Hello, everybody. Thanks for being here. If you don't have handouts yet, we have them at the ends of the tables. If you see somebody coming in late, can you direct them to it so they can grab their handouts? Thanks. I'm Marianne Cloran, and I will introduce my colleagues. None of us have anything to disclose. What we're going to say, it's us, not our organizations. So if we get anything wrong, it's our fault. I am an associate professor of medicine at the University of Maryland School of Medicine, and I was chair of the ACOM Task Force on Coding Quality Care and Workers' Compensation and worked, we'll tell you a little bit about that. I'd like to introduce Dr. Brian Chen, who's an occupational medicine resident from Hopkins, who's been working with me on a paper related to this project and helped pull this together as well. And Dr. David Corretto, who's medical director of employee health services at Sutter Health. And so David kind of represents the person in the trenches. For those of you who just came in, we do have handouts that are going to be important to this. They're at the ends of the tables. So at the ends of the front tables, please grab some handouts. Thanks. All righty. Was there something else I was supposed to announce? I don't remember. Okay. So the history of what we're going to be talking about, there's a little bit of history here. In 2012, which is starting to be ancient history, pick up your handouts, please. There was a 2012, there was a House of Delegates resolution, and it was mostly triggered by docs in private practice who were kind of dying because when they were providing good quality care for workers' compensation and coding and trying to bill for the time spent on it, they got down-coded. They weren't able to kind of meet the kind of arbitrary criteria that were established for outpatient encounters, right? And so the docs in private practice put in a resolution at the House of Delegates saying, you know, help us. And so the task was, and I was on the OEM practice council at the time, the task was to develop a report in one year on the CPT codes that are applicable to workers' comp and the disparities between the Centers for Medicaid and Medicare Services on evaluation management codes and what we need to document for good quality workers' comp care. And in that year, develop member educational tools, and in that year, devise a strategy to correct this disparity. And so that help thing, I think it was them going to the House of Delegates asking for help, but that was also me because I was somebody that didn't do a whole lot of coding and billing. You know, I'm kind of an expert in work disability prevention, but not so much, you know, an expert in these matters. And so I had to learn, and it took more than a year, but we had a really great group. So the problem was that the E&M, and I see a lot of you nodding, so you're familiar with this problem, the documentation rules for workers' comp follow all the same rules as for primary care, right? And it's different, isn't it? Like what we need to document, what we need to do is much different than in group health kind of encounters. You know, group health encounters are, they're symptom-focused. There's no attention to function, work factors, or disability risk. And in fact, if you document them, it's like, well, good on you, but you don't get paid for it, right? There were very arbitrary exam elements that had to be included, you know, so the old rules, which we're not going to spend that much time on, required you to count, you know, widgets of organ systems in order to get paid. And there was medical decision-making credit, you know, for complexity that was based on the risk of procedures. How many procedures do you guys do? I mean, we do procedures now and then, but it's not the bulk of what we do, right? And you know, like the medical documents reviewed without consideration of things like air quality things reviewed, or ergonomic evaluations, or job descriptions, all those things didn't really count as medical documents. And so, you know, OCDocs were being underpaid, basically, when following our practice guidelines and providing great care. And on the other hand, docs that knew how to kind of play the system could document nonsense and get paid for it, right? And you know, not get, and not, there was no accountability, really, for providing good care. So, from 2014 to 2016, we had a whole bunch of virtual meetings, because we were across the country. And we came up with an alternative model, a rationale for it, a value statement, templates. We were really busy. I built a website. I'm not a web designer, but I built a website, it's still up if anybody wants to see it. One of the templates, actually, is the review of systems that was in the handouts. For those of you just coming in, there are handouts at the ends of the front tables. You'll need them. And example modules. So, this was basically what we were proposing. This is kind of a little infographic. And so, for each of the elements of the encounter, the history, social history, the exam, risk analysis, data reviewed, medical decision making, and your plan, we proposed moving from a medical model of what hurts, where does it hurt, what makes it hurt more, how many pills do you have to take to make the pain go away, and comprehensive head-to-toe physical, and plans based on x-rays that you get, and diagnostic tests, and things along those lines, to a function-oriented model, where there would be documentation of what happened, how did it happen, how has it impacted you, how has it impacted your function, what's the work situation. And so, assessing work disability risk. We also provided recommendations for what would count as the data that you review for the medical decision making complexity. And that the plan would need to provide, obviously, treatment of the presenting condition, I mean, we're doctors, but also mitigating the chronic work disability risk that we have identified through looking for it, right, and managing return to work, which are all features that are critical to workers' comp care, and I actually think they're important for primary care as well, but they're not a focus. So we considered that ACOM might create its own codes, we threw that one out the window, like all the systems, all the electronic systems, billing systems, et cetera, are all based on the standard codes. We thought about modifiers, but modifiers can be abused and are not very popular among the payers, you know, modifiers let you charge a little bit more for increased level of care. We totally, you know, you can see the CMS rules, we rejected that idea, like CMS isn't going to change anything, right? And so what we came up with was alternative rules. So rules that we could follow that would mirror the CMS rules, but allow us to document what needed to be documented, and spent a lot of time developing them, and there's best practices were codified in this paper, which is available at the ACOM website. But then what happened? Anybody know? There was a plot twist, okay? So the unexpected happened, and CMS proposed new rules for evaluation management encounters, where they basically, you know, the path that we thought was impossible, and I think there were other specialties that were complaining about the arbitrariness of the rules, you know, for documentation. And so, you know, they originally said there'd be fewer codes, they actually did get rid of one of the evaluation management codes. One of the main things is they got rid of the requirement for arbitrary history and exam elements. So no longer did you have to, you know, look in the ears when you're evaluating somebody for back pain. So that was good. And it also favored time-based coding and documentation. And so that was important for us, because a lot of what we do takes some time, and so it sort of gave us the option of using time-based coding. And so we, you know, ACOM wrote to CMS supporting the plans, but what's the committee going to do then? Is all this work, you know, was it all for naught, you know, was it a waste of time? I don't think that it was, but, you know, we had to regroup and think about, you know, the whole alternative model. I mean, why would we develop, you know, why would we propose mirroring and obsolete system now, right? So the CMS new rules, which took effect in January 2021, basically retained the five levels of codes for established patients, but went down to four levels for new patients. The key thing really is it allows clinicians to choose the visit level based on either medical decision-making or time. So how do you decide? How do you decide what is the best approach? Is time always going to be the best? If you think time is always going to be the best, hold up your clock. That's not a clock, that's a hand. Hold up your clock. Okay. So these are flags. We're going to use these as we go. So do you think that if you think that medical decision-making still has a place, hold up your brain. All right. Okay. We'll see. All right. So we did come up with a tip sheet, and part of it is one of the handouts for you for those just coming in. There are handouts at the ends of the first two tables. And so this is available for free. It's a quick and dirty little tool that you can use in your practice. It'd be good for you to share with your back office teams. The best practices in workers' compensation, right, now we have the opportunity because we have this flexibility. We have the opportunity to document according to what we know is the best practice, right? So in workers' compensation care, we should be documenting causation at least in the beginning or any time we think that there's an additional diagnosis related to the injury event, right? We should be documenting function. At the first visit, second visit, third visit, when do we pay attention to function? Every visit, exactly. Yeah. So the functional impact of the condition and the implications for work. How about work disability risk? You know, that's something that we do and there are systematic ways to do it, but documenting the risk factors for prolonged work disability and making sure your plan addresses them fits now in the new rules. Return to work planning does as well. When do we use which, though? So time-based is easier, right? It's easy enough to say I spent 15 minutes, 20 minutes, 25 minutes and just sort of match it to the table. But you still need to document what you spent the time on, right? And you also have to make sure that your time documentation at the end of the day doesn't add up to like more than 24 hours or ideally more than eight hours or whatever your practice schedule is. So there's the opportunity to game it, but I wouldn't recommend it. But there may be some situations where it's more appropriate to use medical decision making. And so what we're going to show you, we're going to show you some cases and have you kind of work through with us which would be the best approach. And if you're going to use medical decision making instead of time, then it's important for you to understand what you have to document for medical decision making because the documentation requirements are a little more stringent, okay? So who in your practice assigns the code? Raise your hand. I don't care if it's the brand of the clock. In your practice, do you say what the code is? Okay. In your practice, does somebody else like a back office person assign a code? Anybody do that? Okay. And if you assign it, do you get to say whether it's time-based or medical decision-based or you just say what the code is? Yeah, you can shout out. Do you get to say? Okay. Raise your hand if you get to say which paradigm you use. Okay. Raise your hand if you don't get to, if somebody else looks at the documentation. Yeah. So some of you have that. So it's important that those, and I think even if you're the one that's assigning it, it's really important that the people that get the chart after you and are involved in the billing and the auditing and checking on the codes, that they understand how you're making your decisions and that your documentation makes it really clear because sometimes things get adjusted down the road. And if you make your documentation really clear, it's less likely that somebody's going to see it and say, that doesn't count as a 4. So anyhow, we need to make sure that your team knows about workers' comp documentation needs and so what do they need to know? So I think they need to know what's on the tip sheet. So I think I'm going to turn it over at this point to Dr. Brian Chen who is a coding newbie. Raise your hand if you're a coding newbie. Anybody here not know what E&M stood for before they came in? Okay. So you're not that new. That's good. All right. Go on up. »» Thank you, Dr. Chlorine. And so now for all the coding newbies in the room like myself, we'll go into a little more background on what codes are. The AMA CPT or current procedural terminology is a uniform system for coding medical services and procedures. And this has been incorporated into rules for paying for procedures that were established by CMS and are generally used now across the board. E&M or Evaluation and Management Codes are the ones that are used most commonly in workers' compensation as well as other outpatient type encounters. And they increase in complexity based on the last digit ranging from 1 to 5 with a modifier for new or established patients at the second to last digit with a 0 or a 1. As Dr. Chlorine went over earlier, we now have a time-based option of using time-based coding. The table on the right here shows this time-based coding paradigm. As with E&M codes, the last digit increases but based on time instead. And it's important to note that all time spent on the patient encounter qualifies including both face-to-face and non-face-to-face time. And so providers are eligible to use time-based coding anytime counseling and care coordination, which are important elements of any workers' compensation encounter, account for more than half of the visit. In occupational medicine practice, counseling includes work disability, risk evaluation and management. On the other hand, coordination of care looks like return to work coordination. And so this means that clear documentation is important in specifying how this time was spent in deciding to use time-based coding. And so now we're going to shift to talking about what are some of the key elements to capture in documentation of time spent in workers' compensation care. Note that some of these are ACOM additions to CMS guidelines that are specific to high-value occupational medicine practice. And so this includes time spent on chart review, which in OEM also includes reviewing the patient's work history and incident-specific history such as mechanism of injury and work factors like PPE use and so on. It also includes non-traditional evaluations such as evaluating for risk of chronic work disability, evaluation of functional impact and outcomes and requesting other worksite evaluations like industrial hygiene or ergonomic measurements. Other time can also be spent on referring and communicating with other healthcare providers, which with workers' comp can include insurance medical directors and case managers. It can also include any time spent documenting in the EMR, any additional time spent with the medical interpreter, and time conducting causation or apportionment analyses. Finally, the documentation of time should also include the provider's interpretation and your communication of these medical opinions for which workers' compensation includes return to work instructions and activity restrictions. So if less than half the encounter was spent on counseling or care coordination, and remember that time includes non-face-to-face time as well, MDM should be used or when the facts of the case are better captured by MDM. And we'll have detailed examples to follow. And so to review very briefly, as you may already know, there are five different levels of MDM ranging from straightforward to high with a coding level for not applicable overall. But more importantly, there are three elements of MDM. And two of the three elements must be met to code for a given level. »» I'm going to interrupt for a sec. One of the handouts has this graph if you want to follow along on your handout. »» And sorry again, for those of you who came in or don't have a handout, we have handouts at the front at either end of the tables. And so as I mentioned, there are three elements of MDM. And two out of these three elements must be met for a given MDM level to be coded. And so the first element is number and complexity of problems. The second element is amount and or complexity of data. And the third and final element is risk of morbidity. So as an example, if we were using MDM for a new patient who had a moderate problem complexity and a moderate amount of data, but a low risk of morbidity, you can see that this would match with code 99204 in the middle. So the 0 being for a new patient visit and the moderate MDM level being achieved. And this is the 4 in the final digit of the code. As we've met two of the three moderate elements for MDM, which again in this case was the complexity of the problems and the amount of data. So don't worry if you're wondering, well, how do I know what counts as moderate complexity versus low or high? We're going to walk through each of those levels in detail in the next few slides. So for example, a low MDM level has self-limited, stable chronic or acute uncomplicated problems. Acceptable data are divided into different categories and include external note review and test review or ordering. All you need is data from any one given category, but bear in mind that if you are reviewing tests and documents from Category 1 that you will need to review at least two of the three specified types. And then finally, on the risk side, the risk of morbidity is low. Alternatively, for moderate MDM, you start seeing in the complexity of problems acute exacerbations, new undiagnosed problems, or systemic symptoms. And in terms of data, it now includes referral to outside specialists and communication with them. Overall, though, you still only need data from one category to meet the moderate level. Again, note here that the document review for moderate complexity data from Category 1 must now have three separate types instead of two as in the lower level. And here there's a moderate risk of morbidity. And it's important to remember that in workers' compensation evaluations, morbidity includes risk of work disability and its bearing on your return to work or stay at work plan for the patient. And finally, a high MDM level now would cover severe exacerbations, severe side effects of treatment, or acute limb or life-threatening conditions. On the data side, the categories are similar to moderate, but again, the threshold for overall amount of complexity is again higher. Now you will need two out of the three categories as opposed to just one category as it was for the low and moderate levels. And there's a high risk of morbidity associated here. And that is to say a high probability that this person might not be returning to work. And so because MDM was developed around general hospital-facing clinical care, ACOM has added specific points for use in documenting MDM rationale for occupational medicine. So when we're looking at data sources, this includes job review, injury reports, past employment or medical surveillance records, and IH reports. Tests can include functional tests like functional capacity evaluation and ergonomics. And independent historians can include the employer and case managers. In assessing risk, particular attention should be paid to work disability risk and opioid use. And so some additional tips to cover before we transition on. Problems addressed means that these were the problems that were evaluated in this encounter and subsequently addressed in the management plan. And as we've stated before, MDM morbidity risk includes risk of work disability. And one final point. For those who have interaction with other office workers or even with other payers, make sure to label these OEM-specific types of alternative data as coders and insurance reviewers may not typically be familiar with occupational medicine practice. At this point, I will hand things over to Dr. Coretto who will go over some clinical vignettes with us and parse through the finer points of time versus MDM coding. And if you haven't picked up the handouts yet, please come get them again at the ends of the tables up here. We will be using them in the next portion. I know some of you skipped the brain and the clock, so if you missed the brain or clock, please raise your hand up in the air. All right. So next we're going to go through a few cases trying to emphasize these points. I see a hand up over here. Okay, great. And really what we want to hope that you'll come away from with these, going through these exercises, is that the documentation is to support your clinical practice. They're not separate. It's not that we see patients and do an evaluation on one hand and then code to meet regulatory and billing requirements, but they really are part and parcel, one and the same and together. So we're going to start first with case one. This is our new patient. I'm going to ask Dr. Klorin actually to help us out with audience participation as well with the microphone at the front. So we have a 30-year-old police officer who's worked for several hours removing multiple vehicles, interior console parts with a crowbar and pry bar to reach an airbag unit. This person presents two days later complaining of lower back pain. There's no specific past medical history, significant past medical history, and no red flags on history exam. The individual appears motivated to recover and to return to work. And so after your evaluation, your assessment plan, you're thinking that this is nonspecific low back pain. No other comorbidities have been identified. And the plan is modified return to work, engagement with a home exercise program, and a return to work in one week. Does this patient seem familiar to many of us here? Okay. And so thinking about what are some of the salient facts here, there's time spent, 15 minutes for this new patient visit. We've addressed one acute uncomplicated illness or injury. There's no data that was provided for us to review. And the level of risk, again, emphasizing that level of risk in workers' compensation equates to level of work disability in addition to other things that you might think about for level of triage. For this case, it's low. So we're going to take a pause here. Who thinks you would code this based on time? Raise your clock. So we'll do both. Yeah. Clock. Let's see brains or clocks. All right. So we're about... From here, it looks about 50-50. Maybe slight preponderance to brain. And so time or MDM. So let's walk through this. So remember, you need to have two criterias to justify whatever level of work disability you're going to do. You need to have a level of work disability. You need to have a level of work disability. You need to have a level of work disability. You need to have a level of work disability. You need to have a level of work disability. You need to have a level of work disability. You need to have a level of work disability. You need to have a level of work disability. You need to have a level of work disability. And so time or MDM. So let's walk through this. So remember, you need to have two criterias to justify whatever level of medical decision-making you're going to make based on points. And so here we have one acute uncomplicated illness or injury. This is a low risk of morbidity based on low risk of work disability, which equates to a 99203. So this is a new visit, low level code. When you go to time, it's actually for a new visit 99202, because you only spent 15 minutes for this very straightforward case. So in this situation, it behooves you to code based on points or to document based on points. So but wait, there's more. This is your initial note. And we'll go through this. So I'd like to hear from you, is this note sufficient? Is it helpful? Or is there other information that you might want to enter into it based on your history and exam to support your level of decision-making? So we have an initial visit for this 30-year-old police officer who reports hurting her lower back at work. She has no history of prior low back pain or trauma. Pain is constant, low back pain both sides, no radiation. She denies any weakness or numbness, bowel or bladder changes. And notice that we actually spelled that out. We didn't use no red flags for back pain. It's important that we're really being clear about what no red flags for back pain are. Because in the hands of a non-medical provider, i.e. our adjusters, that could be open to interpretation. The assessment plan for this individual is nonspecific low back pain, limited duty with push, pull and lifting restrictions, the home exercise program and a return to clinic in one week. Although we are coding with points, it is always good practice to document what you're spending your time on. And so for here, for this straightforward new patient case, we're documenting what was spent on evaluation and examination of this patient. So we're going to take a pause. Is this sufficient? Mechanism of injury? What would you want to add? »» Definite causation. I.O. is still taking employment, non-patient history, prior workers' compensation claims. Maybe a paragraph on some of the medical decision making, like why barriers to recovery, employability, work restrictions. It's kind of been there, but it's rounded out. »» I'm sorry. »» No, it's good. So that was great. You highlighted the four things that Dr. Cloran presented in the beginning, which was causation slash mechanism of injury, level of function, work disability piece, in addition to the treatment plan. And so rounding it out, being more specific. Anything else that we would add to this? Prior history? Occupational history. And including previous lower back injuries that may have been a part of this. »» I assume the examiner is not seeing it. Any tests or work? So what if not quite? »» Yeah. »» I can't get there fast enough. »» All right. So I'm jumping ahead here. Is this note complete? Is it helpful? I'm hearing it's kind of helpful, but it could be better. So what are some things getting to causation and mechanism of injury we want to add after spending? So the initial history for a 30-year-old police officer who reports hurting her lower back at work after spending several hours removing interior car parts for accident reconstruction. So, again, mechanism of injury and causation. It's also important on any first visit, as we know, to take a baseline but add to that trajectory. Sorry. We'll hold that point for another slide. Rates that the pain is six out of ten and says it's tolerable. She expresses this understanding the need for limited duty at this time and is motivated to return to full duty. So having those discussions around the return-to-work-stay-at-work process, helping encourage our patients to generate buy-in and engagement with the restoration to full duty. And so on our assessment plan, really spelling out what our decision-making is, if we're going to code based on points, that this is nonspecific low back pain with a low risk of work disability. And then also making sure that we're documenting the things that we discuss. Yes. So one of the issues is prescribing and then finding out whether it's accommodated or not. So there's a response from the patient that's not included in the documentation. What I feel is very important in terms of whether any work restrictions have been accommodated or not by the employer. That would be the next visit. Oh, this is only the first visit? Yeah. Yeah. This is the first visit. The other issue is being able to document if work restrictions have been accommodated or not. As work restrictions are our attempt at partial modified duty, but that might not always be accommodated by the disability management on the part of the employer. And just to be difficult, I'm going to argue that it has a high risk of work disability. There is no real mechanism of injury in a 30-year-old. And so there's no trauma, and it's already reported after the time. So I see that as a high risk of disability, and maybe I should get paid a little bit more for recognizing that. You need to document it. So hold those thoughts on documentation, because that might play in if we're thinking about time. And always anticipating what we want our next visit to look like by addressing these things in this first visit. Yeah. Yeah. So what could have been documented here? Think about labeling for others that might be reviewing your notes. What could we have added there to make it more clear that talking to HR is kind of equivalent to talking with other stakeholders, you know, in primary care? So we're considering that care coordination, right? But we haven't – is it going to look like care coordination to auditors in the hospital if you have a medical center-based thing? They're not going to recognize talking to the employer, HR, any of that as care coordination. But if you label it as such, it's more likely to kind of sail through. I made it easy for you this time. Okay. Not to game the system, but would be there any benefit actually labeling in the note causation, colon, function, colon, et cetera, go down that way? Is that a benefit? Yes. It would be for, I think, workers' compensation systems. You know, it really depends on your practice setting. I would say that like a hospital-based, you know, medical center-based thing where people are used to seeing other kind of stuff, they're not going to recognize that as anything more important than just regular old history. Catherine, you commented on it. Do you want to respond to that? Well, I'd just like to add that's an excellent point because it could also be based on jurisdiction. So in California where I practice, in our first report, we have to opine on causation under a rising out of employment or occurring in the occurrence – occurring over the course of employment. I think in terms of promoting our specialty, reaching out to our non-medical stakeholders, care coordinators, et cetera, doing exactly that is just good practice because it's that old adage, if you didn't document it, it didn't happen. And so by calling out causation, et cetera, for care coordination, et cetera, I think might be good practice. So I just want to comment on the function part because I just – I think everyone should start having function as a part of the report. I mean, you're going to be assessing things for seeing whether the physical therapy is working well enough, whether you want to make changes. I mean, all of that is based on whether the person is functionally progressing or not in almost every system and certainly in comp. So making a separate section that you label as that really matters for the overall care of the patient. If you're billing on brain time, do you need to have the 15 minutes spent on evaluation examination because a reviewer is going to look at that and mark it – get confused? No. In time, it has to be at least 50% on counseling and care coordination. I understand. But in this example, you're trying to do on brain. And if you document 15 minutes to spend on that, there's no need to document the time in that because they're now going to review that and say, oh, it's only 15 minutes and everything else is going to be overridden. I think that's an excellent point. Why document the time if you're using MDM-based coding? Yep. Agreed. I think it helps us assess the gap between a presentation versus what we would want to do in practice. And I think for the purposes of here, we're doing this time versus points dichotomy, but that is an excellent point. If you're going to put your nickel down, if you're going to be on points, just document based on points. If it is going to be based on time, you still want to have your assessment in plan. And the same thing, if you're going to do that, I would say 15 minutes to spend documenting and this and that to make sure it gets to that point. And then I would say 40 minutes spent, of which more than 50% was done in evaluation or counseling or something like that. But it is really confusing if you try to mix the two. Do you have time for more questions or do we need to move on? Yeah, we can do one or two more. Okay. At least for California, where I also live, the added complexity of is this a presumed industrial condition, which requires specifically getting the length of time of employment for the police officer? Exactly. So taking that time to establish mechanisms of injury, pre-injury baseline, other comorbid conditions, industrial not, that are playing into your medical decision making. I think saying limited duty with push, pull, and lifting restrictions is pretty vague. We should categorize it into whether it's never, seldom, occasional, frequent, constant, that way. And then I'm not sure if all states are requiring to fill out activity prescription forms. And we can also document filling out that form in this. That's a good point. Filling out the forms counts as time, too. We deliberately shortened this because we wanted you to be able to see the slides. But obviously, that's not enough detail for any employer to do anything with. Yeah, good points. All right. Well, now that we're warmed up, we'll move into case two. So this is actually a new case, just to guard the title. This would be an individual who first presented to the emergency room for care, but then presented to us in the occupational medicine clinic. So for us, in the terms of purpose of billing, this is a new case. And this is a 60-year-old individual who works in dining services. They were lifting a heavy pot of boiling pasta, and immediately thereafter, presented the day of the incident with acute back pain. That's an error that was fixed in the presentation that didn't get uploaded. So they're presenting actually a few days after the event, because they already went to the ER. So just to clarify, there was a few days between the ED visit to then presenting with us. OK. So low back pain, heavy, maybe some axial loading of the spine. On history, it comes out that this individual has a past history of multiple car accidents, prior back strain at work, and is managing their chronic pain with their primary care physician with opioids. They report high pain without localizing findings on physical exam. They have been inconsistent with physical therapy in the past, and they express fears that they're reluctant to try again. The time spent on this case was 60 minutes. Is this a patient that we've all seen in our clinic? OK. All right. So first, I'd like to ask, before we get into time versus MDN, what are the salient points on this case history that you'd like to call out? If you don't want to wait for the mic, shout loudly. Extensive history, so you're probably going to need to do a little bit of digging in the medical records. They need some medical record review. Yep. I'm sorry, what? Comorbid conditions. Comorbid conditions. Yep. Chronic pain and the need for education about chronic pain, so counseling. Acute on chronic situation. OK. Or both. Or both. So a lot more complaints than objective findings, which we see all the time. I see some nods to social determinants of health with the chronic pain managed with opioids and inconsistency with PT. Yep, that may be too. Discussion of, like, is this patient more likely than not has degenerative disease in the lumbar spine? So discussion of, like, you have an acute strain versus, you know, and you may have to get imaging to have that conversation and so on and so forth. Let's say you've seen this patient before in your clinic. And for an unrelated injury, when they come back with a new injury, are they still a new patient? That's a good question. That's totally off topic, but it's one that we didn't include in here. We think that it should be counted as a new patient if it's a new event. I think it really depends on the jurisdiction whether you're allowed to do it that way. What do they do in Colorado? Do you allow that if it's a new injury event? Yeah. But otherwise, it's a six-month interval, I think, between when they were seen and, yeah. Do you have a pharmacy that helps them? Oh, that's not, that's so tangential to our discussion. Let's go on. But I think, you know, it speaks to, is this an aggravation or an exacerbation? And I think where one lands might also help with that determination. Also want to call out, I've heard about opioids. Maybe we want to do an assessment. Is this person having side effects? I know we're not the primary on that, but now they've come to us and we've identified the issue. So is this something we may need to intervene on, call their primary care doctor, help bridge them to Suboxone, et cetera? Do you like your job and the people you work with? Excellent question. Job satisfaction, yeah. That's a good point. Excellent question. So is this time or MDM? So hold up your clocks and your brains. What would you do, time or MDM? Good. And it's unanimous. It looks like a clock for the 60 minutes spent on this visit. So just to round this out, we've covered a lot of this ground, but to highlight, again, if you're going to based on MDM, you want to have two out of three categories. We've identified a chronic illness with exacerbation, progression, or side effects of treatment. We've had to do a lot of digging into the previous hospital records, receiving the ED records, maybe reviewing previous visits to our clinic for related or unrelated issues. And based on points alone, you can code for this new visit as a 99204 of moderate complexity. The issue is, no matter how much data you try to obtain, you'll never get to a 99205. But with time, you do. And that's based on the category for a new visit of 60 to 74 minutes spent. And we also don't want to fall in the trap of ordering diagnostic tests that are not necessary and not recommended according to guidelines at this phase, just to kind of build up the data points. One quick question on time. Does that have to be your time? Or is that time spent in clinic? Or can that include the nurses when they're calling back to supervisors? Or is it specifically physician time? Excellent point. It's specifically physician time spent, physician provider time spent on the clinic visit itself. It does not include staffing. But it doesn't have to be all face-to-face time. It can include reviewing the records, making phone calls, and documenting. And your note. And your note, yes. Yeah, and if you want to be really eloquent about it, you could say records reviewed on the day of the visit. Because that day of the visit also links the work that you're doing to the clinical encounter that you're having. So for this, we've talked about a lot of this. So we'll just kind of speed through this to get to the next case. But we've identified the documentation that's needed. So really rounding that out and spelling it out. This person has chronic lower back pain since a car accident in 2009. Subsequent lifting injuries at work in 2013 and 2019. Currently taking extended release oxycodone, 30 milligrams BID with a 90 MME, morphine equivalents. Prescribed by outside pain management specialist, referred to by the patient's attorney. Also, this is where trajectory is important. So not only is it, so in the previous case, we talked about establishing a baseline. But we also want to establish trajectory. Is the patient getting better, worse, or the same over time? It gives further information as to how you are thinking about this case and coding it appropriately. So he rates the pain as 10 out of 10, says it's intolerable. He is upset that he still has not gotten better. Oftentimes for these type of cases, I'll do a functional review of systems. So what are those specific functional barriers that they have? Here it's notable for difficult concentrating, irritable, emotionally labile, frequent constipation with occasional obstipation, poor sleep, and recent weight gain. Again, bringing in those details that you've done in assessment, they may be having some side effects from their high opioid burden. Other things you may want to think about for these complex cases are patient reported outcome measures. And tomorrow, Dr. Muller and Dr. Ethan Moses will be presenting a session on using patient reported outcome measures in your practice and how you can use them to help you guide your care. So you may, for this gentleman, want to start off with a baseline Oswaldtree disability score. And that's not something you would do every visit, but maybe every month or every few weeks you want to revisit and help get buy-in with that patient. Are they getting better? Are they staying the same or potentially getting worse? We've talked about really rounding out the physical exam with clear pertinent positives and pertinent negatives. And here, if you read this examination, it is a pretty unremarkable exam. But given the level of complexity of the clinical encounter itself, you want to make sure that you're adding those details of the exam in. And so here, we want to just call out that the chronic opioid use is with significant side effects. And we want to have, as part of our plan, high risk of work disability. In this, we've decided code based on time. And that is appropriate. So really spell out what that time was spent used for. 60 minutes was spent on the evaluation and examination of this patient, including review of patient reported outcomes with the patient, job duties with HR, work environmental reports with health and safety personnel, and direct communication with the physical therapist or the primary care physician in this setting. What two words would make that last sentence even better? Care coordination. Somebody said it. Yeah. So labeling things that look a little bit different than primary care as how they map. Yeah. I'm seeing that a lot of the calls that you're making, you're including in this coding. Where I work in Washington state, whenever we call a physical therapist or call the employer, we record it as a separate telephone encounter and bill for that. Yeah, there are going to be differences in different jurisdictions. You have to know your jurisdiction and kind of what the rules and opportunities are. I think that's a Washington kind of cool nuance. Yeah. And I think for today, we're focusing primarily on that clinical encounter piece. But there may be times when you need to do an administrative report. And there's separate codes for that. The document has that all spelled out. All right. So the take home for this, it was hard to meet all the medical decision making points for high complexity. Time may be more appropriate in this setting. So our last case is quick but bad. This is a 48-year-old warehouse manager, sustained workplace injury for a simple lower extremity long bone fracture. It was non-operative per the ortho evaluation in the emergency room. They were cast and immobilized. They present to your occupational medicine clinic a few days after that for initial follow up. And you notice that they're complaining of burning pain, paresthesias, pain out of proportion to the examination. Because you are very astute clinicians, the time spent on this encounter was 17 minutes. And you sent them off to the emergency room for life-threatening emergency. Or limb-threatening anyway. Limb-threatening. I'm sorry, limb-threatening emergency. So let's really focus on that triage piece. What is the one thing in here that really is going to, you see this in your clinic, and it's out the door? So for limbs, neurovascular compromise. So burning pain, paresthesia, pain out of proportion to the examination. Would this be coded based on time or complexity? Raise your things. Which would you do, MDM or time? Okay. Excellent, great. So we went based on complexity. So based on time for a new visit, this was a 17 minute visit. It would only be a 99202. But based on the high level of complexity of one acute illness that is a threat to life or bodily function. We've reviewed the previous ortho notes. We've had discussion with the emergency room because you may have called to help inform the emergency room that the individual's on their way and they should have expedited care and not linger in the waiting room. That this represents a high risk of morbidity to the limb. This can be coded as a 99205. And so next we have some time for general Q&A. The last comment here, and this is what I teach my team, is to be appropriate. It's important to know both. You have to know the rules around time. You have to know the rules around medical decision-making. And I just really encourage them to be appropriate to the clinical situation. To Dr. Clohan's point earlier, I have seen in situations where if someone is inflating time, in some health systems, you're only given 15 or 20 minutes for a visit. And that can be auditable over time. I have, I'm aware of one situation where a provider, not in our department, but outside our department was doing exactly that and they suffered the repercussions of it. So just to emphasize, both are important. Connecting it to your clinical decision-making in general as a whole is important and to be appropriate for whatever strategy you choose to use. So we'll do some Q&A. Actually, it might be easier at this point for Q&A for people to come up to the mic. Might be easier to come up to the mic because I'm not gonna be able to chase y'all. Thanks for the talk. My name is Matthew Keok, solo private practice, Las Vegas. I have a lot of problems with the prescription drug management portion of risk. There's a bullet point where if you manage prescription drugs, it basically turns into a level four. What would you define as prescription drug management? Is it just prescribing? Is it changing doses? Is it the choice not to prescribe? That's a great question. This might fall into opinion base. There's no real evidence around this to my knowledge. I think for me, my line is if I'm prescribing a medication, that would rise to a level four. If I'm advising over-the-counter medication, I would keep that at first aid level or keep it out of a level three. But I'd like to hear Dr. Clarence as well. I would say if you're really diving into mismanagement of prescriptions, that that ought to count, whether you're prescribing or not. I don't know if that's what you're getting at. Or like the choice to continue your medication or someone else's, where you just reorder. I've been downcoded or denied just based on reordering the same medication. Okay. Well, it sounds like the system didn't think that that was management if you're just continuing something that the person's been on without any change. So you raise a really good point on downcoding and recognizing that we operate in an ecosystem. The adjusters and carriers are part of that. I think if I were to see a pattern on that, I would reach out to that carrier and I would ask for a meeting with their medical director and start with the question, help me to understand, and then advocate for my own practice. You know, the other thing to make sure that if you are trying to use that as a risk thing, that you're documenting more than just continuing medication, that you're documenting your lack of side effects, that, you know, the reasons for your decision, that there was some decision-making that went into it. So I'm totally doing all that and I'm gonna talk to the medical director. Thanks. I was gonna say, you made a comment about choosing to not prescribe as a medical director of an insurance company. I think that that, if you documented that in the rationale for that, that there is value. So that's important. Thank you. And that's wisdom from medical director of an insurance company. Just a reminder, I bail on time, but just a reminder to make sure you put the pertinent negatives. In a case like this with non-traumatic low back pain, I actually discussed with the patient about getting a lumbar spine and how if you're not tender on the back, that we probably don't think this is necessary. And I will then document, discuss the x-rays. And then I'll say, patient declines x-ray at this time. And I'll just say, hey, if you don't get better the next week or two, then we might consider an MRI. And I've done that all the time. It came back, thank God I had done this. I returned somebody after three weeks. And then a year and a half later, they came back and tried to sue me for malpractice because later they were found a year later to have a disc herniation. And the primary care doc said, your doc was an idiot for not ordering an MRI. And I had the full documentation that I had offered it and the patient had declined it and it got tossed out. But make sure you document the negatives also. Again, billing on time, it's really good. You can't do it if you do the other stuff. A follow up to that, I think you don't necessarily want to offer something that is not recommended yet. But I think, importantly, documenting that you're not going to get imaging at this time because according to practice guidelines, you're still in the phase where it's not needed and there's not any red flags that would cause you to do it. And that was discussed with the patient. The patient understood. So I think that the point, though, of documenting your decisions against specific things also is really important for both medical decision-making and I think probably time-based because it all goes into- And that's to emphasize the point. By just using time-based isn't a get out of jail free. You still have to document your medical decision-making within that note. And then that also opens up to the opportunity for education for your patient, which sometimes can spend time. I think the classic is MRI comes back with disc bulge. Well, what does that really mean? And sometimes with certain patients, that can take a while to really unpackage and help them understand why we aren't escalating to a higher level of care in that moment. Other questions, comments? In coding whether a patient is a new patient versus established patient, in a state I've practiced in for 20 years, they lock those in with primary care. Primary care rules are that if you've been an established patient and the patient been seen at practice within the last 12 months. Now there's no specific ruling for workers' comp. Now for 15 years, I practiced and never had any pushback that if it was a new event, that was a new patient. And didn't have a problem. But the last five years, I worked for a hospital system that said, no, no, no, you can't do that. Where do you find that in regulation that you can document there's a new event that's a new patient? So I would take the approach that these are actual distinct medical conditions. And there's a cycle of care with each medical condition. So for example, you see an individual in January with an ankle sprain, and they get better over the course of four to six weeks. And then they come back later for a back injury because maybe they work as a fence in construction, in fact, fence building. I would interpret that based on my jurisdiction as those are two separate medical conditions for which I've provided treatment. Exactly, and that's the argument I made. But they say that it's not allowed. I don't think that there's a regulation to back you up there, Miller. Maybe in some states that it's codified that for a new kind of injury event or episode, that that is handled as a new patient. And other states are kind of mum about it. But this is a classic example of working within a system that is used to the documentation and coding rules for group health and primary care. And what we're doing doesn't fit well. If it's multiple different insurers, this might not work. But if it's a specific insurer or two, getting the backing of the worker's comp insurer saying, yeah, we recognize that. You can bill as a new patient for new episodes. That might help. But I think this is one of those cases where you're gonna have to find out what the payer thinks and then translate that to the coding and billing people in your hospital system. Anybody have other ideas there? Okay. Yep, you have. So we have time for one more, one more question. A good microscope morbidity goes off if there's a delay in imaging or consult with a researcher in the case of a person who falls on a stretch of arm and has some obvious clinical, clinical data from the payer. And now you're on five weeks. What's the magnitude of risk of morbidity? And so the question is, the question is, is could the risk of morbidity change due to delays in care? Recognizing we don't operate in a vacuum. There's maybe delays to PT or radiology, diagnostic imaging that would change. And in absence of that or absence of delays to the specialist, the person's condition worsens or decompensates. My thought on that would be document everything and yes, it can change. So you're seeing someone for a partial tear of a rotator cuff, or at least that's what you think based on your physical exam. You've tried to escalate to MRI and or specialist evaluation and then due to barriers within the system, it doesn't get. And then now it's a full thickness tear with weakness and terrible pain for which now they can't work at all. Maybe previously they were accommodated in modified duty, getting back to morbidity being equate to work disability for workers' comp. I would, my style would be to document all of that and then get on the call with my carrier to help them understand that this needs to be escalated and I need help. But I'm reading between the lines a little bit here. I don't think that worrying, thinking about the risk of missing something and the risk of morbidity is not a sufficient reason to be referring everybody for imaging and procedures. So I think just defensive, we know from research that defensive medical practice with early imaging and early procedures increases morbidity. So right now, I mean, there are individual cases but I'm just saying like in general, I wouldn't do defensive practice. All right, I think time's up. I think we're there, yeah. All right, thank you everyone. Thank you all. Thank you. Thank you. Thank you. Thank you.

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