Medical Billing and Coding in Geriatrics: Peter Hollmann, Ken Koncilja, and Audrey Chun

Eric 00:00

Welcome to the GeriPal Podcast. This is Eric Widera.

Alex 00:03

This is Alex Smith.

Eric 00:05

And, Alex, we are going to do part two of billing. So in September, we had the billing boys on. Chris Jones and Phil Rogers talked about medical billing and coding. A lot focused on palliative care. Today we’re going to do part two, but instead focus a little less on palliative care, more on, like, what’s different in geriatrics. Who do we have with us today? Help us through this.

Alex 00:32

We are honored to welcome Peter Holman, who is a geriatrician and chief medical officer at Brown Medicine and member of the RVS Update Committee, commonly known as the ruc. Peter, welcome to Geripal. And we’re delighted to welcome Ken Concilia, who is a geriatrician at the Cleveland Clinic and graduate of UCSF’s geriatrics fellowship. Ken, welcome to the GeriPal Podcast.

Ken 00:58

Thank you for having me.

Alex 00:59

And we’re delighted to welcome back Audrey Chun, who is a geriatrician and vice chair of outpatient care in the Brookdale Department of Geriatrics and Palliative Medicine at Mount Sinai School of Medicine. Audrey, welcome back to the GeriPal Podcast.

Audrey 01:11

Thanks for having me. I’m excited to be here.

Eric 01:14

So we got a lot to talk about. Billing. A little hard subject to do on a podcast, but we’re going to try again. Part two of it. Before we do, we always start off with a song request. Audrey, I think you have a song request for Alex.

Audrey 01:25

I do. It’s Money, Money, Money by Abba.

Ken 01:29

Money, Money.

Eric 01:30

Okay, Audrey, probably is probably not that deep, but I’m just gonna ask. Why’d you choose this song?

Audrey 01:36

I mean, the topic is billing, and why do we bill so we can get paid? So it seemed an apt song.

Eric 01:43

Okay, Alex, here we go.

Alex 01:46

(singing)

Eric 02:40

That was fun.

Ken 02:42

Fun song.

Alex 02:43

Thank you, Audrey. Yeah. It’s increasingly a rich man’s world. Trump Musk. So many others now. Yeah.

Eric 02:51

All right, Ken, I’ve got a question for you. So, Alex said you did fellowship with us. How much of your fellowship was dedicated towards learning the business aspects, billing, coding, all of that stuff?

Ken 03:08

Well, I spent two weeks with Alex on inpatient palliative at the VA. And you did you did teach me about emojis. [laughter]

Alex 03:17

That’s telling you something…

Ken 03:21

I learned more about emojis…

Audrey 03:23

Shouldn’t have asked that question, Eric. [laughter]

Eric 03:28

Can we bill on emojis, Peter?

Peter 03:30

Of course you can. I mean, it’s the emoji modifier. They pay you a lot more if you put a big happy face on it. [laughter]

Eric 03:36

You’re gonna have to teach me which code that is. Yeah, Ken, but I’m guessing, because I know your fellowship director really well, that there wasn’t probably a lot on billing and coding.

Ken 03:48

No, not a. Not a terrible amount.

Eric 03:49

Not a terrible amount. Do you think there should have been?

Ken 03:53

Yes. Yes. What I did learn a lot of was complexity and multidisciplinary care for older adults. And I think the patients that we see in geriatrics clinic, in both primary care and consultative practices, are super complex. And I think proper coding and documentation helps us to capture or sell what we actually are doing, get recognized for what we’re actually doing.

Eric 04:24

But what if we just want to complain that we don’t get paid enough? Is that good enough, Audrey?

Audrey 04:30

Yeah, exactly. Complaining always works. No, I always emphasize to our providers as well, as well as to our trainees, that we’re working really hard and we have complicated patients, and we should get credit for all the work that we’re doing. Like, we should not undervalue the work that we are providing, the care that we are providing. And I think it’s also important to know that that payment actually pays for the interdisciplinary team, the multidisciplinary team that we work with.

They are not billing providers, so no income coming in means that there’s not support for them. So it’s really on us who can bill and get reimbursed for the work that we’re doing. That really covers the entire team that we find to be absolutely essential for good geriatrics care.

Eric 05:17

I love that because I remember from Chris Jones and Phil Rogers, our past podcast, because probably most of us didn’t go into medicine to, you know, document an ehr, bill, code, all of that stuff. It’s like that thing that we have to do, and they made the cases that this is really how we support our interprofessional team. Peter, other thoughts on why it is important to do this, to build, to code optimally?

Peter 05:45

Yeah, well, I think Audrey mentioned the main One, if you want to take good care of your patients, it means you have to have a team. You’re going to need resources, and you’re not going to get resources from your organization or for your own practice unless you can, Bill. And it’s not that complicated. I think people have sort of got a learned helplessness where they sort of think it’s too complicated. I can’t learn this stuff. If you can be a doctor, if you can be a geriatrician, you can do billing. It’s just not that hard.

Eric 06:13

What do you think it is? What’s my hang up? Peter, Psychoanalyze me. Like, what is the. Why do you. Audrey, you teach this, right? You teach this a lot.

Audrey 06:23

I think we undervalue our work. That’s what it is. And so you feel bad. You say, oh, well, they’ll have a co pay, so I shouldn’t pay, you know, I shouldn’t charge this. I can assure you that no other specialty or maybe there are some specialties. But a surgeon isn’t saying, well, I don’t know, I don’t want them to have a copay. So I’m not going to charge them for my, you know, my surgery. That’s not going to happen. Right. So we are providing a service that is of great value and we should be reimbursed adequately for that.

And that’s not just in our profession. And, you know, in all professions that should be the case. And I think as geriatricians, a lot of times we devalue ourselves while putting everyone else, you know, first and trying to take care of them. And I think we need to get beyond. Beyond that victim, victim attitude. I’m not psychoanalyzing you though. Just trying to.

Eric 07:15

Works for me. I got a couple quick questions for you, Peter. You were going to say something.

Peter 07:21

Well, I think the other thing is that sometimes the people that do the teaching are focused in on compliance and they actually intimidate people. And you really need to understand that we can get paid for the work that we do. That it is complex and we should be reporting our services that way so that we can pay for our team.

Eric 07:41

And who just quick reminder, we talked about this with the last podcast with the billing boys. Which team members can bill physicians, nurse.

Peter 07:51

Practitioners, APRNs, clinical nurse specialists, physicians associates, physicians assistants. They’re all sort of considered in that physician class. So the rules that, you know, e M all apply to them. People will have psychologists that are doing certain services in some of their dementia clinics, especially if you have a psychologist or A social worker doing clinical care, not just doing support for getting eligibility for certain programs, financial assistance they can bill.

You can use other team members, sometimes in little ways through care management codes or even through a 99211. That code, that’s really about you supervising people. So a quick pharmacist visit or an RN visit, that kind of stuff can also be billable. The physician is doing the billing, but the person is actually doing the service is somebody else.

Ken 08:42

Okay.

Eric 08:43

And then just, just because it’s been a little while since we had our last podcast on billing. Just a quick reminder, if people want a deeper one, go to our last podcast. I remember there’s procedure codes like cpt, there’s diagnosis those. Real quick reminder. What are those again?

Peter 09:03

Let’s give Ken a question and see how much he’s learned.

Ken 09:06

Well, I’d say these are the codes that we input to get reimbursed for the work that is done. So if it’s a procedure or it’s a. I guess I would say like your most Office visits are 9921-399214-99215. These are the Level 3, Level 4 or Level 5 visits for established patients that are probably the most common ambulatory or outpatient codes that are used.

Eric 09:31

And those are the evaluation and management codes.

Ken 09:34

Evaluation, yes.

Peter 09:36

And there’s CPT. And if you want to get paid, you have to put another code with CPT, the CPT code. And then what code is that? What kind of code is that?

Ken 09:44

Your diagnosis codes.

Eric 09:46

All right, so every procedure code or CPT code needs to have a diagnosis code. Right. And then how important is it. So that’s the ICD10. How important is it that you include, like, can you just include one diagnosis the patient has? Like, how important does it include all of these different diagnoses that we see our patients with?

Ken 10:06

There are criteria for the different CPT, levels of, levels of, or the evaluation and management codes. So whether it’s time based, billing is when you document the time spent in the encounter, or medical decision making is based off of medical complexity and decision making and risk.

Eric 10:26

And I remember Chris Jones and Phil Rogers, they talked a lot about pushing for maybe a little bit less on time and more in complexity to really capture the work. Before I asked, do you all agree with that? I want to go back to how do we decide the ICD10 code? Like, how important is it that we put in all of these different ICD10 codes?

Peter 10:45

It’s important.

Eric 10:46

Why?

Peter 10:47

And not necessarily all of them. I Mean, I’ve seen plenty of notes where there’s 16 codes and you can’t even transmit that number. But if you just want to get paid, if you just want the claim to go through, you can put in something, it should be accurate. But most of us today are in programs. There will be a differential in terms of risk that might affect sort of our budget through an accountable care organization or some other quality program. So they’re usually not directly going to change your CPT payment. So a 992 and 4 are still going to pay the same, but you might have risk sharing and other things where that’s a big factor.

And more and more of what primary care in geriatrics is getting paid is through those factors. So it’s really important for what they call risk adjustment factors. Some of the insurance companies are also looking at the ICD10 codes. Now. There’s quite a few that have announced that they’re doing this. And if they don’t think that an ICD10 code for snidey nose is a 99215, a high level visit, they just drop it down to whatever they feel like. And so yes, Medicare might pay that claim, but another Medicare Advantage or commercial insurance won’t.

Audrey 12:05

I would also say that it’s again about capturing the work that you’re doing. So we’re not suggesting that you keep just adding things into kind of pad that encounter diagnoses. We want this visit to reflect the complexity. So if you are managing dementia and hypertension and heart failure and diabetes in that visit, yes, it certainly accomplishes what Pete was mentioning as far as kind of reflecting the risk. But that’s, that’s the work that you’re doing.

So no, you don’t need to put 13 codes in there, but you should adequately reflect that the, the complex work that’s being done. So I, I really want to emphasize this is about getting credit for the work that we do as geriatricians. And it’s not about like gaming a system. It’s not about, you know, it’s the system is what it is and we are in that. But it’s really about getting credit for the, the work that’s being done, the hard work and the complex work that’s being done.

Eric 13:02

And how important do you think is? Again, what I remember from our last podcast is if we build on complexity for our very complex patients, it tends to be better than time. Would you agree with that, Ken?

Ken 13:12

Yes, I think when you’re in a quick, busy clinic and you have a lot of patients to see. And you’re not spending often spending time managing like a dementia or like a life threatening diagnosis or the complexity of our older adults who have a problem list 30, 30 problems long, building off of complexities, often more revenue for the time spent in clinic for over your whole day. You know, I think, I think if you look at it like patient, we talk about a patient, it might put this into more context. I, I saw this week a 94 year old woman who I’m the primary care physician for and she has mixed dementia, you know, lots of chronic conditions like high blood pressure, dyslipidemia, CAD afib, CKD, iron deficiency anemia.

And she receives care at home from her family since her stroke. She’s very dependent and amnestic. So I had a 70 minute visit with her on Tuesday. We did a MOCA. We reviewed her dementia care, we documented a dementia care plan and we also went through environment of support with the family caregivers. We had our nurse talk about redirection separately when while I was doing the moca, we were going through behavioral techniques and then we also reviewed advanced care planning and functional support. This patient is much more complicated than the 15 minute visits. I was precepting in resident clinic this morning. Yeah, we spent a lot of time for an older adult with dementia and I’d like to be recognized for that. Is there special codes that I, that I might be using for this kind of visit?

Eric 15:05

What do you think? That’s a great case. This is our. How, how would you bill for that? And I wonder if it’s different what Peter responds versus Audrey responding to that. And we can see what Ken ultimately did at the end. Go ahead, Peter.

Peter 15:19

I was going to say let Audrey go first because that way I can criticize her response.

Audrey 15:23

Yeah, definitely. I’m trying. I have all these, I have these additional questions for you. You said this was a new patient or a follow up patient.

Ken 15:30

Established.

Audrey 15:31

And it’s an established patient. You spent 70 minutes doing that. Yeah, all of those sorts of things. I mean that alone.

Eric 15:38

Nurse involvement. Yeah.

Audrey 15:42

So that would be. And that was, that was just the face to face. Forget about all the stuff that you did afterwards. Right. With calling and arranging things with the family.

Ken 15:52

Well, I probably, I actually honestly do it all in the room with the patients. So.

Audrey 15:56

So then it is all face to face while you’re doing that. I mean you already hit your threshold for a level 5 based on the time alone. If you had spent less time than that, you know, and complexity alone would have done that. But you could even do prolonged services for that visit, depending on if they are enrolled in one of these other programs like Chronic Care Management or apcm.

Or while it wouldn’t be additional charge for that visit, you could capture, you know, just all the things that your practice is doing by, you know, outside of that visit to get additional credit for that in that situation. I don’t. I mean, I think it would actually be the time and the prolonged services. But your medical decision alone would put you at that, given the complexity of the situation.

Eric 16:44

And do you, do you just chalk in the advance care planning into that or do you put like an advance care planning code?

Audrey 16:50

Well, the advance care planning would be an addition to that. It’s a separate and distinct service. If you had done that and had spent 16 minutes separate from the rest of your visit doing the advance care planning, then you would add that in addition with a modifier to indicate that it was a distinct and separate service. So kind of depending on the extent of the advance care planning conversation, that could be an addition for sure.

Eric 17:16

Let me ask you this. What does it mean to be distinct? Do I have to, like, move to a different room or I might just.

Audrey 17:21

Yeah, exactly. No, no, no, no. It’s just because we talked about these CPT or different procedures that are being right. An E and M is a subset of cpt. So that’s kind of your office visit where you’re managing all the different things, the diabetes, the dementia, the hypertension. And then when we talk about a separate service, advanced care planning is actually a standalone service. So you could just do advanced care planning for someone coming into a visit. If you did, you know, nothing else but just advanced care planning and spend at least 16 minutes doing that, you could build the initial code.

But if you’ve done that in addition to the other services you are providing through an em, managing all the other medical conditions, in fact, they’re two distinct services. As a geriatrician, again, just because it’s not that complex to us, since we do it all the time, we may not think of it. It’s like, oh, that’s just part of my visit. I always do advanced care planning. Or, you know, something has changed. And we always add advanced care planning to the visit conceptually. In fact, if you’re spending enough time with those services, there are two distinct services.

Eric 18:24

Go ahead, Peter.

Peter 18:26

Yeah, advance care planning is a code that’s based upon time. So it’s. You just subtract the minutes really that you spend on advanced care planning. And I know sometimes it Kind of merges back and forth. But do you think you and Your team spent 16 minutes talking about advance care plans? More kind of just reviewing it? Right?

Ken 18:45

Yeah, she had, she had advanced directives.

Peter 18:48

Yeah.

Ken 18:49

And I reviewed them to make sure they hadn’t changed and her goals were the same. So I did not spend more than four minutes probably on hcp, which is.

Peter 18:57

A typical clinical case. I mean that’s what we’re really about, taking good care of patients, not about coding as was started out. And so you would not bill it separately. And in this case, as Audrey said, you’re probably best off to bill on time, which is I think an exception. But that does happen and that’s a good example of a case that’s like that. If you’re going to bill on medical decision making, we’re kind of assuming that it would be a high complexity, but really I’m not sure what all went into that.

You mentioned several problems that you addressed, but you didn’t mention like the risk level of your treatment. So in that case you might not have really hit a 99215 on the, on the, on the medical decision making. So time would definitely be better off. But I think for most of the follow up established patient visits that’s not going to be the case.

Audrey 19:49

Yeah. I would give a different example actually of someone that I saw this week that she was actually coming for an annual wellness visit, which is another opportunity for us to talk about. But as I walked into the room she said, oh, I can’t. I waited until this visit cause I knew I was seeing you, but I’m having a little bit of bleeding and the bleeding was going through her pants and onto the exam table. So we’re not doing the annual wellness visit today, we’re kind of switching things around. She was on anticoagulation, she had a little bit of a soft pressure, she wasn’t tachycardic, she looked fine and she just been wishing this has been happening off and on and kind of minimizing it.

But obviously this was like a serious and potentially life threatening situation. I had to manage the anticoagulation and decide whether I continue it or stop it. I had to manage her hypertension because normally she is, you know, well controlled on medicines. But since she was a little bit in that low one hundreds, I had to manage all of those things. But I actually, and I had to coordinate a bunch of things. Obviously we’re getting blood work, we’re calling the colorectal surgeon, we’re deciding er, not er. How are we going to manage these things.

But in reality, my face to face with her was about 15, 20 minutes. Right. Because I was just quickly making a triage decision. Am I going to do this ambulatory? Am I going to the emergency room? What are the things that we’re going to need? We’re examining a very focused area to figure out what’s going on. And so my face to face was really maybe 15 to 20, but I definitely build a level 5 because there is a very high risk of morbidity mortality. I did a lot of medication management and there were at least three things that were going on at that time. You know, managing our blood pressure, the afib and the. And then obviously the bleeding that was occurring. So that’s an example where, you know, the time would not have qualified, but certainly the decision making and the conditions were.

Ken 21:41

Yeah.

Peter 21:42

Audrey, are you her primary care doctor?

Audrey 21:44

I am her primary care doctor.

Peter 21:46

So tell us a little bit more about what else you build besides the. Did you bill any codes that are specific for primary care?

Audrey 21:54

What am I doing? So I think you’re referring to the APCM codes, the advanced primary care management codes, or the2212. Is that the one you’re talking about?

Peter 22:05

I’m talking about not the.

Audrey 22:06

Yeah. There’s so many opportunities. I think that’s also, we should educate ourselves because our societies, both in geriatrics and palliative medicine, have advocated very strongly to get credit for the types of work that we’re doing. And now they are actually available and we’re. It’s, it’s a shame if we’re not using the things that people worked very, very hard to do.

Eric 22:30

So let’s get into that because I want to hear about this, these, these things that I don’t know about. But can I ask a kind of a stupid question?

Audrey 22:38

Yeah.

Eric 22:38

How do they decide how much money you get from us? Like how much. Who decides how much money Audrey gets for that 20 minute visit once she puts in the CPT code? Is there like the one person of Medicare that says, okay, this is how much you get for this CPT code?

Ken 22:56

Well, I think this is a great answer, a great question for Peter, because we actually have a representative of geriatrics in leadership in this amorphous body called the rock.

Eric 23:07

The rock.

Ken 23:09

The rock.

Peter 23:09

And American Geriatric Society has a memorial.

Eric 23:12

That’s not the name of your band, Peter, is it?

Peter 23:14

Yes, the Ruck Band. And the American Geriatric Society has a member on the RUC and that is Audrey Chun. So you’ve got two folks that are involved in this. So I think the first thing to understand is what the job of the RUC is, because it’s an expert body, it’s not a representative body, although thankfully we have people with geriatrics expertise that are members. And although it’s called a relative value scale, I know a lot of people think that it has to do with the value to society or other things like that. And they go like, well, why aren’t we paying more for geriatrics and primary care and this and that. But it is having to do with the system that was worked on, the complexity and intensity and time of the work of a task.

So that’s our job. And what is done is that when a new code comes around or when we’re reviewing an existing code, will survey people that do the work and say, how much time does it take and how is it relative to another service? So, Ken, I can ask you, like, is a 99214 harder than a 99213? And you’ll say yes. And you’ll say it’s about 1.25 times harder or something like that. That’s essentially what we’re doing. And then we look over all the information and the RUC actually makes recommendations to Medicare, who decides. Now, that G2,211 code, that’s a code that Medicare created. It’s a G code. It’s not a CPT code. People oftentimes mix them up and say Medicare creates CPT codes and vice versa.

Eric 24:53

What’s a G code?

Peter 24:54

The G code. And that code is for complexity inherent to evaluation and management. It’s for primary care. It’s on everybody. You see. They’re saying, if you’re a primary care clinician, you’re always thinking about all the things that are going on with that patient and you get to use that code. And they just basically said, well, we think it’s this many minutes and ought to be worth that. So they essentially made a decision on their own that did not come through the ruck.

Eric 25:24

So is it a G code you add on top of a.

Peter 25:29

That particular, not all G codes, but that particular code can be added to an office visit code, new or established patient, and in 2026, it can be added to a home or residence Alf type visit patient as well.

Eric 25:45

And what is it today specifically for like who? Like Ken’s patient that he described. Ken, did you add G2211?

Ken 25:55

I actually did not, but I didn’t bill it as an E and M code. I billed that patient as a 99483.

Audrey 26:02

Oh, as a cognitive assessment code, which actually reimburses higher.

Ken 26:07

Sorry. It does, but I think that’s.

Peter 26:09

If you did all.

Ken 26:11

I hit all the criteria for 99483 in that visit encounter. So it actually reimburses higher than our two ruck roughs.

Audrey 26:20

Would have done with the G22 11. Even on top of that, I think. Yeah. So actually the G22 11 should almost always, depending on what kind of a code that you’re using, be added for anyone doing primary care or geriatrics. If you have an ongoing relationship with the patient and it’s reflecting the complexity of that care, you may not use it. For instance, if you just did a consult and you’re not going to be seeing that person again, or it’s unlikely that you’ll be seeing them again, then that would not be necessarily appropriate. But certainly for all of the primary care that we’re doing with an ongoing longitudinal relationship, that’s.

That’s appropriate. I will give the caveat that this code just became available this year and at the beginning it wasn’t widely used because we were advised not to use it. There was a lot of confusion from our compliance folks about who can use it. You’re going to get in trouble that you can’t do it on every single visit. That doesn’t make any sort of sense. And so there is a lot of mixed messages until we kind of sat down and said, this is clearly what the descriptor is. We are providing that type of a service and there’s no reason why we shouldn’t.

Eric 27:29

What’s the Descriptor again of G 2211? 2211.

Peter 27:33

I have it right in front of me, so I’m happy to read it. And I think the issue has a little bit to do what Audrey mentioned about all our patients being complicated. So we have this different, you know, thermostat for what’s complexity. And here’s the problem. It says visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care. So we see the word complexity as geriatricians.

We think that’s Ken’s patient. Yeah, CMS in there. We read all the stuff that they write in the proposed rule and final rule. These are where they’re like putting out what codes they’re going to cover, why they’re going to cover them, how much they’re going to pay. They said no. A patient that’s seen for nasopharyngitis and allergy symptoms can use this code because the complexity is the long term relationship with the patient, not the complexity of that specific visit. So you can see why compliance people might say that wasn’t complex. But that’s not what CMS was talking about.

Eric 28:35

So the complexity of the patient like over.

Peter 28:38

It’s not, it’s. It’s the complexity of the relationship. Oh, it’s not the patient.

Ken 28:43

Yeah.

Eric 28:44

Oh.

Audrey 28:45

As a longitudinal relationship is much more complex than I see you and I never see you again. Right. So like a whole office crazy.

Eric 28:54

If we’re doing Jerry consults or pal care consults, launch tunally. Do we add G2211 if you’re going.

Peter 29:00

To have an ongoing relationships with that. If it’s a one time consult, pain management, you know, for done one and done. No, but if you’re going to be seeing people over time, yes, specialists can use it too. So not just geriatric specialists, but you’re going to. It’s all contingent upon a long term relationship. And in that case the patient must have a complicated condition which all the palliative care people will.

Eric 29:24

Is this like 30 cents or is this like real money here?

Peter 29:28

If you bill it on every single patient, small amounts add up fast. Your overhead doesn’t go up. It’s 15 and a half bucks on average.

Audrey 29:37

Okay, can I multiply that times all of the visits that you are seeing, like again, getting credit for the teamwork and the practice work of that relationship. It’s important.

Eric 29:48

Okay. Speaking of teamwork, you, Audrey, you mentioned something called apcm, apc. If I did, I get that right?

Audrey 29:58

Yeah. Advanced primary care management. So this is one again, a little bit slow because it requires a little bit of work to get patients enrolled. But basically there are three levels of advanced primary care management. The highest level is for those who are Medicare beneficiaries. So those are kind of the patients we take care of with two or more chronic conditions. Sounds very similar to chronic care management if you all are familiar with that.

Eric 30:26

Hypertension, hypercholesterolemia, otherwise like climbing mountains.

Audrey 30:32

It’s really two chronic conditions in a Medicare beneficiary. And so it, you know, diabetes and hypertension and dementia and any combination pick and choose. And you don’t have to list all the, all of the diagnoses. It’s similar to chronic care management. But rather than having to track all the minutes and how many minutes were done in each, you know, did I reach a threshold? Did I not reach a threshold? It’s actually a monthly Charge to Medicare to say that you are an advanced primary care management practice and you are able to supply all of the services that are included in that. So 24 hours, seven, you know, 24, seven, someone can contact you, that you answer your messages, that you coordinate the care that you do.

Transitional care management. All of those things that we do in geriatrics totally is in the definition of advanced primary care management. The lift for this and the caveat is that it does require the consent of the patient and there is some cost sharing. So the monthly charge that would go out if they don’t have a coinsurance, they would be responsible for 20% of that charge as they would for any Medicare service. You know, the E M, you know, the visit that they’re coming to see you, they are responsible for that. So that could be a potential barrier to consent. And again, it hits us and geriatrics were like, oh, I don’t want to make them char. You know, I don’t want to make them pay.

Eric 31:57

So this is not something I’m like, I. Ken decides, oh, I’m going to. Instead of using time based complexity, I’m going to bill for.

Audrey 32:03

No, this is something that would be billed outside of a visit. Whether you saw them, didn’t see them, called them, didn’t call, not every month. You could, as a primary care practice that has offered all the services, should be able to bill each month for each one of those patients who have consented to those services.

Eric 32:22

And then additionally you bill on top of that for your visits.

Audrey 32:25

Yeah, like your usual care. Everything that you would be doing on top of that. It’s crazy that people are not doing it.

Eric 32:31

Ken, are you doing it?

Ken 32:33

So this is the thing. I work in a hospital system where a lot of this is supported for me to do and a lot of this is set up for me to do me billing G2211 was advocated and taught to us by our healthcare system. I think if your hospital system is not using these codes, you’re doing yourselves, you’re doing our profession, you’re doing geriatrics, you’re doing care for older adults a disservice because we really should all be recognized across the country for the work that we’re doing. And I think the AMA said in 2024, uptake of G2211 was only 25% of what was expected. So that means 75% of practices were not doing it. Why are we leaving so much fricking money on the table? You know, I, I guarantee you the plastic surgeons aren’t doing it.

Eric 33:28

Ken, how can I complain about how low paying of a specialty we’re in if we get paid a lot of money?

Audrey 33:34

Like we’re not going to become wealthy by doing all of these things.

Eric 33:40

Not going to make, you know, it’s.

Audrey 33:41

Not going to, it’s not going to do. It’s going to change, change all that. But it does enough of, I mean like when chronic care management, when we first started billing, it almost seemed not worth it, like amount of work to put into it. But now we bring in enough revenue that it supports a care coordinator or medicine. Right. So I’ve, we have to kind of just re. Re shift our thinking in that, that this is really important. The opportunity exists. It is, you know, not fraud. It is getting credit and reimbursement for the important work that’s being done.

Eric 34:17

What are some other interesting newer codes?

Ken 34:20

I think the cognitive assessment and care plan service codes, the 99483 are very.

Eric 34:26

That’s the one that you said you build instead.

Ken 34:28

Yes. So for my patient that I spent 70 minutes with, we did cognitive assessment, I performed a MOCA, we did functional safety assessment, I talked about firearm safety, we talked about what do you do if there’s a fire in the home? Do they have access to call 911. We reviewed the medications, we did caregiver training, we did advanced care planning and I talked separately with family and I spent more than 55 minutes with the patient. So I spent 70 minutes. That’s enough to trigger a 99483, which is a comprehensive care code that was advocated for, for by the American Geriatric Society to help, you know, just recognize the complexity of care for patients with cognitive impairment and dementias.

And I often will build these, try and do this once a year. You can do it up to, it’s like six months in one day. But I think it’s like for me it ends up being about once a year for my older adults with cognitive impairment and we get recognized with more RVU as a practice as a hospital system. But then also my department supports me to spend the time to provide that care. So that protects us as a specialty to provide comprehensive care for older adults with cognitive impairment.

Peter 35:47

And that’s a good example of a service. Well, first of all, American geriatricide brought it to cpt. So it’s not just we advocated for, we essentially created it. And a lot of that work that you described didn’t have to be done personally by you. Just like an annual wellness visit. You don’t have to do everything yourself. You have to put it together. You have to be part of the creation of the care plan. You have to be the one whose name the bills goes in. But you use your team to be able to do all those services, and maybe it doesn’t even take 70 minutes of your personal time to do that. So it’s an important code.

Eric 36:24

Any other new exciting codes out there that we should know about?

Peter 36:28

You mentioned one other thing, which was caregiver training. I think this is something that people. There is new codes for that. They don’t necessarily pay a whole lot. But again, there’s a very generic one that was written sort of like with wound care as the example. There’s ones for caring for behavioral issues. Was actually potentially like people, adolescents with ADD hd. But also it would apply for geriatrics as well. And there’s one that also is for ADL assistance.

It’s really going to be more like physical therapy. So again, these are all things for your team, but the big one is that advanced primary care management. I just want to mention that again because there’s three levels. $15 for people with no problems or one problem, 50amonth. This is every month, so 600 a year for people with two problems. You know, if they have two problems or not, they don’t have to be complicated. And then if they’re a qualified Medicaid Medicare beneficiary, which is Medicaid, it’s $110 and they have no cost sharing.

So for My group with 5,000 Medicare patients, traditional Medicare patients, it’s $2 million, I figure. And so when people said, I’m not sure it’s worth it, I said, you’re going to turn down $2 million? And the nurses said, well, we don’t feel comfortable asking the patients about, can we build this? Because it takes consent and you have to have a care plan, too. I said, you’ve got a care plan on all those patients. Who do you think pays your salary? Do you want to get the $2 million so we can keep you hired here or not?

Eric 37:58

Audrey, I remember going to your AGS talk. Did you just talk on this this year, if I remember correctly?

Audrey 38:03

Well, it was with AD Gap at AGS. Yeah.

Eric 38:06

How hard is it? What’s the lift to create this?

Audrey 38:10

The lift is not. Well, I think it’s. The lift is easier if you’re a smaller practice and you could just hit the ground running. We had to go through compliance. We have to, like, create an epic build so that the code can be put in. We had to create a column and a consent that was approved by, you know, the. The legal department to say that this was a consent, even though the written consent is not required. Verbal consent is fine, but we still had to go through all those steps.

So, in fact, there have been. It’s been slow uptake for us, but we are. We’re pushing forward and really being as aggressive as we can, because it’s not just for us, it’s for primary care. Right. So it’s not just about geriatrics and getting partners and coalitions of other people within the health system to whom this would benefit. So it’s really important.

Eric 38:58

Okay, I want to be mindful of that. Where can people learn more about this? Like, how to set up this apcm, or, like, how much are you getting? Like, Ken is also thinking, not just like, I have these codes, but which one am I going to get more money out of these codes? How do you learn about this?

Audrey 39:17

Each of you can give me, like.

Eric 39:18

One or two resources. One or two resources that you can give our listeners where they can learn more. Ken, I’m going to start with you.

Ken 39:26

I think Geriatrics Care Online or the AGS has some great resources on the AGS website. I think that’s great.

Eric 39:35

I’m going to have Ken send me a couple of those resources. I’m going to put it in the show notes so it’ll link you directly to the AGS website where you can look at those resources. Audrey, what’s yours?

Audrey 39:46

Well, I would say I was advertising Pete’s annual update at the annual meeting where they go through the codes that are of interest to geriatricians. And typically there are webinars in advance, as well as the updated annual.

Eric 40:02

I will include a link to Pete’s video, which I was just watching before this show. Loved it, Peter.

Peter 40:08

Medicare themselves has very good publications. And oftentimes when people tell you that’s not possible, I just Google it. And you can get them the Medicare rule and you can just show them and say, like, nope, this is what it says.

Eric 40:26

We will have links to those in our show notes. Peter, can you send it to me for our listeners? Last moment before Money, money, money. Any other last thoughts that you want to tell our listeners about billing and coding?

Alex 40:37

Yeah, one lightning.

Eric 40:39

Last lightning.

Alex 40:40

Maybe inpatient, like ACE units, skilled nursing facilities.

Eric 40:45

Alex, mixing it up.

Audrey 40:47

You gotta have a third billing episode to do all the inpatient on all the outpatient opportunities.

Eric 40:53

That’s not lighting, Alex.

Alex 40:54

That’s not lightning.

Eric 40:55

Okay, Audrey, anything else no. Ken.

Ken 40:59

Anything else?

Audrey 40:59

Get credit for your work. That’s all I want.

Ken 41:02

Know what you’re getting paid? Look it up. Look up the CPT codes on the physician fee schedule on CMS.gov.

Peter 41:10

Peter, you are worthy. Get paid for what you do.

Eric 41:15

I am not worthy, Peter. I am not worthy. With that said, a little bit more Abba — Money, money, money. Alex.

Alex 41:23

(singing)

Eric 42:17

Audrey Peter, Ken, thanks for joining us on this GeriPal Podcast. It was a blast. I never think billing is going to be that fun. And you guys make it so much fun. So thank you.

Ken 42:29

Thank you so much.

Eric 42:30

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

This episode is not CME eligible.