G2211, pays around 16 bucks. Okay, we're gonna shift from G2211, and I'm gonna try to put all this stuff in context in a couple of slides. So just, I'm throwing spaghetti at the wall and then I'll put sauce on it shortly. So next is the social determinants of health. This is not SDOH screening, and CMS made this really clear. This is SDOH assessment. And the difference between screening and assessment is screening can be done by a patient clicking through a portal, and assessment is done by a human. Your assessment does not have to be done by the billing human, it can be done by the medical assistant, but it cannot just be done by a patient filling out a form and nobody looking at it. If a patient, this is also important, if a patient keys positive for some social determinant, you can't go, oh, I guess they don't have a house, and move on without addressing it at all. So if you're gonna do an assessment, you at least have to have somebody or something you can refer them to. You have to have the handout for what your local community-based organizations are, your social worker at your cancer clinics, you have to be able to do something. You can't assess and then say, sucks to your ass, Marpigee, there's nothing we can do about this, okay? So that's an SDOH assessment. It pays, it's 18 bucks if you're in the office, it's $8 if you're in a hospital-based outpatient clinic. But this is work that could be done by your medical assistant and then attested by the billing provider. So ideally it's work that you're already doing and it's G0136. The only thing about this is you have to use a standardized assessment. There are seven or eight of them out there. There's this PREPARE tool. I pulled a couple of them, a family practice article, but any standardized tool is fine as long as you're doing a standardized social determinants of health assessment. That's all we're gonna talk about for that. Now I'm gonna talk about two codes that are basically the same thing just for different populations. So principal illness navigation is a way that you can get paid for non-clinical navigation. If a patient has a serious illness that's gonna last for three months or more, puts them at risk of hospitalization, right? You're singing the palliative care song for sure. And these navigators are not nurses or social workers. It says on here you could do this with a nurse or a social worker. There's a better code for licensed staff to do care management. So I'm gonna talk about that in two slides. So think of PIN, principal illness navigation, as the way you pay for your navigation program that's staffed by people who are not licensed. So what Medicare says is, and again, you see G-code here. This didn't come out of the AMA in their CPT book. This came out of Medicare. They say that if you have somebody who is trained or certified, trained or certified to do this work, then you can bill them incident two, the provider's work. So incident two, this is that thing that I, when we were burning the sage, we talked about this. Incident two means your clinic has to be set up as an office-based practice. So place of service, I'm 92% sure that it's place of service 12, maybe place of service 11, but it's a clinic, it's an office-based practice. It's not a hospital-based outpatient clinic. Hospital-based outpatient clinics cannot bill for incident two work. So you either, if you're at a place like Duke and my office is a hospital-based outpatient clinic, then we get paid a facility fee that's supposed to cover the staff time. If you're in a regular office, your E&M fee is a little bit higher and you're able to bill some of this incident two stuff. So the principal illness navigation is for patients where your navigation program is run by non-clinical, non-credentialed, sorry, non-licensed staff, not nurses, not social workers. And it pays about $79 for 60 minutes of navigation over a calendar month. You're gonna see almost all the same words with something called community health integration. CHI is for people who have social determinants of health needs, not a single serious condition. I'm gonna make sense of this in two slides. It pays exactly the same as the PIN services do. It's just a different population of people. And then the last thing that I want you to see is I just wanna give a quick reminder of principal care management, because remember I said PIN services, principal illness navigation is useful if you're in a clinic-based practice and your navigation is being run by a non-licensed person. It pays $79 for an hour, but principal care management, same idea. This is clinical navigation done by social workers or chaplain, sorry, social workers or nurses at the bottom bullet here. Again, it has to be incident too. So I can't do it at my office, but people who have an office-based practice, a community practice can. This pays $63 for a half an hour. So not 79 for an hour, but 63 for a half an hour. So this pays better than PIN pays because you're using licensed staff and it pays earlier than PIN pays. So I don't know if anybody quit me yet. This is a lot of alphabet soup. So let me give you some structure. So we're gonna talk about the evolution of care management in two minutes. And this really resonated with me because I think we're all involuting back down to not be a homo erectus anymore as we crunch over our computers and our smartphones. But here's the evolution of care management. The first codes that came to be was transitional care management, TCM. This is the first time that CMS said, you know what, we're gonna pay for non-billing provider time. The downside of it and the way this is structured is the good is up next to the green check mark, the bad is down in the bottom. The bad part about this is it really didn't pay hardly that much more than a high level office visit. So then CMS made these chronic care management and complex chronic care management codes. This sounds like a nice idea, but there were two fatal flaws with CCM and CCCM. The first fatal flaw was that you had to have two chronic conditions. So if you just had cancer killing you, you did not qualify. You had to have cancer and hypertension. The other problem was only one provider could bill this in a month. And so you had everybody standing still. The primary care people didn't wanna steal money from the cardiologist, lest they not take their emergent patients. The cardiologist didn't wanna steal money from the primary care people because primary care gets beat up on. So then nobody billed this. Advanced care planning codes came to be in 2016. Finally, we're gonna pay for planning rather than doing. And then these principal care management, PCM, it took CMS seven years to fix the fatal flaw in the chronic care management. Because PCM said, yep, one disease is all you need trying to kill you. You don't have to be killed by two. And then multiple providers can bill PCM in a month. So primary care can bill it and so can oncology. Downside of PCM is it has to be done by either the billing provider or by a licensed staff member. So nurses and social workers. And we have the same incident two problem. So 2024 comes and now they've, again, we're watching this grow, right? It's broadening. Now, if you have a trained or credentialed non-licensed staff member doing navigation services, it's billable. You don't have to have a nurse or a social worker doing this. And you're broadened from serious conditions to social determinants of health issues. Somebody put the G2211 question on here. And I'm really glad that somebody mentioned this because I would not have thought to say it. So all of these G codes, when they first come out, the only lever that CMS has is over traditional fee-for-service Medicare. So when G2211 came out six weeks ago, the only people who have to pay it is traditional fee-for-service Medicare. What usually happens though, is the advantage plans and the commercial payers come along to what fee-for-service Medicare is doing. But today, if you bill G2211 on a Aetna Medicare disadvantage patient, sorry, advantage patient, they do not have to pay and they likely are not paying yet. So what I would encourage people to do is submit that code, expect that it's gonna get denied by your commercial payers, but there's gonna be some point where a commercial payer starts to pay for this, and then you're gonna be in the habit of dropping that code. And then Carlos's question, PIN and PCM be billed by home-based palliative care services. PIN, no. PCM, Carlos, this is a great question. And I don't wanna speak out of turn. I think you have to have this structured around an office, but I don't know the answer to that question. So I don't wanna lead you astray. Send me an email and let me dig into this one a little bit. I don't know. I don't know the answer. It's a great question. Okay, I'm being mindful of time. So just to give you the structure of this, I told you I was gonna try to put sauce on my spaghetti that I threw against the wall. So you see a patient, not a hospice patient, you see a patient, medical visit, you do your SDOH assessment or your medical assistant does. One option is that your patient is me. I don't have a serious medical illness. I don't have SDOH needs. None of these codes apply to me. Well, what if I have financial toxicity from losing my job? Well, now I have SDOH needs and you could connect me with your community health integration program. This is PIN. It's the same thing. It's done by non-licensed staff for people with SDOH needs. Well, what if I have cancer? What if I have heart failure? What if I have uncontrolled diabetes? Well, then you actually have two different things you can point me toward. You can either point me toward your PIN program, your principal of illness navigation, if the people who are doing it are non-licensed staff, they're trained or credentialed, but they're non-licensed. Or you're gonna point me toward principal care management if it's nurses and social workers doing the program. So just to kind of give you some idea and all of these, all three of these are all incident two. So they have to be hooked to an office-based practice, place of service 11 or 12. It can't be done in the hospital-based outpatient clinic. This is just, if folks wanna take a quick snapshot of this screen, these are a bunch of the codes that I just stole from American Cancer Society from Arif Kamal. But I like that they're all in one place. You didn't hear me talk about peer support. This is behavioral health stuff, but this is everything else that I talked about. PIN and CHI are both payable in federally qualified health centers using a different G code. And that SDOH assessment is every, you can do it every six months. You can't do it every visit. They'll pay for it as often as every six months. Okay, last, really fast, we're gonna go through stuff that the first one matters to hospice, and that is the prolonged codes. Again, how do you separate out? Was this a, as part of the per diem? I don't know. If it was clearly part of a visit, you could make the case and it's 90 minutes on an initial, 65 minutes on a subsequent. It pays about $30, which is better than nothing. If you're not in the hospice space, if you're not in the hospice space, then I'd rather you do advanced care planning codes. But in the hospice space, if you have a visit that takes a long time, you can make the case that it was all related to the medical care and not to administrative stuff, then these G codes are available to you. G0316, if it's in the hospital or the GIP, and G0318, if it's in the house. James's question, if you're billing on time, do you have to document, do you have to torture yourself and say, for 11 minutes, I did this, for 13 minutes, I did this? No. Gina Acevedo, who's a consultant down in Florida, who I really like. Gene says, if you're documenting on time, what you have to do is document to the nodding head standard. And you kind of tilt your head like a Cocker Spaniel and go, what does that mean? And what Gene says is, if an auditor is reading your note and goes, yeah, that could take 60 minutes, that's how much you have to write. Their head has to start to nod. You don't want two lines. I talked to the patient about what was important to them and manage their pain, continue Roxanol. I spent 17 hours in the care of this patient. You have to write enough that justifies that time. How often can we use G2211 for the same patient? Every visit. Every visit that you're taking care of something that requires longitudinal care. If you're seeing them for sniffles, unrelated to their chronic condition, forget it. But if the visit requires some longitudinal care, you can bill it. This is not hospice codes. These are clinic or office codes. You can attach G2211 to 99201 up to 215. Those are the office codes. That's who can get G2211. Okay, really fast, again, not for hospice, but the prolonged service, sorry, the advanced care planning codes. You know what advanced care planning is. You don't have to create a document. Goals, values, preferences. This used to be paid by Palmetto for hospice patients. It's not paid by any of the MACs for hospice anymore. But if you're doing non-hospice palliative care, this code is a little bit different than all the other times you've seen. And that's why I wanna spend just a minute or two on it. This code, you're gonna read that it's a 30 minute code, which it is, but it's in a different spot in the CPT manual. Everything else, all those inpatient codes, home codes, SNF codes, those are all what are called threshold times where you have to get to exactly the number of minutes to activate that code. This is in a different spot in the CPT book where it starts to pay at what's called a minute past the midpoint. So if it's a 30 minute code, your midpoint is 15 minutes. So at 16 minutes, this starts to pay. So advanced care planning codes, 99497, pays from 16 to 45 minutes. And then the next code, 99498, pays at the 46th minute. Same story, halfway to the midpoint. And then one more minute. Couple of caveats. You have to have some statement in there that the patient or their family participated voluntarily. If you're gonna bill an ACP code on the same day that you bill a medical visit, unless it was two times into the doorway of the patient, I really strongly encourage, I don't want you to bill a time-based code for your medical care and a time-based code for your advanced care planning. So if you're gonna bill an ACP code, which pays pretty well, right, like $73, $75, make your medical care that day be billed on time. Complexity. God, I always do that. So your ACP has to be on time. So you want your medical care to be billed on complexity. And if you're gonna bill this code, you as an individual more than once, on your second and subsequent times that you're gonna bill the code, the second day, the fifth day, the 27th day, just give me one sentence about what changed and why you're readdressing it so that it doesn't look like you're stealing $73.35 for not doing any work. So that might look like readdressing advanced care planning as the patient progressed through gemcitabine for pancreatic cancer, readdressing advanced care planning as the patient talked more with his daughter about what's important to him, readdressed advanced care planning because it's been six months and the patient is 900 years old, right? Just give me some reason why you're doing this again. This is an example template that's in that box account. This was built with WashU and Duke's compliance people. So it meets all the statutory requirements and I have what's in the dropdown list in the box account. The one thing I would encourage you to do is make your ACP discussion participants, frame it in the way that your surrogacy order is in your state. So don't just have it alphabetical, have it be in North Carolina spouse, majority of reasonably available children over age 18 and parents, majority of reasonably available siblings over age 18, have it be the way that your statute is. It'll be a good reminder for other people who the boss is when there's no power of attorney. If you're gonna build an ACP code, you can put it one of two places. You can either put it in your note, then you just want it to be really clear like with these dashy lines that this is a separately identifiable service or if you're in Epic, you can open up a new note and put it in there. I'm done. This is everything on one slide. So I told you I'd tell you what I would told you already, time versus complexity. If it's time, all time on day of service. If it's complexity, think about diagnosis and risk for your GIP patients, your GIP times. If you meet the time, you can build just on time to a nodding head standard at 75 minutes for a new 50 minutes for a follow-up. If you are doing advanced care planning, not in hospice, bill for it, 99497 and 498. If you're in hospice and it's clear that your medical care took a long time, you have the prolonged codes. And if you're in a clinic, my clinic or a independent clinic, if you're billing 99201 through 215, the office codes, and it's a longitudinal patient with a longitudinal problem, G2211 is a nice balm that you can lotion up your hatred of prior authorizations with. So that is it. This is the QR code and the Bitly link again. I am done and good luck. Godspeed and don't have low professional self-esteem. Your dying patients in your inpatient unit are level threes. Just document properly. No G2211 for a home visit. I hate that. If I was the king of the world, that would be, believe it or not, the first thing I changed. But no, G2211 is not for home. It's only for 99201 to 99215. And I'm gonna turn back over to Gina. Thanks guys. Thank you, Dr. Jones. We really appreciate you being here today. I think everyone will agree that was incredibly informative and I'm just seeing things come through the chat about how awesome this was. So we just thank you for being here and sharing this information with us. And I think we covered most of the questions in the chat. If you see a couple more coming through, if anyone does have questions, please feel free to put them in the chat. We'll gather them. We can address them at the March Poppy Chat. If anybody's coming to Phoenix, do not come to my talk and Phil's talk. It will be this content. You're just gonna, unless you wanna see it a second time, it's gonna be this content squished into 25 minutes. It's gonna be terrible. So save yourselves, go see somebody else talk. Sorry, Gina, go ahead back. That's okay. It's good to have that tip. So thank you all for being here today. We will send out a recording of today's webinar. You'll be able to access it in the Certification Center and we'll include instructions on how to access it. I'm gonna keep this slide up, Dr. Jones, if that's okay with you, just so everyone can scan that code. But feel free to go ahead and log off and thank you all for being here today. Thanks guys. And I'm happy to do, if there's live questions, I can do two or three minutes before I go back to the consult service.

hospice coding

billing guidelines

time-based billing

complexity-based billing

medical decision-making

G2211 code

advanced care planning

social determinants of health assessment

prolonged service codes

principal illness navigation