So we're gonna move into kind of provider payment and reimbursement, similarly I've no conflicts in relation to the content of this talk, but I will give you a similar disclaimer that I'm a surgical intensivist, I'm not a coder, I'm not a biller. At my institution we do have central fee abstraction who reads our notes and decides what to bill based on the content of that note. I think it's really important for everyone to understand the logistics of how your institution functions in terms of billing. If you're in private practice, you're doing a lot more of this, you probably are very close to the codes and the rules, but if you're not and you're in a system where someone else is doing your actual billing, it's really important for you to understand the logistics of how they function. Otherwise, I do work at a big academic center, I'm at the University of Pennsylvania, and as I said, we have a lot of middle people involved in our payments. So really briefly, what I intend to go over is why billing's important, a little bit of kind of the infrastructure of coding and billing, some of the terms, just to cover the basics, how billing works, and then we'll get into some of the new rules and the new modifiers that have come out in the last year or two. So the first thing I think that's really important for everyone to understand, and as we move into our third talk that's gonna be much more hospital-based, for the most part, all healthcare is broken into really two main parts in terms of the way payments are submitted. There's provider billing and then there's hospital billing. So if you go into the hospital with pneumonia and you have a couple comorbid conditions, your intensivist, the rounding medical doctor, basically all the providers, are gonna submit a bill as providers. Everything else, your labs, your x-rays, the room, everything else that happens falls under hospital billing. They're very obviously interconnected. What happens in the hospital in terms of what the hospital can bill for is 100% based on the documentation of the providers. But the providers are also somewhat dependent on the hospital in terms of creating some incentives. And the reason for that is that the hospitals get the lion's share of the money. They also have the lion's share of the cost, but they get the lion's share of the money as compared to what providers bill for a specific patient encounter. As I said, the hospitals are completely dependent on the providers billing, and that is a little less tangible and so hospitals generally create incentives in some way where they're super up on high, where there's some inter-entity transfer dollars that occur, but they're usually some things that incentivize the physicians to document better. And one of the things you realize, if you get queries from people, they may not be queries about your personal documentation. Generally speaking, the queries are about your documentation to improve the hospital billing, which is basically improving the diagnosis documentation, which allows the hospital bill for I or D or G. We'll talk about that in a second. But so this interconnected relationship is very important. So D or G billing or diagnostic-related grouping is basically how hospitals bill. They're not fee-for-service. They don't say you got two x-rays and three CBCs and it's not that at all. It's really based on your diagnosis and in consideration of other complexities of care, including your comorbidities. So again, that patient who shows up with pneumonia, who also has some chronic kidney disease and has some underlying COPD, each one of those diagnoses acts as maybe like a pseudo-modifier to ultimately dictate how much the hospital will get for that patient. And so that's why we are constantly asked as providers, hey, it looks like this patient has acute kidney injury. Hey, it looks like this patient has some malnutrition. Can you document that please? And the reason we're asked to document that is so that the hospital can get a higher D or G and get payments. Now there's an interesting rationale behind this and that is that you get paid that certain amount for those diagnoses regardless of the patient spends one day in the hospital or they spend 10 days in the hospital. And so it actually incentivizes the hospital to provide the best care possible because the best care possible, generally speaking, is the most efficient. It has the least amount of complications and is the most cost effective. So that's the rationale behind kind of D or G billing as opposed to fee-for-service. In terms of provider billing, because that's where I'm gonna concentrate, there's really two types of billing that are done. There's CPT billing, procedurally related bills, and then there's E and M billing or evaluation and management. CPTs, if you're doing procedures, that's you have a CPT code, you get paid exactly for that CPT. Sometimes what you do, again, as a surgeon, when I do a procedure, I don't write CPT codes in there. Someone abstracts that for me. But there are multiple CPT codes in relation to a particular event. So you have to choose the one that's most appropriate for what you did to optimize your reimbursement. And again, that generally is speaking based on your documentation. Evaluation and management is everything else. So if it's not a procedure, it's E and M. It's basically using your brain to provide care. And that's HMPs, that's consults, that's every inpatient encounter where you document a note. All of those things are, in theory, billable events, including outpatient encounters. Now, these ICD codes and CPT codes basically have come from a joint collaboration between the AMA and CMS. They get updated frequently. And these are the codes that are used for claims, for billing, and so on. They are generally 100% adopted by all the third-party payers as well. So it comes from the government, but everyone uses them. The Aetnas, the Blue Cross, everyone uses these same codes. And they do get updated frequently. We're currently on ICD-10. CPT codes don't get updated as a huge bundle. They get updated kind of independently. You know, this year we just changed, actually this month we changed all the codes for hernia repair, for example. So all of those things just changed. Now, RVUs, we heard that term earlier. These are relative value units. This is what gets down to the level of providers and how much work you do for a particular event. So CPT codes, ICD-9 codes, sorry, CPT codes, whether it's a procedure-related or an E&M-related event, will have a particular number of RVUs associated with those things. So for critical care, 99291, there's a certain amount of RVUs associated with that. As RVUs get calculated, there's three things that are within that. There's the work that you actually do, there's some practice expense overhead, and there's some malpractice built into that. These do change slightly year to year. And there are some geographical adjustments depending on where you are, so you should be aware of that. I'm gonna give you a couple examples of RVUs, but keep in mind that these things do change. And this slide here may be a year or two old, so these numbers may have changed since I put this together as well. But you can see for critical care, the number of RVUs is 6.4. Now, for those of you who don't know RVUs, you may say, well, what does that mean? Well, here are a couple other examples. So if you do a BROC, you get 4.7. If you do a TRAIC, you get 5.5. The other important thing to note is the last two. So if you bill critical care, again, that was 6.4. If your note somehow gets downgraded by your billers or fee abstractors, you get downgraded to subsequent hospital care. You can see that subsequent hospital care, depending on how many elements you have in your note, may be a high level or a low level, but it's still 1.1 or 2.9. So that's way more than half for the highest level subsequent hospital care than you would have gotten if you got critical care. So it is really important, and we're gonna move into documentation shortly, but it's really important to ensure that your documentation is effective to document critical care if indeed you're delivering critical care, because you don't want to be working hard and then not getting compensated for it. This is a really busy slide, but I'm sure everyone in practice has something like this that they get handed, and this is the elements of that subsequent hospital care. We're gonna go into what critical care is, but when you get into the components of subsequent hospital care, there's all types of things, the number of reviewer systems that you tackle, the number of organ systems that you examine. This is relevant because obviously if you're going to do that work, you need to document it, but also as you create templates, you can create templates that actually force you into hitting all of the reviewer systems that you need to hit for each level of billing. So for critical care, there are actually, it's relatively simple, sort of. But there are three elements to document in a note to document or justify critical care. You need to document a diagnosis that is consistent with critical care. We will define what that means shortly, but you need to document the diagnosis, you need to document your medical decision making, and you need to document the amount of time that you spent with that patient. Now each of these have their own caveats, and we're gonna talk about that in a second. The other important thing to note is that just because a patient's in the ICU doesn't mean that they're gonna qualify for critical care. In the same respect, a patient doesn't actually need to be in an ICU for you to bill critical care. If you're providing and constructing these elements in the provision of your care that meet these criteria, critical care is not necessarily based on a specific location. All right, so here's some of the rules. 99291 and 99292 are the two real critical care bills. It's actually really simple. 99291 is for the first 30 to 74 minutes. If you don't spend 30 minutes with the patient or providing care, and we'll talk about what that means in a second, then you can't bill critical care. You must be between 30 and 74 minutes. Once you go over that 74 minute mark, you can start to tack on or think about adding on the second code, which is each additional 30 minutes. The interesting caveat as of 2023 is that to get that 99292, you now need to actually overcome the combo of 74 plus 30. You actually need to now hit 104 minutes to bill for that second code. That is new as of this year for CMS. The other payers have not instituted that yet out of interest, but they probably will. So in my little example, if you spend 120 minutes with a patient, this year you can bill a 99291 and one 99292. Last year you could have billed two 99292s. So that's a really important change. Couple other things. The time does not have to be continuous. It just is accumulation of what you do from calendar day, so midnight to midnight. If you are accruing critical care time at like 1158, but you go until like 1205 in the morning, anything after midnight counts to the day before if it initiated that time period, initiated before midnight. So another important thing to note, and we'll talk about split share billing in a second. So what it is, time is a very important thing to document. The rules state that it's the total time you spent on critical care, and there are a lot of things that can be included in that. The time must be spent at the bedside or in the unit. So in theory, you cannot be billing critical care from home. I said the time does not have to be continuous, and this time does not include anything that's separately billable. And I'm gonna show you that list in a second, but like central lines are in that list. So if you put a central line in, the time it takes you to put that line in cannot be counted towards your critical care time. But there are things that can be included, and I'll show you those. The other interesting thing to say is that teaching does not, does not count towards critical care time, and that's a really important thing. We ran into an issue where we had some of our fellows initiate some of our notes, and our fee abstractors in a very, very conservative fashion said, we're really nervous about this because that implies that you've been teaching, and we don't want anyone to ever audit us and say, well, how much of your time here was teaching? Because the note was initiated by a trainee. Anyway, the logistics are my place. All right, so what does count towards critical care time? All of your bedside work, examining a patient, you know, et cetera, reviewing any patient data, looking at x-rays, reading reports, talking to consultants, making care plans, even your documentation time. So if you type with one finger, that actually is a good thing for critical care billing. Your discussions with the family actually count if it's kind of care planning that is included. So all of those things count towards critical care billing, which is a good thing. Also, things like looking at SWAN outcomes. If you end up having to like draw blood because it's a little bit of a complex draw, if you put an NG tube in, if you put transvenous pacing, these things actually, this list is all things that are included in your critical care time. So if you're doing these things, you can count them towards your critical care time. All right, but these are the list of separately billable events. So these do not count towards critical care, but you should be billing for these independently. So intubations, trachs, central lines, chest tubes, A-lines, CPR, separately billable event, not counted towards critical care. And again, don't count this procedure time towards your critical care. Again, I mentioned that the billing intervals are midnight to midnight, and actually the language is changing, so my second bullet here is no longer correct. And I'll talk about split-share billing in a second. But your time can be a culmination of multiple providers in your group. So if you provide critical care in the trauma bay for someone who comes in with a severe traumatic brain injury, and then they go up to the unit, and you continue that critical care, but it's a different provider, but you're both in the same group, that time is cumulative and added together. That also includes if one of those providers is an APP, and we'll talk a little bit more about split-share billing in a second. Now, documentation is really, really important here for billing, mostly because that's how billing is done. There's no one who's actually looking at what you do and deciding that it warrants critical care. It's 100% dependent upon your documentation. Now, it's not just about billing. Notes are about good communication between providers. They're about a retrospective evaluation of your medical decision making. It has medical legal ramifications. It has downstream research issues, but it is also used for billing. And that's why it's really important for us as we document our notes to clearly relay that a patient meets the diagnosis of being critically ill. Now, this is abstracted directly from CMS, and I'm just gonna read to you, really, the second sentence of the first bullet, which I think sums it up the best. A critical illness or injury acutely impairs one or more vital systems, such that there is a high probability of imminent or life-threatening deterioration of that patient's condition. That is what you need to keep in your mind as you document your care. So you need to be very careful with how you describe your diagnoses in your medical decision making. Sadly, it has become a game. There are, as Scott mentioned, entities out there whose sole purpose is to look at our notes and figure out how to downgrade based on the lack of appropriate language in our notes, and knock us down from critical care to a subsequent hospital care. And they pay for themselves because they actually don't charge the payers for the work that they do. They just take a portion of the money that they recover, which is a really bad incentive. But it is what it is and where we are. So you really need to keep this definition of what it means to be critically ill, and I'm gonna show you some examples. So you wanna say you've had to provide constant attention to a certain problem. You can use the actual language that CMS uses. Critical or imminent life-threatening deterioration is occurring. Their survival is jeopardized. They have, you wanna document organ failure or multi-system organ failure. You wanna use words like shock. The fact that you spent time in a family meeting or you were on the phone with that family discussing goals of care. You need to be careful with how you tie your notes to what the house officer documents because you don't want conflicting things in a note. And that's also very, very important when it comes to copy forwarding. Because if you copy forward something and then you have conflicting data in your notes, that's a very easy thing for some fee abstractor to say, well, this note doesn't make sense. I'm not gonna take the risk of billing critical care. So you really need to be careful with that. You also need to be careful with the use of the word stable. I tell people never use the word stable. You can be stable on a balloon pump. You can be stable on ECMO. And someone's gonna say, well, that's not life-threatening, is it, if they're stable? Yes, it is, they're on an ECMO. But again, the people who are doing your fee abstraction are not providers. They have not gone to medical school. They have, you know. And so you actually have to be a little bit careful and really understand who's doing your fee abstraction so that you can use lingo that they're gonna understand and pick up as critical care. So talk about the patient's instability and the critical nature of their injuries. Talk about the different organ systems that are failing or that have failed. Note all of the comorbid conditions that are making things worse, right? If a patient has underlying intramarincular lung disease but they have a pneumonia, well, pneumonia isn't life-threatening, but if they have underlying intramarincular lung disease, that makes it a lot more of a serious event. So you need to say those things and all of those things that are complicating your care. Use descriptors, use adjectives that really show that the patient's worsening and how your medical decision-making is really complex because of those things. So you can absolutely include numbers. If you're interpreting SWAN numbers, then throw those in there. Again, that just further documents the complexity of care that you are providing. Talk about the things that you have done. One of the things that I'll see every once in a while when people get downgraded is that it was hard for the fee abstractors to recognize what the critical care provider had done versus everyone else, the staff, maybe the hospital-based APPs who don't bill. So what did you as a provider do, right? So you have to say, I reviewed today's chest X-ray. I reviewed the labs today. I placed the NG tube. The more you can kind of relay the fact that you were actively involved and you're not just documenting a note of what everyone else has been doing is also very helpful and important. So a couple things that might raise red flags. Now, these things aren't necessarily illegal, but again, there are audit filters and things that will trigger people to look into your practices. So if you bill critical care every single day, Monday through Friday, but on the weekend, suddenly you're not billing critical care it might be that you just want to round really quick. Hopefully you're still providing good level of care, but it seems weird that on weekends, the patient's not critically ill, but on Monday through Friday, they are critically ill. So things you need to think about. When your notes get timed, if you initiate a note at nine o'clock in the morning and then you sign that note at 9.15, it just seems kind of weird. A fee abstractor may say, go and look at all your notes from that day and say, look at all the notes are like signed within 15 minutes of starting and they're all like lumped in in the morning. How did this person give eight hours of critical care in four hours, cumulatively. So what we do at my place is we will start all our notes during morning rounds, but we actually don't finish them until the end of the day. We make adjustments to document the other things that we've done throughout the day to appropriately document our work and then we sign our notes towards the end of the day and that way it kind of makes sense. Everyone has these nightmares of someone looking at what time you checked into the parking garage versus what time you checked out and I don't know if that's ever actually happened, but you should, in the back of your mind, justify that it should kind of make sense. Now you don't need to walk around with 12 stopwatches around your neck and start and stop as you start talking about a patient, but cumulatively, it should kind of make sense. It should not seem impossible if someone were to audit you. So those are things you need to take into account. Okay, split-shared services. So as we talked about, multiple providers and providers, physicians and APPs can bill. Here are some of the new rules that just came out about split-share services this year and it has to do with, again, how much of this provider or physician will bill 100%, APPs bill 85%. If they provide the substance portion of that critical care. And so that's the new rule. It's who provides the substantive portion of critical care and that is basically greater than 50%. That's all it has to be at this point, I think, as far as I know. And so that is who it gets billed on. So you need to think and do the math of what is most optimal for your practice. As Scott gave a scenario earlier of providers during the day and APPs at night. If those APPs are part of the provider group, right, then they can actually bill for their activities. But you have to do the math. If they're gonna bill and suddenly become the substantive portion biller, now everything gets knocked down to 85%. And so their amount of work now has to compensate for maybe that downgrade. So you have to kind of do the math and see what is most advantageous for your group. Will APP billing kind of add in enough to compensate for that loss of 15%. That's probably gonna be different in every institution. And so you really have to look at how your practice functions. And again, that substantive portion really has all of the elements of the E&M stuff that we went through. And so this now has a new modifier. As of 2023, it's now the coders are gonna add this modifier as they put in that we're billing a 99291 and three or two 99292s. And to those codes, they will add the modifier FS, which states that there is split share billing occurring between multiple providers. And they will include those providers codes when they submit those bills so that CMS knows who's providing that care. So that's the new modifier that was created this year. The other thing that's out there this year or last year was the FT modifier. It kind of took over for the previous 24 modifier, more so relevant for the surgical intensivists in the room who had to document why critical care was above and beyond what would be expected for a post-operative patient who is now in the 90-day global period. Now that modifier basically has changed to basically the FT modifier, which basically says that the critical care involved in the care of this patient is above and beyond the surgical procedure. That FT modifier, when you use it as an intensivist, you should be documenting then the things that occurred. So if you have a patient who came in after a car crash and had a liver laceration and went to the OR for an XLAP, in the ICU, the intensivist should be clearly documenting that they are caring for respiratory failure, for traumatic shock, and the fact that the patient was concussed. The ICU provider should not be documenting that they're looking at the drains that are around the liver and looking at the wound. You're not caring for the surgical process. Someone else can be writing those notes. But as the intensivist, if you apply to bill for that patient, you really need to document the diagnoses that are above and beyond those expected things related to a liver injury that required an exploratory laparotomy. So hopefully that makes sense. So in conclusion, I think proper billing for E and M of procedures really is based on our documentation. And we really have to be very good with how our documentation is done because the folks who are abstracting from those notes, again, aren't necessarily providers with our expertise. You should document as many critical care diagnoses as exist in your patient. It actually helps rationalize your own billing and it helps with the hospital's DRG billing to document all of the diagnoses that you are treating. You should understand the modifiers that we talked about. And then again, we talked about kind of the global surgical period. That's actually slowly gonna go away as the CPT codes get updated. CPTs are gonna actually come with slightly less RVUs for surgeons because CMS is now wanting us to bill independently for all of the subsequent care. So that just rolled out for all hernia repairs and it's gonna roll out for a bunch of things really soon. And again, I think this is a real balance. Depending on how your institution flows, there's a balance between compliance and financial compensation. You wanna be safe, you don't wanna get audited, but you do and deserve to get paid for the care that you're providing. And so it unfortunately behooves us to really have to understand this balance and justify the work that we do. So thanks for your time. Hopefully this was helpful. I have a couple references that'll be out there in the slide set if anyone wants them. And we are going to shift gears and talk about DRG billing, which I'm really interested to hear because that's the other side of things.

logistics of billing

healthcare payments

provider billing

hospital billing

documentation for billing

CPT billing