Good evening. Thank you for joining us tonight for the special webinar collaboration of the AOSSM Fellows and the AOSSM Emerging Leaders, covering a transition to practice topic, coding and billing, with faculty Dr. Albert Lin and Mrs. Lisa Warren. These housekeeping and content slides may be downloaded from the handout section for reference. Dr. Albert Lin is the Chief of Shoulder Service and co-director of the Pittsburgh Shoulder Institute. He is the Associate Chief of the Sports Medicine Division, Associate Program Director of the Sports Medicine Fellowship Program, Associate Professor of Orthopedic Surgery, covering shoulder surgery and sports medicine at the University of Pittsburgh Medical Center and at the Freddy Fu Sports Medicine Center. Mrs. Lisa Warren is the Chief Executive Officer at Andrews Sports Medicine and Orthopedic Center in Birmingham, Alabama, and is the President of the Alabama Chapter of Orthopedic Executives. This webinar will include two presentations with discussion. The audience is muted. Should you have any questions, these may be submitted in written format and time is allotted to ask the presenters during the webinar. To submit a question on the GoToWebinar panel on your screen, click the Questions drop-down arrow on the right-hand side of the panel. This slide shows where you input your question and then click Send. I will turn this over to Dr. Lin to begin. All right, let me just make sure I can get this on. All right, so hopefully everyone can see this. So I'd really like to thank Meredith, Lisa, and AOSSM for inviting me to give this talk and like to thank all the fellows and other surgeons who are logging in and joining us. This is, I think, an area that there's a lot of anxiety probably before starting practice because while we're very well-trained in surgery, we have very little education and training usually in this area of coding and billing. Just a little background about me, I've been in practice for nine years. I practice at a academic institution and I'm hoping to impart some tips that I've learned along the way. And my major goal today is to give you a broad overview and really go over the salient points and I really don't want to get too caught up in the weeds, so to speak. So before we start, I'd like to just kind of point to a few resources that I think are helpful. These links are also kind of in the end of my presentation along with some other resources. I served on the AOA Fellowship Education Coalition and there are modules kind of specifically designed to help fellows transition to practice and it's called actually Transition to Practice Series. And I was on the Coding and Billing Committee with a large coalition of communities that essentially represented every single fellowship. And so some of the slides from this are from that module, so you can kind of refer to these links if you have further questions. And then there are, again, additional resources at the end of my talk and I'll repost this slide as well. And at any point, you can also have access to my talk as well. If you'd like that, we can certainly make that happen for you. I'd like to thank Lisa for helping me update some of these slides with the 2021 changes to evaluation and management. And that's a big change that I think you'll see that we're all kind of still getting used to and hopefully I'll be able to kind of go over that in some detail to help you understand what they are. And so we'll focus a little bit on that as well. So a few tips. Well, really, why is this important? You work hard and you want to make sure that that's recognized for yourself and for your practice. And as I told my residents and fellows, make those RVUs into RVMEs and then RVWEs for your institutions. Time is really of the essence. So really have a system for your clinic and OR dictations and make sure that they're done timely so that they're coded appropriately. If there's anything you forget here, templates. Templates are really, really important. Whether you're on paper or computer, there's really no need to reinvent the wheel with every patient that you see and you really want to make this as brainless for you and your coders as possible. Another major thing is really don't underestimate office billing. There are much higher revenue resource, higher revenue source than you think. The goal in clinic is level four billing if you can and level three really at the very least. And it's really not that hard to get to that to those levels. And then lastly, your operative reports should be brainless for you and your coders as well. And I would recommend as we're going to go through, list your procedures separately from the highest RVU to the lowest, and then you're going to match your dictation likewise to accommodate that. And that's something I learned from one of my mentors, JP Warner. So a big overview here is just going to give you a little bit of a background regarding coding in the office, coding in the operating room, and then provide you with some additional resources. And the goals here is first to understand the basic terminology and concepts involved in coding and billing for evaluation and management, or what we call E&M, and surgery, and then understand the application to orthopedic surgery, and then review some general guidelines, pearls and pitfalls for code assignments. So language of coding, just so that we're all on the same page, CPT stands for current procedural terminology, and it's an alphanumeric system that represents all physician services. RVU is called relative value unit, and this is a unit that's used for the basis for measuring the relative economic value of a medical procedure. And these units are applied across all of medicine. And then ICD-10 are diagnostic codes. They're called international statistical classification of diseases. And these are medical diagnostic classification lists that was developed by the WHO. And so we're talking language of coding, CPT, again, current procedural terminology. This was first established by the AMA in 1966, and it was meant to standardize physician services. And initially, it wasn't really connected to reimbursement. But in the 80s, CMS really mandated use of CPT for billing. And then the AMA is responsible for maintaining and changing these CPT codes as they come. CPT is a five-digit system. And so the ones that we're really going to look at go between the twos and the sevens, the 20,000s to before 70,000, and then the 99201 to 99499 for office evaluation and management. So you've all probably heard this in 2021, as of January 1st, there were a big historic changes in the guidelines. But these changes only apply to outpatient and office visit codes. And so, again, if this is not in the office, including consults, hospital visits, emergency rooms, they don't follow these codes, or sorry, they don't follow these guidelines, and they followed the 1995 or 97 guidelines. And I'll go over those, but very, very briefly. And then the code 99201 was deleted with these new changes. So what's a new and established versus a consultation code or billing? So new is considered, obviously, new patients, but then a three-year rule, where new patients are essentially those that have not been seen by the treating orthopedics or another provider in the same practice within the past three years. So if you saw somebody for an issue, and you haven't seen them again for three years, you can code that as a new visit. Consultation, this is something that must be documented as a request from another physician to either recommend care for a specific problem or determine whether transfer of care should be accepted. And then Medicare no longer accepts consultation codes as of 2010. So again, a little bit of time on the new 2021 codes. These codes are now based on time or medical decision-making. So there's really no more counting bullets on history or exam, but they must be deemed to be medically appropriate. And it's important to note that additional documentation to support medical decision-making is critical. And again, and CMS instituted these significant changes in 2021. And so history and physical exam is no longer a factor in determining level of service. And this will be determined solely on your medical decision-making or the time spent with the patient. The MDM or the medical decision-making will be similar to current MDM calculations. And it's important that now, and I'll go over this as well, time is defined as a total time spent. And this includes time that you don't spend with the patient. So this is non-face-to-face work done on that day. And I'll go over that in some detail. The old rules basically was face-to-face encounters. And then the other major change is that it doesn't have to be more than 50% of required time that's dominated by counseling to bill by time. I think this new system is beneficial for orthopedic surgeons because the majority of our time and effort is really spent in medical decision-making. And the other major issue is there's a lot to kind of gather when you have a 30-bullet physical exam. And that's no longer necessary to really justify a level four new patient visit. So two slides on this, involving coding classes or coding seminars in which we see a table like this, and it becomes very confusing. I will really try to break this down really as simply as I can. Basically, you need two of these three categories per encounter. And those categories are number of complexity or problems, amount and or complexity of data to be reviewed or analyzed, and the risk. And then another table here, which kind of outlines this is, again, if this is being billed by MDM, you need one of these three categories. Or you can bill by time, which is in this category, which I'll go over in a little bit. And really, the goal is to get a level four billing in which you will go through each of these categories and try to at least get two of these three categories. And within these categories, get the right criteria to be able to bill for a level four. And this is kind of an extensive chart, so I don't want to kind of go through this in too much detail. But as an example, if you have one undiagnosed new problem with uncertain prognosis, and then you do one of these three categories, and one of them may just be independent interpretation of a test, say you ordered an X-ray that you state that was independently reviewed by you on which date. And then you determine that the patient needs surgery and discuss the risks, well, then you've gotten two, you've actually gotten all three of these categories when you only need two, and that would suffice for a level four billing. These are tips from Dr. Mark Miller, who sent us an email, and I think he may be on this call as well. He's tried to kind of break this down as well. Basically, you need two of these three, and then he would recommend kind of shooting for all three of these. And again, what we're looking at is number and complexity of problems, so you need to document any of the following, exacerbation of a chronic condition, which may be the easiest, an undiagnosed acute new problem with uncertain prognosis, which I added to this list, address two different droids or an acute complicated injury, for example, an ACL with a meniscal tear or dislocation with a labral tear. And then second, amount and or complexity, or document any of the following, and one of them is independent review of images. So this is, even if the images are old and you're re-reviewing the images, you simply have to say, I personally reviewed on this date, and my findings are. And second, you can also document and review an external note, review a test result, and order a new test. And then the third, risks of complications. You can document any of the following, and probably easiest, if a medication prescription is provided, or a prescription provided, or a decision for surgery, as all surgery is major, even if the patient declines, and you can discuss the risks that were discussed. If you can think, he actually recommended here, if you think you can get a level five, probably best not to sign the note until you send the note to your coder for advice, and we'll talk a little bit about audits at the end of the talk. So again, these were templates provided to me by Lisa, and the major point here is not kind of belaboring sort of all the details here, but to have like a good template, whether using Epic, electronic macro record, or paper notes, that really document all the salient points, which is really not that hard to do. And if you have a template to make this a little brainless as you kind of document this as you see a new patient, then you can see that it can be very easy to get a level four billing. And then this is an example of a surgical template, in which this is an H&P, essentially, and then a discussion of the surgery. So again, templates are really important, I think, in order for you to bill appropriately, and they really shouldn't be too onerous to hit all the salient points. So criteria to code by time, as I mentioned before, the new rules allow you to bill both face-to-face and non-face-to-face time. And this is pretty critical, because sometimes the patient actually is in your office for much longer than you see them face-to-face. And in reality, you know, when I think about patients who sign up for surgery in my clinic, a lot of the time not only is spent with the physician talking about risk and benefits, but also with our nurses and our nurse practitioner discussing the procedure, the day of the surgery, other personnel, including our brace people who come in, and a lot of time is also spent on reviewing notes prior. And really, all of that can be billed by time with the new rules. And this is, again, very different than the 1997 rules, which essentially demonstrated in 1997 rules, you had to spend greater than 50% of time spent counseling, need to document time and what was discussed, and it had to be essentially face-to-face. And again, the 2021 time rules basically allow you much more flexibility in terms of the other things that are really important in terms of the overall episode of the care. And you can see sort of the time allotted to, or the time codes here that are linked to the level of service. And really, at the end of the day, why is this relevant? Well, if you just look at a simple calculation here in terms of billing at a level three or a level four, let's say you see 250 patients a month multiplied by 12 months a year, and then take a look at billing at a level three per patient, and then look at the difference between that and billing for level four, which could easily be changed just based on a few templates and asking perhaps one or two additional things, you'll see that an annual net increase for level four established patients, just established patients alone, is about 100,000. So just think about that as it goes through the year and through new and established patients, and you'll see a marked difference basically in the amount that you can bill for. So that was sort of the major points for the 2021 E&M rules, I think, which are the most important going forward. I'm not going to spend too much time on the 1997 guidelines, but just remember that these guidelines still are in place for non-office visits. So if you see a hospital consult and for other type of encounters. The key components for this is history, physical exam, and again, MDM or medical decision-making. And then other factors include contributing factors such as the nature of the presenting problem, extent of counseling, coordination of care, and then, of course, time. So if you look at level four billing for history, again, these required bullet points. And again, each billing level would determine a different number of bullet points. And again, this largely was accomplished using patient intake forms and templates. And very briefly, all of these categories, HPI, the past medical history review systems, all of them required a certain number of bullet points to get you to an appropriate billing level. And these, again, were usually built into templates. Again, we use Epic, but templates are built into paper templates or electronic medical record to get the appropriate number of bullets to get to where you need to go. And of course, the patient intake forms would also include review of systems, which very much would look like this template here. And these would need to be signed in terms of being valid, signed and dated. Again, physical exam, same thing. Number of bullet points would be required, and this actually got pretty tricky. I would have to say that this was probably the most difficult thing for me to remember as a practicing physician and would only be made, I think, more easy with the use of templates to make sure I didn't have to remember all of these. And again, differences in level three and level four billing typically require just additional bullet points that needed to be documented. And then the same thing here, obviously, with established visits, same concepts here. And this concept of working backwards, I think, is potentially a very helpful concept in which if you have to write a prescription, inject, schedule surgery, you work backwards to make sure that you can document the history and MDM appropriately so you can charge for an established level four patient. And again, I'm not going to go over this too much because this is a little bit outdated, but bullet points are needed to kind of maintain every one of these billing levels. So what's the global period? Post-operative visits, this starts with an index surgical procedure and ends at some defined interval after. And for major surgery, the goal period is 90 days. So this means that payment for the index procedure and every additional cost associated with it would be covered through this 90-day global period. Modifiers are important to kind of remember. And these are the major ones, 24, 25, and 57. 24 is an unrelated problem treated within surgery global period. So this is, let's say, seeing somebody for shoulder pain after they've had knee surgery during the immediate 90-day global period. A modifier 25 is for an unplanned injection that you recommend either at an initial visit or a follow-up evaluation. Let's say you're discussing an MRI and they chose they didn't want to do surgery. You can't bill for an EMM visit for a planned injection, and a good example of this is scheduling somebody for uflexa. And then 57 is basically a modifier you put for the decision to proceed forward with surgery. What's the pitfalls? You can get audits if you overbill or if you underbill. And so it's important, honestly, that in either case that you bill appropriately for the appropriate levels. Audit red flags will typically occur if you are billing level 5 visits and established level 5 visits and less so level 4, but also with level 4 visits. And again, make sure that you have templates that really catch all this data and don't be an outlier, obviously. So take-home points here, new patient visits at level 3, at least established visits all at level 4. This is very easy to do if you have templates, and billing for level 4 is really appropriate if you're writing a prescription, doing aspiration injection, ordering a CT or an MRI, treating fracture dislocations, or discussing surgery. Bill for consultations when it's appropriate, and you can always work backwards from your medical decision-making to determine the level of service. And again, please use a template to capture this data. All right, for surgical coding, this is generally more straightforward. Each procedure is associated with a single CPT code, and your CPT codes that are billed should reflect the procedures performed as documented in your operative report. And so the residents and fellows who are with me, they see that when I dictate and list CPT codes that I do, my operative report also follows in the same way. And so I actually dictate every single procedure in a different section, so it makes it very clear that that is a procedure. So if you have questions regarding this, there are excellent resources, including the AOS Musculoskeletal Coding Guide and Web-based Code X. This is the definitive resource for orthopedic surgical billing. There's also the AOS Complete Global Surface Data. And this basically lists bundling packages that list every surgical procedure or CPT code and which codes can and can't be listed for reimbursement in conjunction with that code. So a word on bundling, bundling basically defines the surgical procedure codes that can be, codes can be reimbursed either separately or in combination. So for example, if you're doing a medial and lateral meniscectomy with a CPT code 29880, the following procedures are bundled together with this code, and you can't bill that separately. So obviously, if you're billing 29881, which is a medial or lateral meniscectomy, or if you're billing for medial or lateral meniscal repairs. So obviously, these are all bundled together into the same code if you end up doing one of these procedures, particularly if you're doing both of the procedures like 29880. Multiple procedures, the general rule lists the procedure with the highest number of RVUs in their first position. And if a secondary procedure is listed, a modifier can be indicated. And again, be cautious of bundling conflicts as we had discussed in the prior slide. So again, some codes are bundled together and you can't bill for them separately. And then if in any doubt, check the Academy Codex resource. Modifier 59, this is a distinct procedural service. This is the most common modifier used with surgical codes. And it can be used to identify procedures that are not normally reported together but are appropriate under the right circumstances. So for example, and this is pretty pertinent in the sports world and arthroscopy. And for instance, if you're doing arthroscopic rotator cuff repair, you may decide to perform an arthroscopic tenodesis or a distal clavicle resection. And those can be included with 59 modifiers. So this is basically the end of my talk. These are the resources here. Again, you can have access to this talk. The links are here for everyone participating here and available. And again, coding resources, Codex, the coding guide, which allows you to check bundling of procedures and which are bundled and which are not bundled and which are bundled. And then again, Codex again. And then I'll refer you back to the AOA transition to practices where much of this information is also available. All right, thanks very much. I hope that was helpful. Thanks, Dr. Lin. I'm going to refer a lot to what you talked about in my talk too. So we'll try to overlap a little bit on this one. Thank you, everybody. My name is Lisa Warren. I'm the CEO here at Andrews Sports Medicine. I tend to talk fast and I'm going to end up talking even faster so we can get through this and maybe allow some time for questions. I'm doing a very, very basic overview of the revenue cycle. And I went, we have 10 fellows here and I went and talked to them to say, you know, how basic is basic? I don't want to insult anybody. And they came back to me and said, please, you can't insult us. Start with the very beginning. So that's what I'm going to do as we run through here. I want to take some basic terms and billing. This is just like anatomy and physiology. These are basic words you need to understand in the billing world. So we'll run through these and then I'll show you how they're applied. So the first thing is we hear all these anacronyms about the types of insurance plans, HMO, POS, PPO, indemnity, what in the world are all these things. So I want to take a minute and define what the difference is between these types of plans. So the HMO plan is typically what we think about with an all encompassing plan. They have preventive services. They've got a closed panel. And this is your traditional gatekeeping model. So if someone has an HMO, nine times out of 10, they're going to have a primary care physician that manages their plan. And in order for a specialist to see them, they're going to need the referral from the primary care physician. So this is the gatekeeper model for the HMO. Now POS sometimes stands for what you think it stands for. But really in the insurance world, it means point of service. And what the point of service plan is, is it actually is two prongs. A subscriber can use the point of service plan either as an HMO where they use in-network physicians and it's a gatekeeper model, or they can choose to go outside the gatekeeper model, either in-network or out-of-network, and that changes their co-pay and their patient responsibility. So a point of service plan means the patient can decide, but it's a little more difficult for your office to manage because you have to figure out, are you in-network, are you out-of-network, how's this going to be managed with referrals and that type of thing. So that's point of service plans. Now PPO is a provider, preferred provider organization. And what this is, is kind of what we traditionally think about where physicians participate inside of a network. And so the patients can, they don't have the gatekeeper model. They see physicians inside the network, the physicians agree to take whatever the insurance allows. And then if they go outside of the network, again, that changes what kind of co-pays and patient responsibility they have. I left indemnity plans on here, not that I think they really even exist anymore, but if you hear it, this is the traditional, what we call fee-for-service. You walk in, the doctor gets paid a percent of charges. Frankly, I haven't seen these in years, but I thought I'd put it on there in case you heard the term from the good old days. Deductibles. So we'll start, these are kind of some of your basic terms and how you get paid. So a deductible is what you must be, the patient pays before anything else is paid. And often this is applied to surgery, this is applied to DME. And when I say surgery, remember that includes injections inside the office because that 20610, that administration for your injection is actually considered a surgical code and that goes to deductible. Same thing with even in-office fracture care, that's considered a procedure and often those go to deductible. And so patients get really mad because they were treated in the office and they can't understand why they're getting treat, they're paying a deductible for a quote surgical procedure. Co-payments, this is what we're all used to. That's the set amount of money paid for each office visit. It can vary based on the place of service, whether it's in the office, it's an emergency department or the hospital. And this is usually paid each day. So even in a hospital, it's paid per day. Co-insurance is usually a percentage. So it's possible people could pay a deductible, but then they also have to have co-insurance. And this is usually some sort of percentage where it is done where you pay $500 deductible and then you pay 10% of each fee after that. Maximum out of pocket. And so this is a cap on how much the patient will have to pay personally. So some plans have a $10,000 cap, some may have a $50,000 cap. And at the point the patient is maxed out, the insurance will pay 100%. Another term you'll hear a lot is called adjustments. And so adjustments are what come off of your charge. Now realize your charge is the retail price. And so when you say you charge $100 for an office visit, that's your retail price. You have your what's allowed, which means what the insurance company will pay you. And then you have the adjustment, which is the difference between the allowed and the retail price you're charged. And there are different kinds of adjustments. The one I just described is called a contractual adjustment. That's what you're obligated to take because you participate with the insurance. You have bad debt adjustments and the patient can't pay you at all. So you have to write off the whole charge. And then there's other adjustments, things like past filing limits, which means most insurance companies require you file the claim within 90 to 120 days. So if you don't get your claim in, it's too bad. You won't get paid. So you have to adjust it off. You don't have a pre-cert, other adjustment codes like that. And your billing system should be set up so you can run reports and tell what's a contractual adjustment, what's a bad debt adjustment, and what are your other adjustments. All right, how does the revenue cycle work? Now, I want to emphasize this slide because I think it's a misnomer that many doctors think revenue cycle starts when at charge entry. And that is the furthest from the truth. I want to go to the very beginning of scheduling. So the revenue cycle begins at scheduling. And so how does that work? Well, the first thing is the person taking your appointment needs to understand, do you participate with that patient's insurance? Do you take it? If you don't, you need to explain to them that we're out of network and you'll have a higher responsibility. Trust me when I tell you it is very unpleasant when this patient makes it to the front desk and you don't take their insurance. It's quite ugly. So your scheduler needs to make sure you take their insurance. The scheduler needs to preferably collect that insurance information. And by that, I mean what the policy number is, the group number and all the rest. And then they also need to set that expectation of payment. So before they hang up with the patient, they say, all right, please bring your driver's license and insurance card and your copay when you come to our office. So scheduling actually is part of the revenue cycle. So then the next step is the pre-office visit. We'll start with that. So what do you do before they even get to the office? Well, most billing systems now can verify insurance if your scheduler has put the insurance in at the very beginning. So you'll verify their insurance before they get to the office. Then if they show up to the office and there's something wrong with their plan, you know it before you see them. So that's kind of the pre-office visit piece of it. Pre-surgery, we're going to pretend like we've already made it all the way through the office visit piece. And I'm going to digress and talk about pre-surgery a little bit. Pre-surgery, what you do is you verify their insurance. We usually do this about two weeks from the surgery date. So that gives us time to reschedule. We verify their insurance. We figure out what their patient responsibility is. We call the patient. We let them know what their patient responsibility is. And we collect it prior to surgery because the reality is after surgery, they have absolutely no reason to pay you. They've already gotten what they wanted and they're not going to pay you. So get a pre-surgery if you can. And then to give the patients the benefit of the doubt, often they're out of work for two to three months. So if they're out of work to two to three months, they're not going to have the money to pay you after their surgery. So try to collect pre-surgery. Your office may have various policies on that. You have to pay 100% for elective surgeries. You have to pay 50% for acute surgeries and work through with athletes and kids and the rest. So you may have different policies on how much you collect, but you've got to collect pre-surgery. So then we do the office visit or we do have the surgery. So we'll start with the office visit. They show up at your office. You need to collect the copay at check-in, not at checkout. So collect the copay at check-in. And in this case, they have the surgery. So this is the actual work for the encounter piece that Dr. Lynn spent a lot of time talking about and summarizing what you need to do. Checkout, checkout is important because when these patients check out, often they've had an x-ray or they've had some sort of DME and they're going to owe some sort of deductible or copay on that. So best case scenario is collected before they leave the office. You send them a bill, they've already got the brace, they've already got the x-ray. It's going to be a lot harder to collect. Then you get the charge entry piece. This can either be done by hard keying on surgical claims oftentimes, or most EMRs have some sort of electronic charge capture for the charge entry. Now realize that you put it in the chart, but it still has to get submitted to the payers. So what will happen is your charge, whatever you put in the EMR, will probably get scrubbed at a look at it and make sure you have the right lateralities. Like you don't have a left x-ray and a right diagnosis code, things like that. And then we'll submit the claim to the insurance company. This is usually done electronically. I think at this point, 95% of claims are done electronically with the exception of some workers' comp carriers. So we submit it to the insurance company and it comes back from the insurance company, hopefully with a check and with this other thing that we call an EOB or a remit. And I'll show you a picture of that really quick in a minute. But you'll receive the payment or the denial, you post the payments, you take the adjustments and you get your check. Or if it's denied, you'll see a code on the remit and it will tell you it's denied and it give you the reason it's denied and then you'll have to appeal it. Now I will say for a lot of you guys that do some of these tip scopes and a lot of these unspecified codes, they will always be denied. And so realize that when you're using an unspecified code, it will get denied the first time, you will have to submit notes and it will take significantly longer to get paid. I know there's sometimes you can't avoid it. I do have a couple of doctors here that do a lot of hip procedures with unspecified codes, but it is more difficult to get paid. And so once you've posted the payment or you've done your appeals and everything gets set, you have a month end close. And so month end is usually, it's a hard close. It freezes all the numbers at that given point. There's usually a mad dash to get all the charges in for the end of the month. So you're gonna have your office staff pestering you, finish your dictation, get your charges in so we can close the month and have an accurate reflection of the work done in that month. All right, this is a remit or an explanation of benefits. This is a real EOB, and I'm gonna run through what, this is what your insurance people look at every day when they are working accounts. So this green circle is the charges. So this is the retail price. The blue circle you see up here, it says patient responsible. So this blue circle is what the patient is responsible to pay. The contractual write-off here is $82. And then you see that in this case, the insurance company here, this payment one, they paid us zero because all of that office visit for this patient went to number one means deductible. So this patient owes us $110. So if we didn't collect anything up front, this doctor got paid zero. You kind of come to the next line. Here's an example of a office visit and a co-pay. So in this case, it's at level two, we charged $82. The patient owed a $30 co-pay. We had to write off 43, and this insurance company paid us $9. Again, if you did not collect this co-pay or you professional courtesy it, or you did whatever, you made $9 on this patient visit. So it's really important. And I talk to my doctors a lot about professional courtesy that you'd be stunned at the amount of money you're writing off when you professional courtesy co-pays because it may have been what you got paid for that entire visit. So in this case, the allowable here is $39. It's $30 the patient owed, and it's the $9 that you received from the insurance company. All right, on this one, you can see this is actually a rotator cuff repair. So you've got the rotator cuff repair, you've got the bicep tendinitis, and then you've got the subacromial decompression. So these are all the codes. You see what the charges are, $9,000. Doctors get super excited. Yay, I'm going to make $9,000. Look at what the contractuals were, 6,500. So in this case, for this procedure, you only got paid $2,620. This goes back to what Dr. Lin was talking about. You got paid 100% for the first procedure. You got paid 50% for the second procedure because of multiple procedure discounts. And then on the third procedure, this happens to be an add-on code, so you don't take the 50% reduction. But in other cases, you would take a 50% deduction. So that's what that... So for this particular procedure, we got paid $2,620. More examples of this EOB, you can kind of see. In this case, $50 was the co-pay, and here's the X-rays. All right, so there are X-rays on this particular plan. And by the way, this is all the same insurance company. So these are all different plans from the same insurance company. So you can't even know just because this is Blue Cross, you don't know exactly how they're gonna pay per patient. So for this one, the X-rays went to deductible. So the patient owed us $114. So if all you did was collect $50 at the front, you've just left $63 on the table, and you only got paid 54. The next example is a total shoulder. Look at this one. All of it went to patient responsibility. You got paid zero. So if you did not collect this up front, your doctor made zero for the payments from the insurance company. This is another rotator cuff. One of the things I wanted to emphasize here is that just because the charge is more, see how on the decompression, it's $3,200, and the biceps tendinitis is $2,600. Just because the charges are more one or the other does not mean the RVUs are higher. It just means you have a random way you set your fee schedule. So don't rely on your practice's charge master to determine which procedure has the higher RVUs. And so, as you can see over here, our charge was 32, but we only got paid $345 plus $86, versus on this one, the charge was less, and we actually get paid more. So don't run into thinking just because the charge is more that the RVUs are more. The codex that Dr. Lund was talking about is an excellent tool to know where the RVUs are. Here's another example of, again, a high copay, $35. You would have only got paid $2,775. Okay, so I'm going to go through. Look, if you guys can read an MRI, you can certainly read AR reports. So what I'm going to do is, again, go through some how I was a consultant for 10 years before I came to Andrews, and so how I would go into a practice of diagnose accounts receivable problems. So now I'm going to give you guys the diagnostics for collection percentages or for billing and coding. So the first term is gross collection percentage, and this is total payments divided by total charges. This particular measurement does not mean crap unless you're comparing it against yourself because just all this is telling you is how you set your fee schedule. So if I set my fee schedule at 100% of the allowable, for example, I charge $100 for 992 and 3, and the insurance company pays me $100, that's great. Now my gross collection percentage is $100. The problem is is every payer has a different fee schedule. So if you set your charges based on the allowable for one particular payer, you could be leaving money on the table. So you never, ever set it at the 100% of allowable because, trust me, if your charge is 100 and the allowable is 110, the insurance company is going to pay you $100. So this number for gross collection percentage, again, if I was talking to another practice manager and they say my gross collection percentage is 60% and I say mine's 40%, it really doesn't mean anything that they're any better than I am. It's just how they set their charges and how many adjustments and their specialty mix and all kinds of other things. So this is only good from comparing yourself against yourself. Now net collection percentage means something totally different, and this is one of those things you can measure against other practice. So net collection percentage is total payments divided by total charges, less contractual adjustments. So if you think about what I'm talking about here, you've got total payments and what you collected divided by what you should have collected, which is charges minus contractual adjustments because you can't collect contractual adjustments. It is what it is. So that gives you your net collection percentage. That's the number that matters. Payer mix. So payer mix is essentially what it says. It's determining what percent of each insurance class you have as your mix. Why does this matter? Why is it a diagnostic? Again, this is one of those good things we watch from year to year to make sure we aren't seeing major shifts in payers. It's also good to know and to help be a predictor of whether your gross collection percentage is reasonable. If you have a high percentage of Medicare, Medicare pays, at least in Alabama, the least. So if I have a high percentage of Medicare, I would expect my gross collection percentage to be lower just because I have to take higher adjustments. Days and AR. So this is one of, again, one of those things you can pair against your friends. Is this a good AR? Is this not? Essentially what days and AR means is how many days from the day you bill it to the day you get paid. And so you take your total number of your mountain counts receivable divided by your average charges per month times 30. And then you've got your accounts receivable aging. So they're buckets, zero to 30, 30 to 60, 60 to 90, and the buckets kind of tell you how old things are. So I'm going to show you some examples of this. So here's a payer mix example. You've got your different insurance classes here. You've got charges. You've got payments. You've got adjustments. So this is just some gross data. If you look at charges as a percent to total. So this tells me that 64% of my patients coming in have Blue Cross. And you can kind of go down and you see this piece right here. Payments to total, I like looking at this because I can see that while Blue Cross may be 64% of the payer mix, they actually contribute 67% to our payments. So that tells me they're a pretty strong payer compared to some of these others, like Medicaid, for example. Gross collection percentage, again, this is not a big question for that other than to look at it for myself and to look at different payers across each other. Net collection percentage. Now, this is where I want to do the caveat. Net collection percentage does not make sense to look at for a month's period because in particular in January, what happens? Well, deductibles reset. So your net collection percentage is always going to be pretty bad in January. So you want to look at your net collection percentage over a 12-month period or a rolling 12-month period to kind of see. So in this case, I'm looking at gross collection percentage of 39.5. The net collection is 99.7. That's really good. You want your net collection percentage to be about 97%. So what does that mean? 97%, you collect 97% of what you should, and 3% is bad debt, i.e. people that can't pay you, won't pay you, or otherwise. So that number there is pretty good. Here's an example of days in AR. Here's the total accounts receivable at the end of the month. This is the average charges per month times 30 equals 40 days in AR. For this particular metric, you want it between 35 and 40 days, but realize your pay, depending on what's going on in your practice and your payer mix over here, can affect your days in AR. For example, workers' comp takes up to 60 days to pay sometimes. So if you have a high percentage of workers' comp in your practice, or you do a lot of unspecified procedures where you have to submit notes, et cetera, your days in AR are going to be higher. That might not be a reflection of your billing office's performance. It's probably just a reflection, or it could be a reflection of what you do in your practice and how it works. All right, I'm going to show you, this is accounts receivable breakdown, and you can look at accounts receivable in a number of ways. You can look at it in an aggregate, just as a total, what is my accounts receivable aging? And that's fine, and it does tell you some information, but what I really like to do is to look at it by payer, but not just by payer. I like to look at it by insurance versus patient because it makes a difference. Are your insurance companies paying you or are your patients paying you? And that's what we're trying to figure out. So for example, I'm looking at Aetna here, and 17% of Aetna's claims are over 120 days. That's not good. And over here, or over 90 to 120, and then they've got 12 over here. So they've got 16 and 23. This is not that unusual to have this much patient on AR over 120 days. It's not good. Your practice should be diligent about writing it off, getting people to collections, but it's not unusual to see this kind of percentage. And frankly, this is what you'd hope. You get what you can get from the insurance company, and by the time it gets to 90 to 120 days for a patient, it's going to be really hard to collect, and it's likely you're not going to get it. So these numbers up here for the insurance company should be as small as possible. To kind of run down here, see, look at Blue Cross. If I had to choose a payer right now, look at how much is Blue Cross. They've paid promptly. We've got paid pretty well, as opposed to up here, Aetna's holding onto it, and in this case, Cigna's holding onto it too. So that's kind of, I can evaluate payers as well as evaluating just my AR overall. All right, I have talked really fast. Just a benchmark, I forgot to say. The benchmark for aging, over 90 should be between 15 and 20% of your AR should be over 90. So I guess I'm open for questions now. Lisa, there was one question that came through. You may have answered it in that second EOB slide. Okay. Can you walk us through how you get the best estimate for surgery surgeon fee? Okay, so that's a really good question. We'll start, I'll go on this slide. Am I still sharing my screen here? Yes. Okay, let me get to that slide and make it big. Okay, so when our financial counselor is going to talk to a patient who's gonna have a rotator cuff with these particular procedures, what she will do is she will look at the payer and say, okay, the allowable for this procedure is 1639, 519. So she knows that we should be collecting 2620 from Blue Cross. If the patient's deductible is $500, then she'll collect $500 of it. If the patient's plan is $500 plus a 10% coinsurance, she's gonna collect $500 plus $262. So there's all kinds of payment estimator softwares out there, good old Excel spreadsheets work if you don't wanna pay for a payment estimator. But our financial counselor, we put her in place back in 2012 when Obamacare first started and some of these large market plan, deductible market plans, and she collects probably 10 times her salary every year. So money well, well spent on a financial counselor. Okay, thank you. We received one other question. How do you go about negotiating reimbursement for unlisted codes? Good luck with that. Usually what we do, you'll have some sort of charge. When we submit, we will try to find a code that is similar to it. And so we'll say, you know, this HIPPS scope is similar to some procedure that does have a fee. And so we'll go in and say, this is more complicated because of X, Y, Z. So if the allowable on this procedure is $1,000, we should get paid $1,500, or it's a little less complicated than this procedure. So maybe we should get paid $700. But frankly, I don't think the payers care. They just make it up. I mean, I wish I could be more positive, but we try it, works sometimes, doesn't work other times. Lisa, I have a question for you. You work in a practice where there's a lot of surgeons. The ones who are able to bill very well, what are the tips that you see, maybe one or two tips that make them a really good biller versus those that don't bill as well? I think what they need to know is what the payer expects. And so documentation is critical. You know, with the HIPPS scopes in particular, the payers have about four or five criteria that they absolutely will have to have before they'll pre-start the procedure. And so back to templates, they've got a HIP exam that's templated to meet every single one of those criteria of the payer. So when we submit the note, it gets pre-started every time. So I think templates, consistency, understanding what the payers want, and don't argue with them. They don't care. Just do what they tell you to do and put it in your templates and you're gonna get paid. So we have received a couple more questions and I think we have time to ask those. Here's the next one. How does one determine their charge for a specific procedure? Okay, we have to be careful because there's all these price fixing laws when we talk about it. But in general, what you'll do is you'll look at what your highest payer is. And so if I have a new procedure that I'm adding, I'll look at what Blue of Alabama pays, Cigna, Workers Comp, Medicare, and I'll take my top five payers and I'll line up what the allowables are for that code. And then I'll just kind of eyeball it. And assign, and I can't tell you what it is because we'll get in trouble for price fixing, but I'll look at it for a percentage and I'll just say, okay, Workers Comp pays the highest. And so we're gonna take the Workers Comp fee schedule plus 20% and that's gonna be our charge. I can tell you in our practice and I would bet in many other practices that this has been done willy-nilly over the years. And there probably is not a consistent methodology from code to code because back in 2000, they did it one way and now in 2021, they're doing it another way and everybody's updated the charge master. But what I always did as a consultant is I would look at it, particularly I'd look at these EOBs and if I was ever being paid 100% of my charge, I knew there was a problem and they needed to raise their fee schedule. Okay, and then one more, this is a question for Dr. Lynn. Dr. Lynn, do you have any tips of how to word op notes to get credit for the procedure? For example, distal clavicle excision or extensive debridement? Yeah, I mean, I think there are certain kind of keywords that, well, so I have a couple of tips for sort of operative reports. And again, I think one is you wanna list all your procedures again, from most already used to least and make them very clear, one, two, three, four, five. So that's what you'll dictate in your op report. And then as you dictate the note, I recommend that you dictate them under separate paragraphs. And I actually go so far as to list them as one period, rotator cuff repair, and I'll kind of talk about that. Two period, distal clavicle resection, and I'll talk about that. And also make sure that your diagnoses also match your procedures. And so I think it's much easier for a coder to say, okay, Dr. Lin found a degenerative labral tearing, anterior, posterior, superior, as well as bursitis, as well as degenerative fraying of the rotator cuff. And then can then look at my procedure and say, okay, extensive debridement consisted of being able to debride the entire labrum, remove the bursa, and also debride the rotator cuff. And so I think it's important that your diagnoses match your procedures. And also, you don't want to have one free-flowing paragraph because I think that's a very difficult way for your coders and the people who are billing to really know what it is that you're doing. And that would be my tips, to be honest. And I think on the clavicle resection, and I don't know what it is, but there's a certain millimeter that you need to dictate, like a minimum X number of millimeters for a clav, and I don't remember what it is. I mean, I can send it to Meredith and she can send it out, but we usually tell our fellows, if you're going to try to bill that, you debride the bleeding bone, and it has to be a minimum of X millimeters. And I honestly, I'm sorry, I don't remember what it is. Yeah, and I would say, if you're doing a distal clavicle resection and you debride bone, you just state sort of the amount of millimeters of space that's looked over after you debride that. And if it's, I would have to, please, I actually don't know the exact number either, but I usually routinely will dictate that there's seven to eight millimeters of space available. And so typically I think that meets the criteria. Yeah, in my head it was seven, but I didn't want to say it out loud. So let's go with that. Yeah, but that's typically what I would dictate. So that is all the questions that we have received. Any other closing comments, Dr. Lynn and Lisa? Well, for you to email me if you have any questions, I'm happy to help. Yeah, likewise. Again, I think the talk that I have here, the AOA resource is there's a lot of links on there for very, very specific questions, but I think, I guess my parting advice is to make things clear, have a good template, have your billers and your coders look at your template, make sure it's capturing what you think it's capturing. And if you do that routinely, then I think you can one, get yourself out of trouble and two, also bill appropriately and again, bill appropriate levels. Hey, that's true. And particularly as new physicians, develop a relationship with your coder. Don't let them be scared of you. Like you're new, go in and say, hey, I'm new, teach me what I need to know and develop a relationship and they will help you in the long run. Yeah, absolutely. That's great. Thank you so much, Dr. Lynn and Lisa for your time and preparation tonight. I'm just going to cover a couple of the upcoming educational events by AOSSM and highlight some of our online education. The AOSSM would like to remind the current sports medicine fellows about candidate membership. If you have not already applied, you may apply online for free candidate membership by clicking on the membership tab at sportsmod.org. Secure your seat at the free upcoming AJSM webinar taking place on March 3rd on slap tears and the overhead athlete. You may register at this link also found on the AOSSM website. Register today for the Anna AOSSM evening edition virtual specialty day taking place on March 17th through 18th. Learn more and register at this link. And open for free registration for current fellows is the pediatric sports medicine webinar series in collaboration with PASMA taking place on April 7th, 14th and April 21st. You may follow the registration directions on this slide. For more online and on-demand education and resources visit the online AOSSM playbook and surgical video library. Fellows, please join us on March 9th for the regularly scheduled fellows webinar series taking place on the second Tuesday of each month. Doctors Banfi, Mather, Ngo and Zhang are panelists covering hip capsule management. Thank you all for participating. Good night. Thanks so much guys. Thank you.

webinar

coding and billing

medical practice

insurance types

documentation

operative reports

reimbursement

templates

AOS Musculoskeletal Coding Guide