Medical Billing and Coding with the “Billing Boys” – Chris Jones and Phil Rodgers

Eric 00:01

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:04

This is Alex Smith.

Eric 00:05

And Alex, who do we have with us today?

Alex 00:06

We are delighted to welcome back Chris Jones, who’s a geriatrician and palliative care doc. And get this, for today’s podcast, a certified professional coder. Chris is clinical vice chief for outpatient palliative care at Duke. Chris, welcome back to the GeriPal Podcast.

Chris 00:21

Thank you.

Alex 00:22

And we’re delighted to welcome Phil Rodgers, who’s a palliative care doctor and family medicine doctor, and a dean, professor, and chair of family medicine at my alma mater, the University of Michigan. Go blue. Phil, welcome to GeriPal.

Phil 00:36

Happy to be here. Thanks for having us.

Lynn 00:39

And me.

Alex 00:40

Oh, yeah. [laughter].

Lynn 00:44

Wait, that was like a blooper. [laughter]

Alex 00:49

And we’re delighted to welcome back Lynn Flint, who’s a frequent guest and host on this podcast, today serving as a guest host. And Lynn Flint is a palliative care doctor from the office next door. Lynn, welcome back.

Lynn 01:01

Thank you very much.

Eric 01:03

So we’re going to be talking about medical billing and coding, the subject everybody wants to listen to on a podcast. I’ve actually seen Chris and Phil talk about this. They make this actually really exciting. And we’ll talk about why it’s important for everybody to know at least some components of billing and coding. But before we get into that topic. Who has the song request for Alex?

Chris 01:27

I think that’s me today.

Eric 01:28

Chris, what is the song request?

Chris 01:32

We really thought through what would be a valuable song request around billing, and it has to be If I Had a Million Dollars.

Alex 01:41

Great choice. Here’s a little bit.

Alex 01:51

(singing)

Eric 03:04

Llama or llama?

Lynn 03:06

I had the same question.

Alex 03:08

I don’t know.

Chris 03:12

We’re just hoping you can get a chaplain or a social worker with that million dollars.

Phil 03:18

Maybe a massage therapist. You don’t have to have a donor fund.

Eric 03:21

Well, let’s talk about that, because you know what? We’re talking about billing and coding and the importance of billing coding when we think about palliative care teams. But damn it, Phil, I am a doctor. I need to be doctoring. I’m not a slave to the C suite. Do I really have to? And does my team need to really know about billing and coding?

Phil 03:45

That’s an excellent question. And there’s a few things, having done this a while, that we find are important to make sure we say. And one of them is actually a line of Chris’s that I’m going to share with you, which is that palliative medicine pays for palliative care. And what I mean by that is that the primary people who are going to be coding on your team are the physicians and the advanced practice professionals. Right? Your MPs, your PAs, your docs.

Residents can bill under appropriate supervision. So can fellows, with few exceptions. The other extremely valuable members of your interprofessional team, your social worker, your nurse, your spiritual care provider, in some cases your psychologist, if you’re so lucky most of the time, cannot bill in a lot of the settings where we work. So ensuring that you optimize revenue for your services enables you to have the resources to support your interprofessional team. Did I get that right, Chris?

Chris 04:47

Yeah. When we talk about this with folks around the country, what I’ll often encourage, because you have to get people, you have to hook them when you’re trying to teach this stuff. And why does it matter? It matters because if you can get a bit more revenue, you can turn that into a social worker, you can turn that into a chaplain. So the work that you’re already doing as a provider, if you can turn that into a bit more money, it’s going to be more help for your patients. So this is not feeding some stock plan somewhere. This really does turn into the care part of palliative care.

Eric 05:24

And just to clarify, the folks who can bill, it sounds like, are the MDs and advanced practice nurses and physician assistants.

Phil 05:36

Right? So we use the term advanced practice professional to cover NPS. PAS. Also CRNAs are in there and other folks. But on palliative care teams, it’s NPs and PAs.

Eric 05:45

All right.

Chris 05:46

And on the outpatient side, I’ll just add, if you have a social worker who’s doing therapy, that’s available service. If you’ve got a psychologist in the clinic, that’s available service. But if you think about the breadth of true palliative care, if you’ve got a full idt, there are not a lot of the members of the IDT who can submit those bills to Medicare.

Eric 06:11

Okay.

Phil 06:12

Yeah.

Eric 06:13

All right. So my other question and me and Lynn had a chance to review your CAPSI slides and stuff. And I went to your last talk at ahpm. It was fabulous. We’ll have links to that on our show. Notes for everybody. But I remember one of your slides which was really helpful for me is like, how does this billing stuff work? And there’s all this Alphabet soup of words. As we think about the billing process, can you just real quick for our listeners, how does billing work in the steps that you’ve outlined?

Chris 06:48

Yeah, so real quick is going to be the goal and that’s what I’ll shoot for. So you see a patient, you prepare to write a note. What you have to do is somehow talk to or communicate with the payer what you did. Right. So there are, there are two kind of Alphabet soupy buckets. The first are the diagnoses you treated. Those are called ICD10 diagnoses, International Classification of disease. And that’s things like dyspnea or COPD or non small cell lung cancer. And those. Now ICD10 has the numbers and the letters.

So depending on what you treated, you pick a few ICD10 codes. Then you think about either how long you spent taking care of the patient or how complex the visit was and you turn that into a billing code. What’s called a CPT code or common procedural terminology. That’s the five digit code. If you run in the hospital, that’s 99233 for example, and 99233, that billing code counts as a high level or high complexity hospital visit and that turns into money.

So the way that I think about it is you see the patient as you’re writing your note, you think about your diagnoses, ICD10, you figure out what level or what the complexity of your visit was. That turns into a CPT code. And then that CPT code goes into the payer and then your institution will have a contract with the payer that turns that into a certain amount of money.

Eric 08:30

And this is all true. If I’m doing geriatric consults, palliative care consults in the hospital, kind of the process is the same and it’s similar process in the outpatient setting. Is that right?

Chris 08:40

Yep. Absolutely.

Phil 08:41

Yes. Only there’s only one set of CPT codes that Any clinician can use to describe the service that they deliver. One of those other Alphabet soup phrases are E and M codes. You might have seen that. Or E N, and that stands for evaluation and management. Those are the most commonly billed codes in cpt. All specialties use the same code. So in the outpatient setting, that’s 99202 through 99205 for new patients and 99212 and 99215 for return patients. Whether you’re a palliative care pediatrician or cardiologist, you use those same two codes to describe the work you do in that setting.

Eric 09:24

E, M is a part of cpt.

Phil 09:28

Correct. They are a subset of CPT codes and they are a minority. Here’s where those of us who do not procedural work have it a lot easier than our proceduralist colleagues. There are, you know, over 10,000 CPT codes. There are probably about 30 of those in the E&M space. Maybe 50 if you count the emergency department codes. Everything else are very, very detailed procedural codes. It’s whether or not you remove the stone from the proximal middle or the distal ureter. Right. There’s a lot of that complexity.

We don’t have to worry about most of that. I will say we’ll probably get into this. The advanced care planning codes, which are celebrating their 10th anniversary this year, are also considered evaluation and management code. So they’re under that E M umbrella.

Eric 10:18

So let me ask you one other question, because ICD10 always confuses me. So ICD10 are the diagnoses. Right. How important is it to be as specific as possible with those ICD10 codes? So let’s say Lynn comes to me as a patient. She has a wound in her leg. Should I put it as a wound in her leg? Or if I find out that she was bitten by an orca, whether or not I should use there is a nice.

Lynn 10:46

Orca.

Phil 10:47

Thumbs wouldn’t counter.

Eric 10:48

Yeah. How important is it to be that specific? Or can we just pick and choose kind of our ICD 10ish.

Chris 10:56

I don’t feel strongly about this. I usually pick the unspecified code because it’s fewer clicks for me. And I just lost my certified professional coder standing by saying that you’re supposed to go out to the seventh digit, the left, right up, down, thumb, forefinger.

Eric 11:13

What type of orca was it?

Phil 11:16

Right over 80.

Eric 11:18

Northern Pacific specific.

Phil 11:24

Exactly. When you think about one more, just nuance to that, if I could, and I’m going to Take off my clinician hat on. Because Chris is right. As long as you put a code in for the cpt, the payment is the same. I’m going to put an institutional hat on though for a second and say that actually the only way that we can describe how complex the patients you are seeing is in the ICD10 codes and in your documentation.

That really matters. We’re talking a lot about fee for service, Medicare today and commercial payers in the Medicare Advantage world, which is now in my market, 60 plus percent of patients. Having an accurate depiction of how complex our patients are actually makes a difference. So I will get off my, I will take my chair hat off for a second. But it does matter institutionally.

Lynn 12:12

Well, that relates to my question actually, because you talked about the beginning of the life cycle of a bill. So the provider puts all that info in and then it goes off somewhere and some person reads those codes. And is there somebody who in certain institutions might be tweaking them to reflect complexity? What does that look like on the other side?

Chris 12:35

So a lot of this on the hospital side, they will tweak complexity because the more complex the patient looks, the more they’re going to get paid by the payer. On the outpatient side, the complexity is more at the level of the code, not at the level of the patient. So did I do a high level visit, a moderate level visit, a low level visit?

It’s never a low level visit. In palliative care, what I always say is I am a level four patient when I go see my pcp. I, I have two chronic conditions, asthma from cats and I’m a little fat. So I have GERD and they refill my albuterol. That’s a level four visit. So if you as a palliative care doctor are seeing somebody weller than me, then they could be a level three. But you’re doing your clinic all wrong. So in the hospital, they try to build on the complexity of the patient because that does depend on how the hospital gets paid. But in the clinic, it really is the complexity of the visit rather than the complexity of the patient.

Lynn 13:37

Okay, got it.

Eric 13:38

Okay, I got another question, actually. Should we go to another question? Should I just read my, my first, our first case.

Lynn 13:44

Let’s get into the cases.

Eric 13:45

Let’s go to the case because I want to talk about this, this question about time versus complexity coding, which should I use? But I’m going to start off with the case just to get this a little bit clinical. So we got a new consult. It’s a 73 year old with metastatic pancreatic cancer in the hospital who pal of care was consulted on for goals of care. The fellow sees the patient, spends 60 minutes with them talking about goals of care, their cats, their asthma and their gerd. Afternoon the team meets with a fellow to discuss the case for 45 minutes together. I do some really amazing goals of care teaching with them. We talk about our cats.

Lynn 14:27

You show pictures of your kid?

Eric 14:29

Yeah. And then the attending, the fellow, the pharmacist and the social worker all come together and we walk to the patient’s room, we review kind of what was discussed with goals of care. For 15 minutes with the patient, we leave and we plan for a family meeting the next day. No new changes to meds. So I’m trying to think about the process of billing. So you said the first step is I’ve done my clinical encounter. Right. What do I do next with this?

Chris 14:54

Phil, do you want to drive this bus?

Phil 14:56

So a couple of clarifying questions that I will hand it off to Chris because he’s got a special power here. Did I hear you say that the fellow spent 60 minutes in the room alone?

Eric 15:08

Yes.

Phil 15:08

Before they came out and sat.

Eric 15:11

And then we talked about it, we reviewed it with the team, we talked about it amongst ourselves. Know they’re no cardiology, oncology, nobody else was involved. Then we go back, we Talk with patient, 15 minutes and we agree that, you know, we need a bigger family meeting.

Phil 15:25

Okay.

Eric 15:25

And then we leave.

Phil 15:26

And no symptom assessment, no symptom management. No.

Eric 15:30

Did all that. But when they talked to us, we’re all, no, we’re not going to focus on symptoms. Seems really well controlled. They’re not having your symptoms. So we just focused on, we need next step that we’re going to do as a team is a palliative care family meeting with a patient and maybe oncology.

Phil 15:45

Okay, a couple of things. One, fellows cannot bill on time. Just hear that only attending physicians and credentialed advanced practice professionals cannot. So fellows cannot bill on time, so their time doesn’t count. Fellows can bill on complexity. So I’m going to assume that this fellow, did your standard new patient consult on a palliative care patient who’s got all the things and did they reflected the complexity of the care that’s being delivered and not just the goals of care, but everything else.

And then if I got the kind of sequence right, you spent 15 minutes in the room with the patient. How much time did you personally spend outside the room talking about the patient’s care with either your team or the consulting team, does that include teaching about.

Eric 16:43

The case and patients, issues like care, discussion like talk and education for half an hour. The rest of the time, we spent 15 minutes in particular talking about this patient’s case. But half an hour talking about goals of care, how to run, how to have these family meetings.

Phil 16:59

If my compliance people are listening, you cannot count teaching time. You know, that’s, that’s a. That is a lot. Now where does teaching and clinical care, where does that, you know, that kind of charcoal gray area set. I will leave that up to your high ethical judgment, but it truly is your time. Now, what is now different? That I will point out. So we did a big overhaul of EM starting in the outpatient setting in 2021 and then all settings in 2023, pre2021. You could only count your time, maybe attending physician time in the room with the patient face to face.

What is now the case is time in any setting, outpatient, inpatient can count total time on day of service, whether in the presence of the patient or not. That can include everything that is, you know, record review time. That is, you know, talking to the consulting team to actually get their concern time. That’s what I like to call crazy uncle time. Right, like the time that you’re on the phone with the family member who just needs a lot of you. So you can count all of that up. That counts.

Strict teaching time gets carved out of that. So I think, and Chris, this is where I’ll hand it off to you. What it’ll come down to is what are all those minutes versus the note that your fellow writes to reflect what they did about the complexity of that. And then you need to add it up and decide which is which.

Lynn 18:31

What are ways to document complexity? Like what kinds of words document those complexity?

Phil 18:37

Dr. Jones?

Chris 18:38

Yeah. If you. I think back, Charles Von Gunton has been a mentor of mine for years. And what Charles says is, whenever you’re a question like that, or if you’re fighting with your coders, you have to return to the sacred texts. And the sacred text that answers your question is called the CPT book. That common procedural terminology.

Eric 18:58

Yeah, I got that right here.

Chris 18:59

Well, so here’s the thing. I do have a copy of it because I have to. But your coders have a copy. And this is where. When we teach 350 people at AHPM, and then they go back and said, but Joan said X, Y and Z. No, your coder does not care about me. What you have to say is, can we look at the CPT book together and interpret it together. So there’s a table in the first part of the CPT book in the 2025 version, it’s somewhere between page 10 and 15 where there’s a chart that looks at the diagnosis, the data, and the complexity of the risk of the patient.

And there are words like severe exacerbation of cancer, pain, severe progression of ILD. I personally interpreted an EKG. I discussed management of the patient with Dr. Smith from cardiology. The decision was made for a DNR today. All of those sorts of words are the high complexity things that we do in palliative care.

Eric 20:04

What did you say? Those three components, the diagnosis, diagnosis, data.

Chris 20:09

And risk, are the three columns. And if you end up, if you get a copy of the CPT book and you look at the high level component, and if you meet criteria in two of those three columns, so you don’t need all three, then you have a high level note. So I’ll estimate, when I do inpatient palliative care, I would estimate 90 to 95% of my initial consults are high level. We do a ton of cancer pain management here. We do a ton of advancing dyspnea from COPD and ILD and heart failure. Those things are all high complexity. If you write the right words because.

Eric 20:48

You have, you have, you have bad diagnoses, complex diagnoses, and because you’re changing around like pain medicine, IV opioids, particularly.

Chris 21:00

Vision regarding an IV opioid and you have a severe exacerbation of a thing. Those two things, just those two things together make it a high level note that day.

Eric 21:11

Yeah.

Lynn 21:11

Even, even if it took you 10 minutes with your expertise.

Chris 21:15

Yes.

Phil 21:16

So this is an opening for one of the other things that we want to make sure that we say, and we say this often enough in all of our presentations, just because something complex and valuable is easy for you to do as an experienced and trained palliative care clinician, like IV opioid dosing, like high dose opioid rotation, like concomitantly managing benzos and opioids, like things that are in our wheelhouse. Just because they don’t feel hard to you doesn’t mean they’re not complex and they’re not valuable. I can speak from my experience as both a primary care and a palliative care doctor.

We have kind of professionalized low self esteem just because we tend to get less than everyone else. Right. So we just walk around saying, well, maybe they’ll let me in the room today. No, like, you walk in there, they’ve asked you to come. People don’t call you unless the patient is sick. Like, by definition, as clinicians, something serious is happening. So that gets you in the door. And then you’re doing really important, complicated, high risk things. And you’re doing it at a very high level. And as you get good at it, you process it very quickly and easily. So it doesn’t feel like a heavy lift for you, but it sure as heck was a heavy lift for the referring team. That’s why they called you. So kind of own your expertise, know your value, and bill for it. Great.

Alex 22:39

I’ll ask a question. Lynn has many educator roles as well, including being director of our GeriPal Fellowship. Lynn, do you teach this to the fellows? And then we could turn to our guests and see to what extent they teach billing and coding.

Lynn 22:55

Great question. We do teach this to our Jerry fellows and palliative care fellows in a didactic way. Also in clinic, I have to make sure I’m teaching them everything correctly. And I would say, I often say those words, that you are seeing the most complex people. So you’re pretty much always going to be a very high level visit. And I also still, I can think of a visit yesterday where I did an opioid titration for somebody. It was really easy for me and I thought, oh, that didn’t really take me that long. And I probably coded it lower than I should have.

Phil 23:34

I’m not going to pick on surgeons, but they get paid the same whether the appendectomy is easy or hard.

Lynn 23:39

Right? That’s a good way to put it.

Phil 23:41

Yeah, right, like that. And, and, and that’s not their fault. That’s the system we have. I mean, you know, we should all start by invoking Barack Obama, who back when the ACA was out, said no one would build our system if they were starting from scratch. Right. This thing makes no sense in any way, but knowing this system we have and understanding how we can survive and even borderline thrive in this, I think is a responsibility we all have together.

Eric 24:06

So it sounds like that’s part of the reason why we should probably learn more about complexity based coding versus time based coding. So, for example, this case on the inpatient side, I only saw them for 15 minutes. I didn’t spend a whole lot of time reviewing the CPRs. Maybe 10 more minutes on top of that. So 25 minutes total. And then the fellow is then contacting the other team members to organize the family meeting. So spent 25 minutes with the patient you know, with my documentation, co signing. So it would be pretty low level of time. But if it was based on complexity, I actually may be able to bill at a much higher rate.

Chris 24:49

You actually have, you have two things there. Because the case that you gave us, because the fellow did some symptom assessment, even if it’s continue the ms, Cotton, continue the oxycodone, that is some symptom assessment. They’re managing the pain, they’re managing the dyspnea, the constipation that nobody manages. I once had a patient say, you’re the best doctor I ever had. I said, why do you say that? You’re 92, you’ve seen so many. She goes, you ask about the bowels every time. Right? Like that’s something we can bring to the clinical encounter. So if you do some symptom work, even if you’re not reinventing the wheel, and then you spend some time on goals, values and preferences.

Eric, you mentioned 15 minutes for your advanced care planning. I might encourage you to spend 16 minutes because you’re a member of the Medicare volunteer corps. At 16 minutes, you trigger 994, 497, which is the, the first advance care planning code, but yet you can go in the room one time and leave with two codes. If you do symptom assessment and management and also do advance care planning for 16 minutes or more.

Eric 25:57

Okay.

Phil 25:58

And one other small nugget about that particular case, Eric. Time based billing is even harder for initial encounters because the time thresholds are higher for the initial encounters than they are for the subsequent encounters. It takes more time to get to the higher level. So I’m going to guess that you would do better. You’re probably getting a 99204 at least maybe an 05. Out of your fellows work, you probably can only get a 992. Chris. What? At 25 minutes?

Chris 26:25

Well, these are probably inpatient. This is inpatient, Eric, or outpatient. Yeah, so the times are 75 minutes for the high level, 55 minutes for the moderate level, and then I think it’s 35 minutes for the low level.

Eric 26:40

So real quick, for what counts, what, what things can I look at as far as judging my time so face to face with the patient?

Chris 26:48

So I got you. It’s everything except for travel time and teaching in the generic. Okay, so looking through the chart, getting history from the nurse, talking to the patient, examining the patient, getting collateral, writing your note, writing your orders, looking at the ekg, teaching your team about hyponatremia when they have hyponatremia in the context of that individual patient’s care. All of that stuff is billable toward time. But remember, if you’re going to build advance care planning, you don’t want to bill your symptom work on time. You want to build it on complexity. That’s a bit of a nuance. That’s best practice.

Eric 27:29

And that is that true also in the outpatient setting, as far as all the things you mentioned, that counts for time.

Chris 27:34

Yep. The only thing in the outpatient setting, the home care teams get killed on this. The windshield time. You’re a volunteer, but everything else. It used to be you’d have to write your note in the house, even if the house was itchy. But now you can go in your car and write the note. Because anytime you’re doing time based service, it’s all time on day of service. So it’s not unit and floor time, it’s not in the house time, it’s all time on day of service.

Lynn 28:01

Okay. Should we move our patient to the outpatient world?

Phil 28:04

Yeah.

Lynn 28:05

Okay. So the same patient gets out of the hospital, they’re referred to the outpatient clinic for palliative care. The nurse for the clinic calls him a week ahead, does a nursing assessment for 45 minutes, talks with the caregiver, and then gets the patient an appointment in clinic. On the day of that appointment, on the consult, the patient sees the MD and the rn. Since the hospitalization, he’s now developed poor appetite, abdominal pain, and the MDNRN spends 60 minutes face to face. They do rapport building.

They evaluate symptoms, they order opioids, and then they review the advance care planning that was done in the hospital. Then they finish the visit. The doc then sends a teams message to the oncologist to let them know what they did. And then a few days later, the nurse follows up to check in with the caregiver and see how the symptom management plan went. And then a couple days after that, the palliative care pharmacist calls and checks in about the meds, provides more education. What do we do there?

Chris 29:11

I love this care. I’m going to make you so sad. So there’s so many bad things I’m about to tell you. Oh no, the first bad thing is because they were were seen by your inpatient team. If it’s the same practice group, same subspecialty, they are not a new patient in clinic, they are an established. Really? Yeah. So in clinic you get zapped with the the follow up codes. Essentially the established Codes.

Eric 29:38

Wait, can I ask you the other way? If outpatient was seeing them and then we see them on the inpatient side, is that a new patient?

Chris 29:44

Yes. So this is the interesting thing is on the inpatient side, hospital gip, hospice, and snf. Each time you get admitted to an inpatient setting, the first time a specialty sees you, you get an initial visit. But the way new patient is defined in the clinic as is, they’ve never been seen by anybody. Same specialty, same subspecialty in the practice group in three years.

Alex 30:10

Whoa.

Chris 30:11

So if someone. If you’re.

Eric 30:13

Wait, what’s considered a practice group? Can I just shunt Lynn off to a different practice?

Chris 30:18

It depends. There are some practices like my group here. Our inpatient and outpatient hospice are all the same practice group. So if somebody saw the patient two years and 11 months ago in the hospital and then they come in on fire to be in clinic, they’re an established patient. I know.

Phil 30:39

Yeah, I know. I think it’s the same, especially under the same tax ID number in the same enrollment group. I mean, that’s. That’s the back end, but it’s truly unfortunate. So, Chris, in what other ways are you going to disappoint our colleagues?

Chris 30:54

Yes, in other ways.

Eric 30:56

Breaking my heart.

Chris 30:57

Our end time is critical palliative care, but it’s not reimbursable. If you saw the patient in clinic and created a principal care management program or a chronic care management program, and you enrolled them in that, then your nurse or your social worker time would be payable. But that. This is what palliative care is. Please don’t. No show our appointment because we’re giving you a lot of time. That nursing call is free. We actually have that done by our volunteers at Duke because they wanted to be helpful and it’s. It’s an unbillable service.

Your pharmacist also. Telephone calls by pharmacists are not billable. Phone calls by nurses when people are outside of principal care management, chronic care management, or principal illness navigation, all of that is non billable. And that’s the thing we said at the beginning of all this is palliative medicine has to pay for palliative care. Because all of these other people who do such a sometimes more important job than I do when I’m fiddling with a methadone prescription, and they’re the ones dealing with the anticipatory grief about dying as a 30 year old with two kids. I don’t know how to do that. I’m not good at that. So they’re not.

Eric 32:14

When Lynn is deciding to choose the lower level because she said, oh, that didn’t take a lot of time or complexity, I’m just going to choose that versus the higher one. She should be thinking, this is for my team here. This is so I can continue to support the social worker.

Phil 32:29

Exactly right. Exactly right. And the other nuance about outpatient care, if we just now cone in on your time, Lynn, you can only count the time on the calendar day of the appointment, Right. So you know, midnight to 11:59. So if, for example, you know that there’s a complex patient coming in Tuesday and Monday afternoon, you do the deep dive on the chart. That’s volunteer time, unfortunately. So it truly is just total time on the calendar day of service on the inpatient side, because of the nature of how we do it, we tend to do each day’s work on that day. But you and all know how outpatient work can go. It can bleed over. And so just know it’s calendar day only in the outpatient setting. If you’re tracking time.

Lynn 33:21

Question about time. So if you do, if you want to bill for time using time, you’re going to document the time that you spent in the visit. If you want to bill on complexity, how do you document that? If you have a free form, a system that has kind of a freeform note, and then in a separate encounter form, do you do anything in your note?

Chris 33:42

I have so many thoughts on this.

Phil 33:44

Yes.

Lynn 33:44

All right.

Chris 33:45

So if you’re billing on time, you need a time statement. And the generic time statement is. And I’m going to speak in epic. So I’ll say start Star, star. I spent Star, Star, Star minutes providing care to this patient on the calendar day or on the day of service, face to face and non face to face period, separately billed, procedures not included or something like that to just push out the like if you’re doing a hip injection or something. Your other question, which I just forgot. Oh, if you’re going to build it on complexity. So technically, what they teach the coders is it’s the four corners of the note.

The problem is a note in EPIC prints out on average at eight and a half pages long. And the average coder has four minutes to code a note, so they can’t read the whole thing. It’s just impossible. So when Phil and I teach this around the country, what we teach is we teach a billing smartphrase. So I actually have what we call our medical decision making smartphrase, where you are picking the pieces from that Complexity table in the cpt. What did I do today? You’re putting them in one spot at the bottom of the note. So when the coder or the auditor looks at the note, they always go to the bottom first because they’re looking for the time statement. And then whether they find the time statement or all these complexity words, they know what you’re intending.

Eric 35:10

And the complexity words, do they, do they refer to those three things? The diagnosis, the data and the risk?

Chris 35:16

Yeah. What I always encourage is that you as a clinician, if you can learn the words or if you have a medical decision making pick list, what you want to do, you want to create for the auditor the most boring search award in the whole world. You want them to find the words. They’re looking for severe exacerbation decision regarding dnr. Because what you don’t want a coder to have to do is interpret or intuit anything. Their job is to translate the note into a code.

So if you give them the words that are in their rubric, then they’re going to know what you intend. Where if you just say bad CHF on a bunch of oxygen has an aki, they’re going to go, is that a severe exacerbation? I don’t know where. If you say severe exacerbation of CHF with an AKI and 6 liters nasal cannula, then they know. Okay, that’s high level in the diagnosis column.

Phil 36:11

Yeah. And just the other thing to underline, which I think has gotten a little bit internalized, which is great since the rule changes in 2021. If you’re billing on complexity, the only thing that matters is the medical decision making section. You may remember, Eric, and probably practicing years ago, where like six, the 12 points on the review of system and the family social history and then the.

Eric 36:36

Physical exam, you got to meet all those.

Phil 36:39

All of it’s gone.

Eric 36:40

Do I even have to document that stuff anymore?

Phil 36:43

Well, so the HPI and the physical exam is for your colleagues and your lawyers. Right. Like you want your colleagues to know what you did as good clinical care. And you do want to make sure that you actually reflect what happened. But you no longer have to go point by point by point by point, like that old review of the Systems. Negative times 14 should be expunged. Now. Our notes have not caught up like our notes. I think it’s going to take a generation for our notes to improve.

But ideally the notes can be tighter, smaller. But as Chris said, sort of if you can get to that language and get in the habit of using it. It actually makes things easier on you because you get more stock language. I don’t think we’ll ever get to templated palliative care notes because we want to tell our patient story. But we can get, I think, to more efficient documentation that accurately reflects the complexity of care that we have and then serves your billing purposes.

Lynn 37:37

So to be really, really granular, to reflect complexity in your. You do not talk about time in the note, no time statement. And you have an assessment and plan that contains these buzz phrases like severe exacerbation. We made a decision about a code status, those kinds of words. We titrated an opioid, as long as.

Chris 38:01

It’S parental decision regarding parenteral controlled substance.

Lynn 38:06

So the word decision is important. Got it?

Chris 38:10

Yeah. If you can. If you can reach out to your coder and say, hey, can you send me the complexity table from the front of the CPT book? Number one, they’ll think you were dropped from outer space because clinicians never ask them for that stuff. And you will realize all the answers were there the whole time. They were just never taught to you in a way that you were able to internalize. That’s kind of what Phil and I try to do is say, hey, there’s a book that on half of a page, it tells you what the answers are to billing. You’ve just never bought the book because it’s $138. Your coder will copy that page for you.

Eric 38:47

Is there a page on the Internet or do we have to. To get that book?

Chris 38:51

You should reach out to your coder so that they know that you care about this stuff.

Lynn 38:56

Okay, wait. We don’t have that much time left. I think we need to spend a few minutes on advanced care planning codes.

Alex 39:00

Yeah, we do.

Lynn 39:02

Okay.

Phil 39:02

Of course.

Lynn 39:06

Okay, so first advanced care planning code, we learned you need to talk at least 16 minutes. How do you document in your note to indicate to match up with that code?

Phil 39:18

Yeah. So there. There is actually no language in any of the. The code that. That prescribes this. CMS has provided us some guidance. Right. You should, in general, to document who is present in the discussion, because you can have the discussion with the patient or with their surrogate if the patient is not able to participate. In the early days, there was all this question of like, do you have to be in the room? Can you be outside? Can you be in the ICU lounge? Do you have to see the patient from here?

Chris 39:50

Right.

Phil 39:50

So. But in general, you need to be in the same side of service. You should broadly discuss what you shared with the patient and any decisions that the debtor made. Specifically, you don’t have to make any decisions. Right. You could say we’re going to continue care and revisit. You do not have to complete an advance directive, but you should document it if they were discussed, if you’re going to try to identify a legal decision maker, you know, a patient advocate in our state. So best practice, who was there, what did you talk about and what was the outcome of that? Even if it is simply to continue current plan and revisit and then you.

Eric 40:29

Can add that to your complexity code.

Phil 40:32

Yes. If you build on complexity, you can then also build the advanced care planning code. That’s the Chris Jones go in for one service, come out with to codes. Right now, best practice is to write a separate advance care planning note.

Chris 40:47

Right?

Phil 40:48

That is best practice to write a second separate note. If you’re going to include it in your note, segregated out very clearly from all of your other E and M documentation. Put it as an advanced care planning addendum, something like that. There’s actually an advance. I’m going to speak EPIC for a second because EPIC is of course the Walmart of health records outside the va. They actually have an advanced care planning note type which will flag and you can search. We use that because that’s where our colleagues go to see our work and it’s super valuable when they’re trying to figure out what’s going on.

Eric 41:19

Okay, another lightning question. A social determinants of health assessment. Is that a code? Is that. I hear that was a code.

Chris 41:27

Yeah, that’s a code in the clinic. It has to be an assessment. It isn’t just a survey. So you can’t just have them fill something out on paper and then it not be addressed with the clinician. If you find a social determinants need, you have to have a referral process in place. So you can’t just write, oh yeah, they don’t have any food and then move on with your day. And it is a code. It takes. It’s about a five minute code. It doesn’t pay very well. It’s about eight bucks. Eight or twelve bucks.

Phil 41:56

Yeah. It is not a lot of money.

Lynn 41:58

Okay. And then another lightning round when somebody goes onto hospice. But let’s say I’m an outpatient palliative care doc, I may be their geriatrician and I keep in touch with the patient and I’m doing some visits. Can I still Bill for those visits, even though they’ve now gone on to hospice.

Chris 42:15

This one stresses me out.

Phil 42:17

Yeah, yeah. So. So this is where I’ll step in because I don’t mind. As long as you do not have a financial relationship with the hospice. Right. As long as you’re not hospice position that you’re not employed to bed them, you’re not on contract. If you’re truly serving as this patient’s geriatrician, you can sign up to be their hospice and doctor, as long as you don’t take anything of value from the hospice itself. If you’re employed by the hospice, you cannot separately bill part B because you are to be paid under the hospice per diem.

Eric 42:48

All right, my last lightning iron question. Because we couldn’t cover everything, there’s so much more to learn about this. Clearly I understand that this is important. Where can I learn more?

Chris 42:57

Yeah. So there’s a couple of things you can pull down from online. Capsi has really leaned into this and Phil and I have helped them along with Andy, Ash and Bryn and her team.

Eric 43:08

We’ll have a link to that in our show notes. We’ll have a link.

Chris 43:10

Yep. Capsi. And then there’s two other things we did back in 2016 when the ACP codes came out. There’s a top 10 article about advanced care planning. That’s open access.

Eric 43:20

Great, we’ll link to that too.

Chris 43:22

Yep. And then the CPT book. You want to get the copy of the CPT book, those couple pages. And then the last thing about advanced care planning, the Medicare Learning Network has offered back in February or March of 25 some documentation guidelines and best practices around writing up your advance care planning documentation. So Medicare Learning Network advance care planning. If you Google those words, you’ll get a seven or eight page PDF from the government.

Eric 43:50

Great.

Phil 43:51

Yeah. And last thing I’ll say because Chris won’t every time he says Phil and I, what he really means is Chris Jones. So Chris is the brain behind the operation. He’s the Al Michaels. You know, whatever Chris Collins were through. I used to color. Chris does fabulous consulting on this. So you know he will not self promote, but I will promote him. If you have the interest in your organization, I would make the very strong case to have Chris Jones work with your team. He could do it virtually. He’ll. He’ll do it on site if you’re in the right place at the right time of year.

Eric 44:23

All right.

Phil 44:25

But that’s high value.

Eric 44:28

We have a link to you on our show notes as well.

Chris 44:31

Yeah, that’d be great.

Chris 44:35

And then my stuff is so important. And the thing is, it’s complicated, but it’s not hard. If you can manage hyponatremia, this is way easier than hyponatremia because you don’t have to figure out if they’re wet or dry.

Eric 44:49

I love this. I am convinced that this is going to make me $1 million. I want. My last question is, Alex, what are you going to do with the million dollars that we’ve just earned?

Alex 45:06

(singing)

Eric 46:16

You get a chaplain, a pharmacist. Chris, Phil, thank you for joining on this podcast.

Phil 46:23

Our pleasure.

Chris 46:24

Thank you. Thanks so much.

Lynn 46:25

That was fun.

Eric 46:26

Lynn, thanks for being our guest host.

Lynn 46:27

No problem.

Eric 46:28

And thank you to all of our listeners for your continued support.

This episode is not CME eligible.