3M’s Quality Webinar Series

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(DESCRIPTION) Slide, New year, new webinar platform! A great company is showing what interesting applications a fantastic product can bring for motivated users. Blank elements are labeled in an image of the platform. On the left, a media player, Resources field, and a Q&A box. In the middle, a slide box and Ask An Expert button, and on the right, a speaker bio with a photo and a box with two survey questions. (SPEECH) Hello, and good afternoon. (DESCRIPTION) Title slide, 3M Quality Webinar Series. Part one: The evolution of C.D.I.. See how far your C.D.I. program has come. May 2022. An image of a woman holding a tablet while speaking to a doctor wearing scrubs as they sit at a table. (SPEECH) Thank you for joining our May quality webinar where we are going to be talking about the evolution of CDI. This is a part 1 to a two-part series within our series. Part 2 will be in July. And we'll be sending you information about that soon. But again, this one is the evolution of CDI. See how far your CDI program has come where we're going to be welcoming one of our regular presenters that you've all grown to love Cheryl Manchenton. Before we get started, I did just want to go over a couple of housekeeping items. (DESCRIPTION) Slide, New year, new platform. (SPEECH) If this is your first time joining our webinar, we are on a new platform this year called ON24. And it really is a better experience for our attendees. Because this is a web-based platform, we do ask that you use Google Chrome. Close out of any VPN or multiple tabs because that will slow down your bandwidth. And because this is a web-based platform, there's no dial in number. So any audio is going to be coming through your speakers. So if you are having any issues, do a quick refresh and hopefully that'll take care of it. We do have more engagement sections, so you can make the video larger, presentation larger, close out of anything that it's distracting to you with those engagement sections. There is a Q&A section. So we ask that you put all questions in there. We'll get to as many as we can at the end. We do provide a certificate of attendance. That is in the resources section as well as the handouts. If you are or if you did join us in our March webinar, we told you that we would provide the questions and answers. We had a lot from that last webinar. So we did compile all those. So if you were on that one in March, you can download those as well. Again, with that certificate of attendance as well as the handout section. And at the end, we always appreciate you completing the survey. So let us know how we did. You can either fill that out during or at the end. But let's go ahead and get started. I'm going to pass that over to you Cheryl and to go over the agenda and to get started. Thank you so much. (DESCRIPTION) Slide, Agenda. Evolution of C.D.I.. Challenges on the journey. To infinity and beyond? Fine print: The information presented herein contains the views of the presenters and does not imply a formal endorsement for consultation engagement on the part of 3M. Participants are cautioned that information contained in this presentation is not a substitute for informed judgement. The participant and/or participant's organization are solely responsible for compliance and reimbursement decisions, including those that may arise in whole or in part from participant's use of or reliance upon information contained in the presentation. 3M and the presenters disclaim all responsibility for any use made of such information. The content of the webinar has been produced by 3M, and its authorized third parties will use your personal information according to 3M's privacy policy (see Legal link). This meeting may be recorded. If you do not consent to being recorded, please exit the meeting when the recording begins. (SPEECH) Absolutely. So good afternoon or good morning to whoever we are at in the United States, et cetera. It's my pleasure to talk to you. Really going to talk about how is CDI evolved because it really, really has even in the 13 years that I've been involved. What challenges have we stumbled upon on the way. And what's next? Where are we going from here? (DESCRIPTION) Slide, The Evolution of Clinical Documentation Improvement. A blue panel above a right-facing arrow labeled "Inpatient" reads, Initial Model for C.D.I. Programs - Financially based review of Medicare population. (SPEECH) So the way you want to think about this, and we're primarily talking about inpatient. And again, as a reminder in July, our inpatient-- our outpatient people will talking about that. And by the way I just saw a typo which is why I was somewhat. It's not a query rat, it's a query rate. So you love when you see your typos right in front of you. But let's talk about how CDI programs got into being. There over 25 years old, almost 30 years of doing this work. And the initial model was really financially based. Wow. We're missing money. If we had done some chart reviews and ask them questions, we'd improve our CMI. And really in the beginning, it was very much focused on Medicare clients only. You start in somewhere for a couple of reasons. One, Medicare is usually the biggest volume or was 25 years ago of our inpatients. And the second piece being very clear rules of documentation coding, et cetera. But knowing it was at that time your primary payer, it made sense to cover just on that one. There was not as much collaboration with coding. It's not that there wasn't any, but we did not have big dialogues. We just have some discussions sometimes or again. CDI operated in one world and coding operated in another world and the two did not meet. And I still have some programs where that is the actual state today. Definitely had no collaboration in the early days with quality or quality outcomes. And we had traditional key performance indicators or KPIs. Such as how is the CMI changing? What is that MCC/CC capture rate? What is the coverage rate. How many cases we're able to see. And again, what does that query rate. (DESCRIPTION) Slide, The Evolution of Clinical Documentation Improvement continued. A green panel to the right of the blue panel reads, Next Generation Model for C.D.I. Programs. Financially based review of Medicare and other D.R.G. based payers. Focus on severity of illness and risk of mortality in reviewed populations. (SPEECH) Moving forward, that next generation is we expanded not just from Medicare to other DRG-based payers. And certainly as we had more managed care, in the managed Medicare is outpacing Medicare as the highest volume in most hospitals. So let's look at all of our DRG-based payers. And Yeah. Let's look at that severity of illness and risk of mortality now that we have good tools that calculate our severity mortality, let's take a look at those. You had the same KPIs. Your leadership might have added or included that observed expected mortality rate as a measure. Of course, to have that next generation where you're doing more, you need to actually have a way to measure how well you were doing. So you had to look at your baseline and your current state on severity mortality. Certainly there are proprietary models out there. Not just the three on APR-DRG methodology. And many of the outcomes or the measures are only on war, back in the day only on the O/E ratios only. Of course, when you started adding new payers in, you brought some challenges. The payers, depending on what type of payer it is, they can set up their own rules. And certainly, it's not that we never had denials in the past in the traditional model, but it was normally what we'll call coding errors. And again, I use that word very lightly. Please take it how I meant it. Those were perceived coding errors. But as we started adding or covering new payers, we would see an increase in the denial rate. And again, as those teams really started focusing not just on the financial, there really need to be more engagement with coding, but still really not a whole lot of involvement with quality. And again, less that program, that organization was what we'll call a next-gen or a little bit more advanced program. But again, this is certainly how the programs in general have evolved for those that have been around a long time. Some programs starting new have zipped past these first two and really done a more advanced model. (DESCRIPTION) Slide, The Evolution of Clinical Documentation Improvement continued. A teal panel to the right of the green panel reads, Phase 3. Financially based review of Medicare and other D.R.G. based payers. Focus on severity of illness and risk of mortality in reviewed populations. Documentation integrity and clinical validity. (SPEECH) So that next phase three. It's not just financial review of Medicare and other DRG-based payers because remember, that can also be APR-DRG-based payers. Not just those in the Medicare or the MS-DOG groupers. But we've moved into a world or have experienced where our payers are now including Medicare, getting involved in clinical validation. And we've seen a huge uptick especially in the last five years in those payer denials for what they'll consider clinically nonvalid conditions. Because of those denials, that alone has really impacted us in terms of the reimbursement certainly. But I think a cost that we forget about is the loss of productivity. What are the labor costs and fighting? Reviewing and fighting those. Second thing that we have found is more and more payers have decided they're going to dip their toe into the clinical validation pool. There's different rules. And I will say, a commercial payer that only has acronyms for their name as an example has very clear criteria for when obesity as an example is reportable. Where other payers don't ever challenge the diagnosis. Another thing that we have consistently seen at this point in a CDI journey. The CDI department was not always given access or insight to trends. What was happening? If the CDIs don't know what's happening, how could they avoid those denials. How can we preemptively review that chart, ask some clarifying questions. How do we preemptively help the providers. The providers are certainly frustrated because why am I getting more queries on this and why you challenge my diagnosis. And that did, no matter what we say it is definitely increase the minutes. We need to spend on each chart because we're now having to apply an additional layer of scrutiny through that to really look for integrity and clinical validation. (DESCRIPTION) Slide, The Evolution of Clinical Documentation Improvement continued. A blue panel to the right of the teal panel reads, Phase 4 - Comprehensive C.D.I. Program. . Review for financial opportunity, severity of illness and risk of mortality in all patient populations. Documentation integrity and clinical validity. Quality outcomes review of P.S.I., P.P.R., H.C.C., P.P.C.. Second level review for financial, profile, and quality opportunities. (SPEECH) Third, next sort of phase four, shall we say, is really a comprehensive CDI program. And you're looking at not just financial opportunity or severity of illness and risk mortality, but you're looking at all inpatient populations. Not just those that reimburse me appropriately. And of course, we're continuing on with integrity and clinical validity. But now the CDI teams have really been asked to understand and/or participate in quality outcomes reviews of such things such as Patient Safety Indicators, PSI; Potentially Preventable Readmissions, or PPRs; Historical Condition Categories, HCCs; or Potentially Preventable Complications, PCCs. And then certainly many CDI programs now have incorporated a second level review process to not just look at this financial or profile opportunity, to also look for quality opportunities. And again, for us that is a much more quality. Comprehensive look is really having those second level reviewers. And I use air quotes when I say full pay for performance because really it is an acronym. There are multiple ways that are reimbursement, that the hospitals are receiving for inpatients could be affected whether it be the hack, reduction program, or CMS star ratings, value-based purchasing, ACO relationships, through accountable care organizations, shared savings models. And of course, getting those HCCs allows us to negotiate better for those blended rates with our payers. And again, it requires a lot more second level reviews and truly requires a lot of collaboration. Not just between CGI and coding, but certainly with quality and sometimes beyond quality. Sometimes infection control and some focused departments in our organization. But here's my question. If you have moved into really a phase four program. If you have moved beyond phases one two or three on your CVI journey, have you changed your KPIs. And again, I think this is an important distinction I'm making. Why are we using the same old metrics if we're asked to do more? And it's not that we should maybe remove some of those even though I could argue about removing some of those, but should we be adding in some? And that's really what we're going to spend a lot of our time today talking about. (DESCRIPTION) Slide, What C.D.I. metrics should be deemphasized and why? Coverage rate. Number of initial versus continued stay reviews. Financial goals per individual C.D.I.. "Match Rate." (SPEECH) So what metric should be de-emphasized and why. So let's talk about that first one. That coverage rate. Why is coverage rate so important? Are there cases that truly don't need a review because they don't have any opportunities, such as short stay elective surgical procedures, one or two-day stays? Why is the coverage rate so important? What benefit-- what happens when a CDI does or does not review that case? If you're not seeing opportunities there, and I had a client and it's been golly, eight or nine years ago. They did a test project where they had a second level review or look at all those discharges that happened over the weekend that were admitted and discharged before we could get a CVI review on the case. And what happened if that second level reviewer, again, a really seasoned reviewer looked at those cases. How many opportunities did he find? And the answer was very few. And it didn't justify the loss of productivity for a whole day for him to perform all those reviews. So I think coverage rate may or may not be the best thing. And secondly, when you think about what cases should have review, that's where prioritization comes into play. And we will talk about that a little bit later. But is coverage rate the best metric? Second thing, the number of initial verses continue to do reviews. I think sometimes CDI managers say you have to have 10 new and 15 continuous day reviews. I'm not putting numbers out there as in these are three goals. My point is, why is that an appropriate metric? How does that benefit? What happens if we see less initials? Certain days of the week obviously like Mondays, we're going to see a lot more initial patients trying to catch some of those new ones, but why are we trying to see every patient? What is the goal now. Please understand that there are some programs that do really advanced work with some of the proprietary methodologies such as Vizient or Premiere. So their coverage is different because their focus is very different. But instead of saying how many I do, how many charts did we actually perform quality reviews on. So maybe this should not be a big measure but maybe a KP around the quality of the work that I did in that chart is more important than the volume of initial or continued stay. This third one, I still have one program and I know of a few out there that sets a financial goal for queries on an individual CDI. I think this is harmful. I will say that. I do not like it. Yes. My client knows, I've told them many times. I think it pushes the envelope. It pushes the CDI too hard to say, oh, wow, have I hit my number this month? But what it also does is I think it also demotivates us. Well, I already hit my 50,000 this month. I don't really need to work so hard the rest of the month on finding opportunities. So I dislike it. Intensely, I don't find any value. I think there's better ways to measure the effectiveness of our CDIs and attract and train them. The last one that match rate and I use that in quotes because it has different names and thoughts. So I want to make sure that I explain what I mean there. Is how often do the CDI and the coder get the same DRG. With a really expense program, that match rate again, air quotes, is usually really high. So if the number really never changes much, why is it a metric? And when you think of a match rate, it's usually just a DRG match. And they're using in the softwares reason codes for why we had different DRGs or not or optimal to assess that match rate. But I find that it is not helpful other than to trend a new employee. And it's not telling the story. What if we got the same DRG and it's really not a good DRG for the patient to be in. Or we have the same DRG, but our severity and mortality are very different. And/or we have the same DRG, the same severity and mortality, but we have very different amounts of coded data or diagnoses listed and not the same POA. So I think match rate is as a global metric overmatched. And I think the other thing that I just saw in one of the charts is can I comment on CMI being a goal for the CDI program. My comment would be, we have to have some goals. We have to keep the shops in business. We have to keep our staff employed. So I am putting a slight caution sign on removing that. But what I would say is it's become increasingly difficult in the time of code, but I was actually trending. Two of my clients CMI recently watching them longitudinally. And again, I could see that CMI go up and down and we could draw arrows to exactly where their COVID spikes were. So a CMI goal is fine if your patient population is stable. We haven't had a stable population in over now almost 2 and 1/2 years. And I hate to say that we're approaching the half year mark. But not certain that it's the best KPI. (DESCRIPTION) An interactive poll question with four options. (SPEECH) So you'll see here an opportunity to please interact and answer this polling question. And the question is, does your CDI and/or your coding team because I think it pertains both, have KPIs, or those Key Performance Indicators, for quality metrics such as the hack reduction program, value-based purchasing, star ratings, O/E ratios or the readmissions reduction program. And you'll see your choices in terms of we have all of these, some of these, none of these, or that's OK to say, I don't know. And it's not-- and it doesn't mean that it's a bad thing if you don't have any of these The question is, we're curious to see how many hospitals, organizations, departments actually do incorporate those additional KPIs. (DESCRIPTION) Poll results appear. 6.1% chose "All of these," 37.8% chose "Some of these," 28.9% chose "None of these," and 27.2% chose "I do not know." (SPEECH) And what you see is we have-- 6% of our audience said yes. It's all of those. I'm like, Wow. Again, not saying that's good or bad. I'm just-- I'm very impressed. 37% said some of these. And again, I'm glad. Usually I would expect it's around-- PSI is a really common one or the PSI 90. For those that said none of these, again, the question is why not. And again, we're going to talk about that here in the next couple of slides. But I think we're doing ourselves an injustice by not having nontraditional KPIs. (DESCRIPTION) Slide, What workflow should be added? Prioritization of C.D.I. reviews. Focused second level reviews (not just mortality) by clinical coding and quality staff. 100% reconciliation between C.D.I. and coding (S.O.I./R.O.M., code set, AND P.O.A.). C.D.I. and provider participation in denials. Collaboration with infection control on H.A.I. definitions and measures. (SPEECH) So what workflow do I think we should add. As we're trying to move to that advanced model, that comprehensive CDI model, how do I still get my-- I'm sorry. I was thinking of a bad phrase. How do I maintain my productivity when asking the CDIs or the coders to do more. I think the first thing, the prioritization of the review is making sure that we're seeing the right patients. Does this DRG in general have a high likelihood of being moved with an additional MCC or an alternate. But I'll also say that when you think about the prioritization of reviews, I'm trying to think of a really, really good example. And the one that comes to mind is in the female in the obstetric population. There are now CCs and MCCs for our moms. But those DRG are fairly low weighted. So getting a CC on a really low weighted case might add $100 or $200 to the case where prioritizing the case that getting a CC is worth $2,000 or $3,000 or more makes sense. So it's making sure that we're getting our bang for our buck. And it's not just prioritization for financially, it's those length of stay outliers. Those low severity mortalities, and adjusting your priority tool to do that. So I do think if you're not doing some sort of prioritization beyond this is my primary period that we review. How are you-- I would ask you to consider that. Again, second thing if you're not doing it. Those really in-depth focus level reviews. not just mortality reviews. And I think the second thing that happens is we have a different glasses or lenses that we're wearing when we review the chart. Our coding professionals are looking for coding opportunities. They're not looking to say, what clinically should we have queried? Meaning, the coder should focus on, is this coded correctly? Is there anything absent? Our clinical staff should be looking for again, what is clinically missing. What could be clinically clarified. Letting each of us use our areas of expertise and our quality staff saying, that seems very strange that you have this with the POA of no. And my favorite example of this was anaplasmosis. And I don't know if any of what that is. I had to look this one up when I read the chart. And it is a tick bloodborne infection. And this was coded at one of my hospitals with a POA of no. And my physician advisor smiled when I told him that he says, yes, it's not like we have deer walking up and down the halls of our hospital. So a quality person might be the one to recognize it. It might be a clinical person recognizing something seems strange here. And not just looking at just the complication codes. So I think that's another workflow if you're not doing is really and again, I think you have to be focused. Pick a couple of DRGs or if I'm working on the CMS mortality measures, those DRGs that are in the CMS mortality measures on the star ratings. Focus your DRGs, your second level you use on those patient populations. This third one, I will tell you. I get a lot of pushback on this from clients that haven't known me a long time. And I'm going there. We should have not just the same DRG. We should also have the same severity mortality or coding. You should have a higher one. Why is CDI reporting 30 codes and coding is only reporting 10? And I'm using a gross exaggeration. Normally coding reports more codes than CDI. But is there a specific code that CDI captured that coding didn't and why not? Is it because it's not reportable? Is it because it was not auto suggested in a way that we could see it? What is the reason that we did not capture a particular code. But the one that really sets people's teeth on edge is looking at the present on admission status. And one of my clients last week said, I want you to reemphasize that we should be doing a comparison on present on the mission. And the reason why it's important is because that is a specific necessity for the risk-adjusted models. They won't consider or utilize certain conditions when they're not present on admission. So it doesn't matter that you get the code on the chart if it's not going to be utilized in risk adjustment. That fourth one. Several of my clients actually have the CDIs whether it be the leaders or second level reviewers. They have clinical people participating in those denials reviews and those appeals. And having the providers also join in. Certainly when it goes peer to peer with a physician involved, we have found with some of our clients, especially those that are good at it, they tend to overturn a lot of those denials. So that's something that you're not doing. We certainly encourage you to have clinical people take a look at that. And again, participate in the formal denial process. This last one. The collaboration with infection control on those hospital acquired infections or HAIs. Our coded data should be as close as it can be to actually what is reported to CMS to the National Health Safety Network HAIs. They're very clear, maybe hard to understand, but they're very well-defined definitions for the hospital acquired infections. What is a CLABSI? What is a CLAUDI? And working collaborating with them and deciding who's going to have that conversation with the provider. Either we're underreporting it on our claims data or we have overreported. I had one that I looked at this week that the provider said that. That patient was intimated less than 48 hours. That is not a vap by definition on anybody's criteria. Even though that's a very convoluted definition, the patient had to be on the vet more than 96 hours. So already there's an opportunity to do some clinical validation on why we're calling it vap. And I the CDI or the coder may not know that criteria inside and out. So I might need to work with my friends to get clarity and say, is this on your list or not. I mean, that one like I said was really obvious for me. It just was not a vap. It literally was an aspiration pneumonia as he was seizing. OK. (DESCRIPTION) Slide, What metrics should be added and why? Query compliance. Missed opportunity for risk-adjustment. Average codes per case (Coding). P.O.A. accuracy (Coding). (SPEECH) So let's talk about-- so we talked about what workflow will still allow you to-- that you should consider. But what about what KPI should we add and why. And again, I see a really-- a couple of really good comments over there. And I appreciate. I see one of my new coworkers who joined us with a really good comment. What about your query compliance? We should be reviewing those queries making sure they're compliant. Did you offer all appropriate choices? Did you pad your clinical information to point the doctor in a certain position? And I know that is time consuming and cumbersome, but it goes back to the Hippocratic oath, first do no harm. Did we the CDI or the coder miss an opportunity to capture a career for risk-adjusted diagnoses? How many diagnoses did we miss? And again, the audit that I'm working on this week, I am very carefully looking. And actually the manager said, I want them to stop thinking about how will this affect the chart. Instead of how will this affect the chart, does this diagnosis belong on the chart. Not, what does it do to the chart, but why shouldn't it be there. I think another really good metric that one of my clients is really tracked and noted was the number of codes for case that were captured. Again, they have to meet UHDDS reporting requirements. But if all things are equal, meaning if I don't have specialized coders, so I do realize that we have to make some considerations there. We should be able to trend our department over time. And again, one of our clients we specifically watched and looked and we actually did some extra education with the coders on the use of our software. And said, are you taking full advantage of the software. And we saw a dramatic increase in the number of codes per case. And remember, those extra codes are part of risk adjustment. Now, of course, that leads what when you're reporting more than 25 codes. So again, we'll talk about that in just a second. And the last thing that I really do think should be-- and again, I could argue CDI as well on this one. But primarily when it goes out the door are we getting the appropriate POA assignment on this case. Do we misread it? Do we miss an opportunity to ask a question? So POA accuracy is not just did you assign the right one, but did you miss an opportunity to query to get the appropriate POA. And remember, this is just a short list. I could come up with probably 20 or 30. But realistically I think you have to start small and say, are some things that we should add in. This is really where our programs need to evolve. (DESCRIPTION) Slide, What else? Shared metrics between quality, coding, and C.D.I.. Extensive provider education. E.M.R. enhancements (smart phrases etc.). Standardized definitions for high value diagnoses. Collaboration with infection control on H.A.I.. Definitions and measures. (SPEECH) But what else? My question is, why don't we share the metrics? Why are we not all held accountable. And it has been really interesting to watch one of my clients on their journey. They weren't allowed at the table in the meetings. And they fought for a place at the table when it came to quality outcomes such as star ratings or their premier rankings, et cetera. And they're all held accountable for that performance. In other words, quality should be working on the quality of the actual physical care. Meaning can we improve the care that we're delivering or are patients on a daily basis. Where coding and CDI can look at the accuracy of the claims going out the door and making sure that we're doing all that. But why don't we share the metric. I think we need to really, do more education with our providers. I was doing some education this morning with an ICU CDI specialist specifically on NICU. And helping-- some of the struggles that we were having. And that she was having, we think could really be mitigated by some education. Helping them understand why is this question being asked. Why is this important to get this accurate on this baby's chart? What are the implications not just today, but on the transfer of care to that pediatrician in the outpatient setting. Letting them know what we're focusing on and where it's affected. EMR enhancements. Many people have instituted smart phrases. The smart phrases are a good thing and a bad thing. Again, we could spend three hours debating that. But for example, if a provider keeps using a dropdown for a very unspecified choice, why aren't we giving them the specified choices? Why don't we customize that to that type of physician so that we are getting better documentation out of them. A great example is now with our nonacute nonischemic myocardial injuries. Why aren't we adding that to the cardiologist drop down choices instead of demand ischemia? Why don't we remove demand ischemia and replace it with better smart phrases? Or really for example, with malnutrition because of the OIG. When the provider-- a lot of my clients have ways to have the provider sign off on the diagnosis. Well, I just worked with one to say, not just that they agree with the dietician but they agree with the dietician and it impacts the patient in the following ways and gave the providers some choices, some smart choices that they could choose. And then, of course, a free text and requiring them to comment on that. That fourth one again. Many hospitals have been able to achieve this and some have not. We should have standardized definitions for what we call high-value diagnosis, meaning those that are frequently denied. Our sepsis, our encephalopathy, our respiratory failure, renal failure, ABLA, hyponatremia, things like that. And not only is helping all of us when we approach the charts, but it's also helping in that defense in case it does try to get denied. And again, I do think we need to collaborate with infection control. If you weren't collaborating, why aren't we? And understand that. We're reporting in two different worlds in two different sets of metrics, but we should have the same understanding of what is the clinical picture here. (DESCRIPTION) Slide, Non-Traditional C.D.I. R.O.I. Metrics. Decrease in medical necessity denials. Decrease in external auditor denials for clinical validity. Increased success rate for appeals, A.L.J., etc.. Decrease in P.S.I. rates and improvement in A.H.R.Q. performance. Improvement in Value-Based Purchasing (V.B.P.) score and H.A.C. reduction program total score. Improvement in Medicare Spending per Beneficiary by increasing expected expenditures via capture of HCCs. Decrease in rate of potentially preventable readmissions and decrease in readmissions penalties where applicable. Increase in national quality rankings (U.H.C., U.S. News and World Reports Best Hospitals, Star Ratings/Care Compare, etc.). (SPEECH) Some nontraditional CDI ROI metrics for you. Is we should see our medical necessity denials. So the clinical validation denials really can substitute either one there. You should go down. If we have a cleaner chart going out the door, we should have less denials. That's not solely on the backs of the CDI, I know that there is a lot more behind that. There's payer negotiations that has to occur. But overall, and I'll give you a great example, that same NICU senior specialist their hospital has seen an increase in denials in that population. Why? Because she's asking the doctors to document more. So we have to put that in context that is once you've stabilized and worked with those payers, if we have cleaner charts going out the door, per chance we should be able to see that trend down. And I would set very, very minimal changes here. I would not ask for big ROI gains in either the medical necessity or the clinical validation because again, sometimes it takes time. We should have-- what is our success rate for turnovers? Whether or not we got in denial, how is our success rate? I know again, one of my clients is presenting this summer at the client experience summit on how well that they have done on winning. Successfully winning their appeals. So why is that not a metric. Again, if the chart stands well and is documented well and then the CDIs are insurance clinically valid, we should have a higher success rate. Certainly, decrease in PSI rates because that is coded data. What I will say, though is at a certain point that's going to tap out. Meaning you're going to hit a certain nadir there where you're probably not going to make any other improvements. And an example, one of my clients they had horrific, I'm going to use their words, not mine horrific PSI performance. And it was publicized on the front page of a national newspaper. And the one facility in particular. So they underwent a very long journey. And they put these PSI metrics in their KPIs for the CDI performance. And they got everything down into the top five decile performance for how well they are doing on their PSI except for one category or two. But the one in particular that was way out of their control was their DVT PE, post-op PE and DBTs. They had validated them as much as they could. They had done everything they could. And they hit a point where they weren't seeing any missiles anymore. There weren't miss queries. There weren't miss coding opportunities. They then took that back to the providers and said, you know what, it's on you now. We need to figure out how we can clinically improve this. So again, that decrease or that maintaining of a good PSI rate might be a better metric. It may not be just a decrease, have we maintained this exceptional performance. Again, value-based purchasing and hack reduction program. There are components that are very much based on claims data and some that is not based on claims data. But, again, it is still worth a certain portion of your score. So why aren't we sharing in the both success and/or the failures in doing well on those? Why aren't we taking the same credit that quality does? What is that Medicare spending per beneficiary? It's very easy to track and trend. It's out on the CMS compare every year. If we are getting additional HCCs captured in any setting that, Medicare spending per beneficiary should reflect the care or the necessary cost that we're delivering. Again, the decrease in the readmissions and the penalties again where applicable. Alternate principle diagnosis and risk adjustment. Just focusing on those CMS mortality and remissions it's the same group of cohorts. They have the same risk adjustment. So if we're adding extra diagnoses that are clinically appropriate, we're extending our expected rate of readmissions. And so we should see that we're either continuing to do well or improving our performance in that. That next one. Again, our hospital focuses on those. As a whole our quality does, but why aren't we part of that. As an example again, the client that's speaking this summer is talking about their leapfrog scores. And it's one of their metrics because the organization came to them and said, we've got a bad rating, how are you going to help us improve. So if CDI and coding are being asked to participate in the performance, we should be allowed to measure and be appreciated for the improvement. And they did actually move up to several of their hospitals, that being five stars and leapfrog and now one is a four star. And again, they were much worse than that. So I mean, sorry, A rating. I'm so sorry. A rating now. In one hospital and a B compared to where they were before. And again, sorry, that last one is a duplicate. I already did discuss that. (DESCRIPTION) A thought bubble pointing to "Decrease in P.S.I. rates and improvement in A.H.R.Q." reads, Shared between C.D.I. Coding and Quality. (SPEECH) OK. And again, it's a reminder that the CDI metrics, I just want to remind you that they don't have to be my metrics and your metrics and their metrics. Why aren't they our metrics? And we present to leadership our performance. Because again, almost all of these have some involvement. There are parts of CMS star rating out of our control. There are parts of value-based purchasing that are out of our control. But we should be sharing those together. (DESCRIPTION) Slide, Challenges. (SPEECH) So what are some challenges on the journey. We don't have good measurement tools. Or we may not have good measurement tools to measure that ROI. And stay tuned on my next slide because I'll also show you what I mean by that. But many times we're waiting for publicly reported data and we don't have internal reporting to know how we're doing. Secondly, we may not have really good artificial intelligence or prioritization tools. One of the biggest things I'll say for those of you on the line that are 3M clients. It should be customized by you based on your facility population. It should also include quality specific prioritization factors. And if not, I'm-- and if you don't have a 3M product, your tools should do this. It should be able to help you prioritize based on certain DRG that your focus or again are unique. In other words, you can keep telling me that this is a priority and that I might find an MCC here, but we've audited these 80 times. I want to take this weight down because we never find anything. It's a waste of time to continue to see this patient. Second challenge is really sometimes getting the buy in from senior leadership it's usually not a problem, but where it becomes a lack of buy in from senior leadership is, it does require some extra personnel to do this work. Even with prioritization and computer assisted coding and all the technology we have, it's sometimes hard to get the senior leaders to agree. That's why you need those non-traditional ROIs so that you can say, look, the extra three FTEs you gave me, here's what happened with our quality scores. Another good reason to try and put that in. The fourth one, sorry, I roll my eyes here. The frontline staff, but that's your job as a leader. And it's my job as a frontline staff to do my job. This isn't my job. I'm supposed to look for this and that. I'm not supposed to be checking up on the coders work. You're not checking up on the coders work. The question is, are we as a team looking at this chart before it goes out the door to ensure it's tucked in appropriately. Well, this. Is going to take more time OK. I laugh when somebody says, I didn't have time to write all those queries because I have to get my reviews done. That drives me crazy. I had somebody saying if you're salaried like, I'm so tired of working over 40 hours. I'm like, but you're salaried. So I think we have to manage that behavior. We also have to share the ROI successes with them and the opportunities. Let them see we've added these extra personnel, we've given you more time, and look at what's happened to the performance. This last one, again, is probably my personal frustration. We don't always get timely return on investment because there is a significant lag time for your publicly reported measures whether it be CMS or US News and World Report, Healthgrades, Leapfrog. Their weight they're either utilizing Medicare data and/or they're using two or three years of data. And again, my next slide is probably my favorite. And I encourage you all to share this next slide with your leadership. Do know that there is some proxy, shall we say? That will give you some real time results. So you'll have an idea how you're going to look publicly or it's a good guesstimazation of how you're going to look publicly. (DESCRIPTION) Slide, C.M.S. reporting and payment adjustment. A timeline lists data collection periods across the top - July 1, 2017 to December 1, 2019, July 1, 2018 to June 30, 2021 (excluding January 1 to June 30, 2020), July 1, 2019 to June 30, 2022 (excluding January 1 to June 30, 2020), July 1, 2020 to June 30, 2023 (excluding January 1 to June 30, 2020), July 1, 2021 to June 30, 2024, and July 1, 2022 to June 30, 2025. Listed below are yearly Public Reporting/Star Ratings and H.A.C. V.B.P. and H.R.R.P. payment adjustments between 2021 and 2026, with arrows labeled "What the public and executive leadership see" pointing to 2021 and 2022, and arrows labeled "What C.D.I., Coding, and Quality can influence" pointing to 2025 and 2026. (SPEECH) And again, this next slide is probably my favorite. And I actually created this for a CFO who said, I am wanting to improve our CMS mortality. So he was very specific about what he wanted. And so we wanted to show him where we were on the journey, where we were working today, and where that data is going to be reported. And of course, when you look at the timeline across the top, look at the times of data, the data time collection periods. 2017 to '19. With their reporting out in 2021 and 2022 what we did several years back and the work that we are in right now, anywhere between July because we're in May of 2022. So even one more arrow over to the left that purple. That's the area that we're currently in that we still have an ability to influence So helping your C-suite and your board members understand the slide is probably the biggest thing that I encourage you all to do. It's the ship is sailed. But it also says, look, what we're doing right now, we're not going to see results until 2024, 2025, 2026, that's frustrating. You've got to give us time to put these measures in place. And they have to give us the grace and be patient. So I'll add in that other thing is it's giving them and then begging them for some patience with this. (DESCRIPTION) Slide, Where should we go from here? A fifth green panel is pictured to the right of the other four from the The Evolution of Clinical Documentation Improvement slides, with that and the fourth panel now above a right-facing arrow labeled Outpatient. The pane reads, Phase 5 - Holistic Clinical Documentation Improvement. Comprehensive review of documentation in all care settings. Comprehensive review of all payers. Comprehensive review of all diagnoses. Focus change from case impact to documentation completeness. (SPEECH) Where should we go next? Well, what you see is phase five, holistic clinical documentation improvement. You'll notice I also incorporated outpatient. This is my reminder that in July our outpatient team will be talking about that evolution. But the one that I really want you to think about is the second, third, and fourth dots over there, still apply to inpatient. Are you looking at all payers? Are you looking at all diagnoses, not just those that move the needle. And you know again, as my CDI director said, I want them to stop thinking about what does this do to the case and change it to does this condition belong on the case, the software, our software will tell you what it did to the case. It added an elixir. It added an additional MCC. Removed to PSI whatever it might be. The other thing sorry that I didn't even throw in here and I meant to is the advanced sequencing. As we're coding more diagnoses using the advanced sequencing tools to make sure our most impactful diagnoses, those that are needing to be there for risk adjustment end up in the top 25 positions. And I have a CDI that I am going to smile because he is a coder by nature. I love having CDIs coders respiratory therapists. I have all sorts of people. So it's not a specialty thing. But being a coder, you can't quite let go of his coding hat. And so he organizes all of his working CDI codes in a hierarchical order himself. And he moves all the Z codes down to the bottom because those aren't important to him. And I'm like, oh, but for risk adjustment, a lot of those Z codes need to make it up in the top 25. And they're about to go live with automated resequencing. And I've told them like, oh, you're going to have to let go of that because it's going out the door looking very differently than how you're looking at this chart. So again, let the technology be your friend where it can, but we need to focus more on documentation completeness. And by that, of course, I do mean accuracy being specific to that. (DESCRIPTION) Slide, Q&A. (SPEECH) So. Again, I purposely left a little bit of time. I see we had some great questions coming in. And Lisa, I think we can start right with question two. I think that's so-- I think the question so far really do look good and worthwhile. I think we can get through most of them. Awesome. OK. I think you had said question two, correct, with Helen with Forge Health. Yeah. OK. Perfect. So first question, do you think at some point in the future CDI encoders will become one in the same just with a different title. No. I think we still need some specialization. I think we need people to really get immersed in the code and the code accuracy and the coding guidelines. I think we also need people with real world clinical experience. I know what this patient looked like when I see them. I think we. Again, I don't mean all CDI should be nurses. I'm not saying that at all. I am saying, I think we need to have distinct skill sets and in trying to find what I'll call the super person that has good clinical and good coding-- sorry, that's looking for needles in haystacks. So I do think that we should still have those specialists but then we need to collaborate. I think a lot of the work we do is similar, but it's still different and we need different lenses. If everybody looks through life with the same prescription lens, I think will be missing things. But I'd like to the question. It's just definitely I don't think we should get there. All right. Next question from Ellen, are most CDI programs reporting up through quality departments? So the answer is, I have seen pretty much every model. Probably the most common one nowadays is where CDI and coding both report up through HIM. I have seen some report through quality, I have seen some report through nursing. I don't think there is a perfect model there. That's why I like the shared metrics so that regardless of where you're reporting your collaboration and your shared metrics bring you together as a team. But I've seen so many different versions that I don't think there's a-- I have one that they report directly to the CFO, which has always been interesting to me. And actually they started out reporting through case management and then through nursing. And then finally directly to the CFO. So they have all also changed their model, the reporting structure over time. And then Lisa, we did already answer question 5 so we can skip that one. Because I saw that pop up and I could cover it while we were there. Yep, I thought so. All right. Perfect. Next one, do you recommend match of other elements besides DRG? Absolutely. As I said, we should be looking at the severity and the mortality. We should be looking at what codes has CDI accepted. Again, many times CDI could be an error, but other times you know CDI is recognizing that this is an impactful diagnosis that means reporting requirements. But I think where we have failed to push to the next frontier is really even the present on a mission. So I really think that when we consider a match, we need to define that for our staff and decide how far. But as far as I'm concerned, one of my clients, yeah, they go code to code and I mean code to code and POA to POA. But remember, they're working in a specific proprietary model so they have to be that diligent to hit those outcomes. Great. Great. Next question from Michelle, how do clinical validation queries calculate into the financial goals? My metric would show negative dollar since clinical validation is what I primarily do to prevent denials. So that depends on how you value your clinical validation. So forgive me for using a double negative there. But the way that I think about this is if you're asking if something is clinically valid, you should not count the negative dollars when you take that code away if it was not valid in the first place. And I will tell you philosophically as recently as three months ago, I was having a really strong debate with a new client and saying, why are you taking the dollars away? Well, because the chart isn't going out that way. But the question should be, if it should not have gone out the door that way because this is not valid sepsis. And my favorite example, a patient was eating a chicken wing. The dog was at his feet trying to get the chicken wing out of his hand and bit the web of his hand right here, and he got cellulitis. And the doctor said, he had sepsis due to cellulitis. The patient was there with two days, no fever, no elevated white count, I mean like nothing for sepsis. I did a clinical validation of it. We should never have gotten paid for sepsis. So I'm not going to take the negative impact from that financially. I absolutely think that is inappropriate to count that as a negative value. Great. The next question is, how do you tie these quality metrics back to individual staff levels, the CDSes? Ah. That's a tough one. I think the quality metrics need to be department and not individual. I think you should focus on individual metrics such as again, a thorough chart review. Appropriate POA assignment. I think quality for an individual CDI should be query compliance. Should be accuracy of my code that should be missed opportunities for quality risk adjustment, yes or no. I think we need to not say a PSI score should be assigned to Susie because understand if I have a reviewer and one of my clients is very much specialty based. And I have a couple of reviewers that cover the surgical floors. Wow. A lot of those PSIs are postsurgical. So it's not fair to set PSI goals for individual CDIs because they're going to get a higher percentage. So I like to think of different types of quality metrics at the individual level. Next question is, this is the long one. So regardless of productivity, the quality of a CDI review should always-- let's see. Always be there. Yes? OK. Sorry. There's something goofy that was happening when I'm reading it. It's grayed out. So you want me to continue with this one? Yeah. For some reason it's not working for me. Go ahead. Yeah. Initial reviews are extremely important to establish the working DRGs set up the CDI to file a medical care and get a clinical picture of why the patient was admitted. It continue to say is the body of the documentations. CDIs or the non-MD Tracking. The consistency of the assessment plan of care. So I believe these are in line with the expectations on productivity where the quality is not negotiable. And as I long as a supervisor to think of this way. I don't think it's an or thing. In other words, yes, an initial review is important to get the theme of the chart going. But that subsequent review is normally where most of the queries occur and where the gaps in the documentations are. So setting metrics on those solely or making those so heavily weighted in an employee's performance says and again, I've seen CDI as they literally count. Oh, good, I hit 10. Now let me jump to this. I hit my 25 charts for the day. We had a reviewer that years ago. I've had a couple not more than, not one, but several reviewers that would suddenly stack a bunch of reviews in two hours at the end of their day to hit their numbers. What's the point of having the number of reviews if you did nothing with them? So I think we need to expand the way we think about it. Years ago when it was financially driven, that might have been a better metric. But I think we need to move beyond that because there's so much more important than how many charts or types of charts I reviewed. Onto the next one. Quality shouldn't be the only department capable of identifying when something is unlikely to-- unlikely to-- I'm not sure what that means. To be hospital-acquired, yeah. I expect CDI to be able to do this and understand HRRP, readmissions, mortality, complications, HCCs, et cetera. And yes with a focus on correct POA for all codes. Do you want to comment on that? I do. And, again when I said I see my new coworker out there, I don't disagree with Ellen's statement. Ellen and I are actually on the same page on many things. And what I would say, though, is you have to meet your people on where they're at on the journey. And so I have to train them and guide them to get them there. And if I don't have the people and I don't have the training yet, get the training for them. But I think we have to meet each of our programs where they're at on the journey and help them move along the journey because I think that is important. And the other part is I may not stay current. I'm also depending on quality. And I'll also say, quality doesn't always know their metrics the way we think they do. I have found that more often than not that sometimes as I'm doing some quality education I'm like, no. The metric was written this way and this is the criteria. And this is how it works. So it is that collaboration. But I think we have to yes, I want my CDI to understand quality. And again, I think we just have to guide them in a journey, but not wait. Who can I lean on until I've gotten my team up to that skill set. Awesome. Well, I am going to go ahead and stop here since we are just about out of time. I did want to remind everyone that there are some resources in the resources section. The handout is there, the certificate of attendance is there. And we also have links to like I said some other resources for you. (DESCRIPTION) Slide, 3M Education boot camps. Virtual advanced C.D.I. training - August 1 - 5. Virtual advanced quality training - June 13 - 17. (SPEECH) We do have our educational bootcamps, we have the advanced CDI training, and the advanced quality training both coming up here in June and August. So if you are interested in learning more about those, there's links in the resources section. And after the webinar, you will be getting just an email with more information that if you would like to get that we would like to get that information you can as well as registering for our upcoming webinar in July. So that'll be part 2 of this series of the evolution of CDI. (DESCRIPTION) Slide, That's a wrap! (SPEECH) So again, we really appreciate everybody's time today. If you do have any questions, please fill that out in the survey. We'll be happy to follow up with you. And Cheryl, is there anything else that you would like to add for today? No. I see some of the extra questions we didn't get to. And again, I think you have to figure out where you're at in your journey and set yourself some realistic goals to get there. A goal should be SMART-- Specific, Measurable, Attainable, Realistic, and Timely, all the pieces of whatever that would be. But the point being give yourself reasonable goals. And again, think of your nontraditional metrics. The other question that I saw in there I just want to comment on is yeah, 3M is limited on what we can incorporate into the software because a proprietary methodology. So things such as Vizient or Premier can't be built in because we don't have a relationship with them. And until they agree to partner with us, we can incorporate them. And that advanced sequencing, the last one I want to cover yes it includes HCCs, CMS risk adjustment, PSI and/or PSI, exclusion criteria, and the Alex Hauser criteria. And it will incorporate a little bit more in the future. And I liked one of the suggestions about prioritization. I'm going to share that with the team on one of those great questions about the fact that patients covered under an ACO. That's a great question that I'm going to share back with our development team. So I thank you guys for the really lovely comments, questions, challenges. I like when you provoke and stimulate my thinking as well. (DESCRIPTION) Slide, Thank you! (SPEECH) Awesome. Well, thank you so much again, Cheryl. We certainly always appreciate your knowledge and information. And so thank you all again for your attendance today. We will be posting this recording on our website in the next couple of weeks. So if you do want to go back and listen in, you certainly can. So again, thank you for joining, and we will see you in July. Thank you.

(DESCRIPTION) Slide show. (SPEECH) Good afternoon, and thank you all for joining us for our March Quality Webinar Series. We are excited, if you haven't noticed. Last year, if you were with us, and you joined us, it was a different webinar platform. So we are excited that we have a new platform to really enhance the user experience. So before we kick things off, I just want to go over a few things with you. (DESCRIPTION) Text, New year, new webinar platform! 3M. A great company is showing what interesting applications a fantastic product can bring for motivated users. The left column of the page shows boxes labeled Media Player, Resources, and Have a question? Let us know. The center column has a large box labeled Slides. Under that is a red button that reads, Ask an Expert. The right column has a box headed Speaker Bio. Under that is a box headed Survey with two questions: 1. How would you rate the subject? 2. How would you rate the speaker? (SPEECH) Some of the new features and layout just to make sure you're finding everything as you're navigating this new system. So because this is a web-based platform, there is not a dial-in number. So you cannot participate by phone. So if you are having audio issues, please check your speaker settings, clear your cache, and then you can refresh your browser. There is an engagement toolbar down at the bottom of the screen where you can see the different resources that we have. You can move things around within this portal which is great. You can minimize, close it out, so it is much more interactive than our last platform. If you do need closed captioning, that is available as well. So in the actual media section in the live stream, you can click on closed captioning there which is fantastic. We always encourage Q&A. We'll get to as many as we can. So if you do have any questions, you can put that in the Q&A box there are not CEUs, but we do provide a certificate of attendance. So you can add the-- I'm sorry, you can download the certificate of attendance and submit the CEUs that way. That is also available in the resources section. I do see a couple questions that are saying that there's no slides in the resource section. So what I'll do, again, because this is a web-based platform, I'll double check. In order for you to get that, you will just have to refresh the browser. So by the end, just make sure you do a quick refresh, and the presentation slides will be there for download, as well as that certificate of attendance. I'll double check to make sure it's there. If you would like to learn more about our products and solutions, if you click on the learn-more button under the slides, you can let us know if you'd like us to follow up with you there. We always appreciate your feedback, so please complete the survey either in the portal, or it will launch at the end of the webinar. And, again, if you do have any questions or comments, you can put it in the Q&A section or in the engagement tools. You'll see a little envelope with the at sign. That would send us an email there. OK, so enough from me. We are really excited to get started with the COVID-19's continued impact on CDI and coding across the care settings. (DESCRIPTION) New slide. Text, 3M, Science. Applied to Life. 3M Quality Webinar Series. COVID-19's continued impact on CDI and coding across care settings. March 2022. New slide. Text, New year, new platform! On24 Webinar Platform for a better user experience! Check speaker settings and refresh if you are having audio issues. Ability to move engagement sections. Ask questions! Certificate of Attendance available to download. Engagement tools and CC available. Resources Section. Complete the Survey. (SPEECH) We have a great panel of speakers today. They are no strangers to you. (DESCRIPTION) New slide titled Meet our Speakers, showing a head shot for each speaker. Text, Colleen Deighan, RHIA, CCS, CCDS-O. Sue Belley, M. Ed., RHIA, CPHQ. Audrey Howard, RHIA. Bobbie Starkey, RHIT, CCS-P, AHIMA. Cheryl Manchenton, BSN, RN. To see their full bios, check out the Meet our speakers in the portal. (SPEECH) If you have been with us before, you recognize all these lovely faces. If you would like to learn more about them in the speakers' section, in our meet our speakers' section of the portal. You can read a little bit more about them. So I'm going to go ahead and turn things over to Sue to go over the agenda and get started. Sue. Oh, and Sue, it looks like you're still muted. (DESCRIPTION) New slide. Text, Agenda. Inpatient COVID-19 challenges, admitted with versus admitted for COVID-19, History of COVID-19 versus sequelae of COVID-19, Present on admission. Outpatient COVID-19 challenges. New COVID-19 codes and guidelines effective after 1/1/22. Public Health Emergency. Update on COVID-19 and quality metrics. (SPEECH) Thank you, Lisa. My name is Susan Belley, and I wanted to thank you all for joining us today to continue our conversation on COVID-19. This is the third time that we're coming together since the start of the pandemic to talk to you about COVID, and its impact and how it impacts us with regard to CDI coding initiatives. We actually started developing this particular webinar during the Omicron surge in early January. We started to hear and read all of the national discourse about patients being admitted with COVID-19, and patients being admitted for COVID-19, and we thought it was some very interesting dialogue. A lot of it from people who might not understand how we represent patience being admitted with versus for COVID-19. So what we'd like to do today is talk about ongoing COVID-19 challenges in the inpatient setting, and we're going to start out with this conundrum of admitted with versus for COVID-19, as well as a few other topics that we see people having questions with or perhaps struggling with. We'll move on to outpatient COVID-19 challenges, and then we'll spend some time talking about new COVID-19 codes and guidelines that became effective after January 1 of this year. And I'm sure most of you are aware that we're going to be seeing a few new codes and guidelines go into effect on April 1, just two days from now, and then we're going to finish out by talking a bit about the public-health emergency and have a small update on COVID-19 as it pertains to quality metrics that our facilities report. And I think we'll definitely have time at the end to take any questions or comments that any of you might have, and we'll do our best to answer those. If we can't answer them on this particular webinar, we will respond after. So again, thank you for joining us, and I'm going to turn the first part of the presentation over to my colleagues, Cheryl Manchenton and Audrey Howard. (DESCRIPTION) New Slide. Text, Inpatient COVID-19 challenges. (SPEECH) Good morning, afternoon, I should say. There might be some morning people here. We will specifically talk about those challenges. Not only have we vocally heard or read that, we have actually performed some chart reviews where we have seen the struggle. So I do think it's a global one. The first topic, again, is that admitted with COVID versus admitted for. (DESCRIPTION) New slide titled COVID-19: Admitted with versus admitted for. Two columns, the right labeled Before and the right labeled After. Text, Before: PDx, Pulmonary embolism. SDx, Septic shock. SDx, COVID-19. SDx, DVTs, cardiogenic shock, COVID-19 pneumonia. After: PDx, Query: COVID-19 versus sepsis. SDx, SDX, and PPX are blank. Before: MS-DRG, 175. Relative weight, 1.5460. After: MS-DRG, 177 versus 871. Relative weight, 1.8491 versus 1.8722. Before: APR DRG, 134. SOI subclass, 4. ROM subclass, 4. SOI weight, 1.5965. After: APR DRG: 137 versus 720. SOI Subclass, 4. SOI Weight, 1.5682 versus 2.0860. ROM Subclass, 4. Explanation: Patient transferred from OSH for possible thrombectomy. Patient still in septic and cardiogenic shock and with active COVID-19 infection with COVID-19 pneumonia (confirmed COVID-19 status on this encounter versus query). Consult noted PEs due to hypercoagulable state from COVID-19 and from immobility from previous hospitalizations, but attending did not connect all the pieces. Recommend confirming PE and DVTs and sepsis are due to COVID-19. Per the COVID-19 guidelines, manifestations of COVID-19 are sequenced as secondary diagnosis (meaning U07.1 would be sequenced as PDx over the PE/DVT) but the sepsis and COVID-19 guidelines note sepsis would be sequenced as PDx over COVID-19. (SPEECH) So just to orient you to the screen, on the left side were not all of the codes, but some of the secondary or significant secondary diagnosis. And you'll see the first listed diagnosis on this encounter was the pulmonary embolism, with secondary diagnosis of septic shock, COVID-19, DVTs, cardiogenic shock, and COVID pneumonia, and you can see the MS-DRG assignment. Its relative weight. The APR-DRG assignment. The severity of illness, subclass four, risk mortality, subclass four. On the right side, you can see what would happen based on some clarification. In other words, the documentation was insufficient for what we consider to be telling the whole story. So at the bottom, of course, you can see that the come in-- this patient did come into this inpatient facility for thrombectomy. That was the intent, and we know that when you think about circumstances of principal diagnosis, the reason for transfer is typically sequenced as your principal diagnosis. However, reading the whole story, this patient had just been recently diagnosed. So they literally went from hospital A to hospital B still in an active, really bad COVID situation and also had DIC. There's other codes of course not listed here, but she had not recovered from her COVID. She was not doing well, and had this massive pulmonary embolism. And so, of course, they were sent in here to see-- it was possibility to do a rescue thrombectomy on this patient. Again, still on maximum pressers, active treated, and everything. The consult notes came close. They said the patient's PE was due to the hyper-coagulable state from COVID-19 and from, of course, immobility from that long hospitalization. Unfortunately, the attending didn't really connect all the pieces, tell the whole story. It's clear this was still an active COVID, and this was an active manifestation of an active infection. So of course, we can't just code it the way we think the story should be told. We need to place a clarification and say is this PE due to COVID-19, and again, there's this whole picture ongoing due to the COVID-19 and, again, is it sepsis. And of course, depending on our physician answer, either COVID-19 would be sequenced as principal, or the sepsis would be sequenced as principal. And, of course, what you see is that MS-DRG depended on the principal diagnosis with definitely a higher weight. The other piece I will tell you is unfortunately this patient did expire. She ended up having a hemorrhagic stroke and was made comfort care and expired during this encounter. So when you think about this mortality, this is not to me the right story that we told. And so again, of course, we needed a clarification. And I'm going to hand it over to Audrey to discuss, again, our coding guidelines around that. (DESCRIPTION) New slide titled Sequencing of COVID-19 manifestations. Diagram. A blue circle in the center of the slide reads, Sequence of COVID-19 (UO7.1) as principal diagnosis. Above and to the left of the circle is a purple box with an arrow pointing to the circle. It reads, Acute respiratory manifestations related to COVID-19. To the right of that box is a light purple box with an arrow pointing down to the blue circle. It reads, Non-respiratory manifestations related to COVID-19. Text in the bottom right corner of screen: Assign code(s) for the manifestation(s) as additional diagnoses. (SPEECH) Right, because we know when it comes to COVID, we are still looking at the principal diagnosis definition, which is that condition established after study. That's chiefly responsible for occasioning the patient's admission to the hospital. So we're always looking at why did the patient come in, but there is an additional guideline for COVID that if they are relating the presenting manifestations or the presenting condition to the COVID that according to the COVID coding guidelines that we are supposed to put the COVID as the principal diagnosis. So this kind of still plays into are they admitted with COVID or are they admitted for COVID, and the fact that if the documentation is linking the condition to the COVID, then according to the COVID coding guidelines, we will put the COVID code as our principal diagnosis. And it doesn't matter if it's an acute manifestation. I'm sorry. An acute respiratory manifestation or a non-respiratory manifestation of the COVID. Either one. The fact that it's a manifestation of the COVID, you'll put the COVID as the principal diagnosis. And that's what is being shown on this slide. (DESCRIPTION) New Slide. Text, Current COVID-19 infection versus residual effect. Before: PDx, Myoclonus. SDx, COVID-19. SDx and PPx are blank. After: PDx, Myoclonus. SDx, Add: Post COVID-19 condition (U09.9). Sdx, Delete COVID-19 (U07.1) Before: MS-DRG, 091. Relative weight, 1.6508. After: MS-DRG, 093. Relative weight, 0.7822. Before: APR DRG, 058. SOI subclass, 2. SOI Weight, 1.0587. ROM Subclass, 2. After: APR DRG, 058. SOI Subclass, 1. SOI Weight, 0.8002. ROM subclass, 2. Explanation: Patient admitted with myoclonus secondary to post-COVID-19. As this is a post-COVID-19 condition and COVID-19 was diagnosed a month prior with no active signs of infection or treatment on this visit, this should be assigned to U09.9, not U07.1. (SPEECH) So our second scenario, again, is this a current COVID-19 infection, or is it a residual effect. This was definitely an unusual chart, and it really piqued my interest. We have learned over the last two years lots of different manifestations, or we'll call long-call conditions that we might have seen from COVID. This patient came in with tremors, and they were really admitting him to determine what the source of these tremors were, wondering if he had new onset seizures. After study, again, after this whole chart, the doctors actually get a really nice job here of saying, this myoclonus was actually secondary to a post COVID-19 state. In other words, he had had COVID, it was cleared up, and this is one of his residuals from his infection. And because of that, of course, we would not assign the UO7 code. We would have added the post-COVID condition, the UO9.9 code. And of course, what you see is in this case, it did drop our reimbursement and our severity and mortality, but that would be consistent. In other words, that is the true story. So it's not just whether or not COVID should be your principal diagnosis or not. It's is it a secondary diagnosis. Is this still an ongoing COVID infection. In this case, again, I thought the providers did a fabulous job of noting that. And again, for those that use computer-assisted coding tools, many times, again, the engine is not smart enough to know it shouldn't assign UO7, that perchance there should be a UO9.9 code. That natural language has not been processed yet, so we have to look at the codes and determine is that the appropriate code, or is there an alternate code that should be assigned. (DESCRIPTION) New slide. Text, Post COVID-19 (U09.9). Assigned when the patient no longer has an active COVID-19 infection but has continued residual effects of COVID-19. Do not assign code U09.9 in cases that are still presenting with active COVID-19. However, an exception is made in cases of re-infection with COVID-19, occurring with a condition related to prior COVID-19. (SPEECH) And as always, the code assignment is going to be determined based off the provider's documentation. And sometimes, it's not easy to decipher when a patient is admitted with a condition. Is that COVID infection an active infection, or is it already cleared up. It's no longer current, and therefore, it is going to be a sequelae of the COVID-19. So if it is documentation saying it's an active infection, then we would still put the U07.1 code for the active infection of the COVID. However, the documentation that they are coming in that it's related to the COVID, but the COVID is no longer an active infection. The new code was created for U09.9, and that was effective October 1, 2021. (DESCRIPTION) New Slide titled Coding for long haulers. Flow chart, starts with a light blue box on the left side that reads, Admitted with COVID-19 related condition. Two bright blue boxes are connected to the first box with lines. The top one reads, Documentation supports the condition is an acute manifestation of a current COVID-19 infection. Two navy blue boxes connect to this box. The top one reads, PDx/first listed: U07.1. The bottom one reads, SDX: acute manifestation. The bottom bright blue box that stems from the first light blue box reads, Documentation states patient no longer has an active COVID-19 infection. Two navy boxes are connected to this box. The top one reads, PDx/first listed: presenting condition. The bottom one read, SDx: U09.9. (SPEECH) On the next slide, you're going to see kind of a decision tree, if you will, regarding which code to be assigned. Once again, always based on the provider's documentation of how it relates to the COVID-19. So the documentation is linking that condition to the COVID-19, but then you have to decipher is it an active infection, or is it no longer active to help you decide which code you're going to put. And you may need to query the provider to get that clarification, because we're, once again, even though we're two years into this pandemic, we are still learning more and more about the virus, and about how long it may stay in the body, and if it's active or a past medical history. (DESCRIPTION) New slide. Text, COVID-19: Current infection versus residual virus. Before: PDx, atrial flutter. SDx, Type 2 myocardial infarction. SDx, COVID-19. After: Atrial flutter. SDx is blank. Second SDx reads, Clinical validation: COVID-19. Before: MS-DRG, 280. Relative weight, 1.6069. After: MS-DRG, 280. Relative weight, 1.6069. Before: APR DRG, 201. SOI Subclass, 3. SOI weight, 0.8214. ROM Subclass, 3. After: APR DRG, 201. SOI Subclass, 3. SOI weight, 0.8214. ROM Subclass, 3. Explanation: Patient presented with palpitations. New diagnosis of atrial flutter. Ablation planned as outpatient. Recent COVID infection. Tested positive on this admission. COVID infection 2 months prior. Recommend confirming if positive test is reflective of residual virus (e.g., viral shedding) versus continued active infection. (SPEECH) So this is a nice segue. Is this a current infection, or is it residual virus. So this patient presented with palpitations with a new diagnosis of A flutter and also had a type-two MI. They plan to complete the ablation outpatient. They had had a recent COVID infection, and they were still positive submission. Again, what was nice about the documentation is the provider had said that COVID infection was two months prior. So the fact that they are still having antibodies in their bloodstream, is this an active COVID infection, or is this residual virus. (DESCRIPTION) New slide. Text, Sample query COVID-19. Patient presented with new diagnosis of atrial flutter. Noted to have received COVID-19 infection 2 months prior and COVID-19 test positive on this admit. Please clarify current status of COVID-19: COVID-19 infection not current; positive test due to residual virus. Active COVID-19 infection current on this encounter. Other (please specify). Clinically unable to determine COVID-19 status on this admit. (SPEECH) And so what we have done for you on this next slide is given you an example of how to ask this question. Please clarify the current status of COVID-19. Of course, you'd put all the appropriate clinical indicators, reference, your documentation, et cetera. But your options here, is COVID-19 infection is not current. The positive test is due to residual virus. An active COVID-19 infection current on this encounter, other, unable to determine. And again, the point being, you want to make your query as explicit as you can. You're not introducing. You're not leading the providers, but the more specific you are in your choice, the better that provider understands the question. Because I think most of us would agree that the provider's answer is probably going to be that first choice that is just a positive test to the residual virus. And of course, this is an educational opportunity to the provider saying don't make me query you. Be a little bit clear. You know, and I actually have seen some providers that have noted that where they have made the distinction for us without a query. But when it's not clear, we would want to actually, again, place a query similar to this. (DESCRIPTION) New slide. Text, Current Infection versus residual virus. According to the CDC, people who have recovered from COVID-19 can continue to test positive for up to three months after their infection. Viral shedding can mean either that the patient has an active (current) COVID-19 infection or a personal history of COVID-19. If active COVID-19 infection, assign code U07.1, COVID-19. Viral shedding in a patient with a history of COVID-19 is classified to code Z86.16, Personal history of COVID-19. If documentation is not clear, then query the provider for clarification. (SPEECH) And this goes into that what code assignment will be assigned based off that documentation. You may see documentation in the record about viral shedding, and viral shedding still, once again, could mean that it is an active infection, or it's a past medical history, or the virus is no longer current. So we still sometimes need to get that clarification, and that previous slide was showing a great example of how to word that query to the providers. And that example was actually written by Miss Howard and myself. We actually crafted that one together to think of-- we wanted to make sure that it met both a coding need, but it also was reflective of the clinical condition. And so that's an example of sometimes you need to partner with each other to ensure that we're hitting all the state of objectives of a clarification. (DESCRIPTION) New Slide. Text, Present on admission status. Before: PDx, Cerebral infarction. SDx, COVID-19 (POA N). SDx, Hemiplegia of right dominant side. After: PDx, Cerebral infarction. SDx, Query: COVID-19 (POA Y) The rest of the chart is the same in both the Before and After column. Text, MS-DRG, 064. Relative weight, 1.9189. APR DRG, 045. SOI Subclass, 3. SOI weight, 1.2650. ROM subclass, 3. Explanation: Patient admitted with CVA. First COVID-19 test negative. PN stated, "Reportedly, patient had some COVID + family members who she has been in contact with prior to admission." Discharge delayed until past quarantine period. Recommend clarification of POA status as this does not reflect well on hospital to have hospital acquired COVID-19. (SPEECH) Our last category is present on admission. Again, in the literature has been this discourse, this conversation, regarding patients getting COVID while in the hospital. Did we the hospital give this patient COVID-19? And our data, our coded data, is how they're making research determinations, how they're studying, how they're analyzing to determine whether or not these conditions were present on admission or were hospital acquired. So it is so important to get this right. I can't stress enough how it may reflect bad on our hospital that we didn't protect this patient. There are those times where you've got a roommate who you didn't had some sort of exposure, and it happens. But overall, through our testing and through all of our stringent protocols, this should be a relatively rare occurrence. So on this particular case, this patient came in with a CVA. And of course, on admission as most hospitals do, she was tested for COVID, and her COVID test was negative. A few days, six days after, she's ready to be placed in a SNF facility, and again, as many know, she had to have a negative COVID test yet again right before she had left to ensure that she wasn't going to be transmitting COVID to the nursing home. And unfortunately, that test turned positive. So of course, this patient had to then stay in house in quarantine until she tested negative, so she could be transferred. There was a progress note from the provider that said, reportedly, the patient has some COVID-positive family members who she's been in contact with prior to admission. So of course, my alarm bells popped right up on that sentence. And again, I think the provider was speculating. Was that sufficient enough? No, I do not believe that was sufficient enough to have changed the POA assignment. I think we can also debate, discuss, depending on which variant is out there, what is that incubation time. We know the BA.2, as an example, the Omicron BA.2 has had a much shorter incubation. But the Delta, and this would have been actually more so in the Delta-variant time, did have a little bit of a longer incubation period. So again, to me, it is conceivable that this patient had been exposed to the virus on admission. And again, that first test she had not had enough virus to turn positive. So of course, again, we would have to place the clarification, and what we've done is, again, also given you the guidelines on that POA. But please do know we would not routinely just assign POA. We would need to ask that provider that question. (DESCRIPTION) New Slide. Text, Present on admission status. Present on admission is defined as: Present at the time the order for inpatient admission occurs. POA guidelines state, "The provider should be queried regarding issues related to the linking of signs/symptoms, timing of test results, and the timing of the findings." (SPEECH) And that's basically what these guidelines are saying. So what's on this slide is that the highlights from what I felt like was the most pertinent part of the present on admission guidelines related to this sort of a situation. It's not much. Basically, the definition of present principle-- I'm sorry. The definition of present on admission is just that it's present at the time the order for inpatient admission occurs. So that's not a lot of guidance when it comes to assigning the correct POA indicator in this sort of a situation where the initial test was negative, and then the subsequent test was positive. It makes you think, well, of course, they had to get the infection while they are in house. But because, as Cheryl was saying, the incubation period can vary, and we're not for sure when they were exposed, that it is good to query the provider in this sort of a circumstance, and that's the other part of the guidelines that if you're just not sure based on when did they develop any signs or symptoms. And a lot of times that a patient may be asymptomatic when it comes to COVID-19. So there are no signs or symptoms. So what's the timing of the test results, or the timing of the findings. So if it is unclear, it is appropriate to query the provider to get that information regarding the present on admission indicator. The whole thing about present on admission is did the patient bring it in with them, or is it something that is hospital acquired, and are we sure that the patient really got exposed, and therefore, got the virus after admission to the hospital. So that's kind of really the question that we're really trying to decipher. Was the virus in the body prior to the inpatient admission. And so that's kind of the deciding question that we need to have the provider tell us so that we can assign the most appropriate POA indicator on these cases. So that is the end of our section on inpatient. Again, as Sue had noted, we do have a Q&A portion coming back, and I do see a lot of very nice questions in there, but I'm going to turn it over now to my colleagues from the outpatient side. (DESCRIPTION) New slide. Text, Outpatient COVID-19 challenges. (SPEECH) Thank you, Cheryl. Thank you, Audrey. So now, I want to talk just a little bit about some of the outpatient challenges that we're seeing. (DESCRIPTION) New slide. Text, Reporting Z20.822. Reporting Z20.822 - Contact with and (suspected) exposure to COVID-19. ICD-10-CM/PCS Coding Clinic, First Quarter ICD-10 2021 Pages 38 to 39. For asymptomatic individuals with actual or suspected exposure to COVID-19, assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases, for encounters prior to January 1, 2021, and code Z20.822, Contact with and (suspected) exposure to COVID-19, for encounters after January 1, 2021. For symptomatic individuals with actual or suspected exposure to COVID-19 and the infection has been ruled out, or test results are inconclusive or unknown, assign code Z20.828, Contact with and (suspected) exposure to other viral communicable diseases or code Z20.822, Contact with and (suspected) exposure to COVID-19, depending on the encounter date. Official Coding Guidelines I.C.21.c.1. c. Categories of Z Codes. 1, Contact/Exposure, Category Z20 indicates contact with, and suspected exposure to, communicable diseases. These codes are for patients who are suspected to have been exposed to a disease by close personal contact with an infected individual or are in an area where a disease is epidemic. (SPEECH) One of the things I wanted to mention was the reporting of code Z20.822. And that code is the contact with and suspected exposure to COVID-19. And I think we're seeing people hesitant to use this when the physician doesn't specifically state that there is suspected exposure or actual exposure. But if you look at-- there are two coding clinics. One is here on the slide. The other one is coding clinic second quarter 2020, pages 8 and 9. They refer to this coding guideline for the Z20 contact and exposure code. And it says that categories Z20, which is on the right of your slide here, indicates contact with and suspected exposure to communicable diseases. And it says these codes are for patients who are suspected to have been exposed to a disease by a close personal contact with an infected individual or, and the or part is where we're at, or in an area where disease is epidemic. So during the PHE, the public health emergency, we are in a pandemic. It would be appropriate to report the Z20.822 when a patient has a COVID test that comes up negative, because they are assumed, due to being in an area of an epidemic, that they were exposed. And so we just want to make sure that people are reporting this in those instances. (DESCRIPTION) New slide. Text, Coding signs and symptoms with COVID-19. Per updated FAQs from AHA, August 27, 2021: Response was revised on 8/25/2021 to read, "People infected with COVID-19 may vary from being asymptomatic to having a range of symptoms and severity. Therefore, for coding purposes, signs and symptoms associated with COVID-19 may be coded separately, unless the signs or symptoms are routinely associated with a manifestation." (SPEECH) The next thing I wanted to address for outpatient is coding signs and symptoms with COVID-19, and we have these coding guidelines ingrained in our heads, so we are very hesitant to code symptoms with a confirmed condition. It goes against coding guidelines, but COVID-19 has made a couple of different exceptions to the rules that we've been following, the guidelines that we've been following in the past. So the AHA puts out a list of frequently asked questions regarding reporting codes for COVID-19 conditions. And they revised this list of frequently asked questions on August 27, 2021, and it actually went into effect August 25, 2021, and they revised it to say people infected with COVID-19 can either be asymptomatic or have a range of symptoms and severity. For coding purposes, signs and symptoms that are associated with COVID-19 can be reported separately, unless the sign or symptom is routinely associated with a manifestation of COVID. So if you have a patient that comes in, and they have shortness of breath and a cough, and they test positive for COVID-19, you can report those signs and symptoms even though they are respiratory signs and symptoms with that COVID-19 that use 07.1 diagnoses. Unless in the case where you have a patient who has a cough, and they are diagnosed with pneumonia due to COVID-19. That cough would be integral to the pneumonia, which is the manifestation of COVID, and then you would not be able to report that symptom. And the reason for this is it explains how severe the case of COVID is. So they want to make sure that you're reporting all of the signs and symptoms with the COVID. (DESCRIPTION) New slide. Text, CS Modifier. Application and appropriate use of the CS Modifier. The Families First Coronavirus Response Act waives cost-sharing under Medicare Part B (coinsurance and deductible amounts) for Medicare patients for COVID-19 testing-related services. These services are medical visits for the HCPCS evaluation and management categories described below when an outpatient provider, physician, or other providers and suppliers that bill Medicare for Part B services orders or administers COVID-19 lab test. Cost-sharing does not apply for COVID-19 testing-related services, which are medical visits that: are furnished between March 18, 2020 and the end of the Public Health Emergency (PHE); that result in an order for or administration of a COVID-19 test; are related to furnishing or administering such a test or to the evaluation of an individual for purposes of determining the need for such a test; and are in any of the following categories of HCPCS evaluation and management codes. For services furnished on March 18, 2020, and through the end of the PHE, outpatient providers, physicians, and other providers and suppliers that bill Medicare for Part B services under these payment systems should use the CS modifier on applicable claim lines to identify the service as subject to the cost-sharing waiver for COVID-19 testing-related services and should NOT charge Medicare patients any co-insurance and/or deductible amounts for those services. At the right of the screen is a table labeled CS Modifier Appropriate HCPCS codes for OPPS with a list of codes. G0463, C9803, G0378, G0379, G0380, G0381, G0382, G0383, G0384, 99281 through 99285, 99291, 99304 through 99310, 99315, 99316, 99318, 99324 through 99328, 99334 through 99337, 99340 through 99345, 99347 through 99350, 98970 through 98972, 99421 through 99423. (SPEECH) The next thing that I wanted to talk about as far as an outpatient challenge is the CS modifier. The CS modifier, they had used it prior. I think the Gulf spill, they used this modifier for, but when the Families First Coronavirus Response Act was put into place, which waives cost sharing under Medicare Part B, and cost sharing is the patient's payment of co-insurance and any deductible amount. For COVID-19, the Families First Act waived these payments. So in order to show that these payments needed to be waived, we were instructed to apply the CS modified. While back when this first happened, we didn't have a lot of clear guidance. CMS told us in a report to CS modifier, but they really didn't give us good instructions until August. I think it was August 27th of 2020, they did send a MedLearn Matters article that said this is how you need to use the CS modifier. And they said it shouldn't be reported with COVID lab test codes. It should instead be reported with the evaluation and management service, and then they gave us this list of-- a small list of evaluation and management code that you could attend the CS modifier to. And then in October of 2020, we finally got-- our Mac finally instilled the edits for the CS modifier. So from middle of March until October, before we actually had edit to catch any errors with the CS modifier. We're still seeing hospitals that either are applying the CS modifier to the lab code, or no one's applying the CS modifier. And I think it may be a matter of the front end and the back end doing it, and the back end thinks the front end is doing it. So CMS gives us guidance about if you put the CS modifier on the wrong code, they will return those claims to the provider. So RTT those claims, but they don't address what's going to happen if the modifier is not there at all. So since the modifiers put on the evaluation and management code to keep the patient from having to pay the co-insurance and the deductible amount, think about what's going to happen when those modifiers aren't applied if we have to go back. And just one more note, the CS modifier can be applied to the ENM service in this table on the right any time the ENM service results in either performance of a COVID test or ordering of a COVID test. So if the physician orders the COVID test, even though it's done at maybe an outside laboratory, that physician's office can still put the CS modifier on the ENM service. It's also only for testing for COVID. It's not for treatment of COVID. So I'm going to use the emergency department as an example. It happens to be the codes on this table are the emergency department range, and the patient comes in. They test positive. They've already tested positive for COVID prior, but now, they're really having shortness of breath. So they come to the emergency department. They're not going to test the patient again, then they would not be able to apply the CS modifier to that service in that case. (DESCRIPTION) New Slide titled CPT/HCPCS code changes for COVID vaccines, treatments and administration. A table with a column labeled Vaccine Code and one labeled Administration Code. The vaccine code column is blank for the first five administration codes: 0003A, 0004A, 0013A, and 0034A. Vaccine Code 91305, Administration code, 0051A, 0052A, 0053A, 0054A. Vaccine code 91306, Administration code, 0064A. Vaccine code 91307, Administration code 0071A, 0072A. Vaccine code 91308, Administration code 0081A, 0082A. Text, 2022 CPT Manual Appendix Q lists all COVID-19 vaccine codes that were created and effective prior to 9/22/2021. (SPEECH) So another out-patient challenge. You probably wouldn't be surprised if I told you there are currently 31 COVID-19 CPT/HCPCS vaccine codes, and 24 antibody therapy codes for COVID-19. That doesn't even count all the new CPT codes for the lab testing. So these codes have been coming at us fast and furious since COVID started. They're coming so fast and furious that I actually have a new one that was just approved that is not on this slide. This slide, it is all of the codes that were effective after 9/22, 2021, that did not make it into the 2022 CPT manual. So because it was September, 2022, was the earliest one and after, the manual was already published. They didn't have time to get those codes in. So this is a listing of all the codes that are not in your code manual. I will add the CPT code 91309, and the administration code is 0094A, and that is for a new Moderna booster vaccine. The reason that it has a new code is because the 91306 is the old Moder-- not old. It's the first Moderna booster vaccine. This new code 91308 a different dosage, and in addition to that, it comes in its own packaging. So it's administered-- I guess, the 91306, they were drawing the medication from the same vial that they use for an initial dose of a Moderna vaccine. This 91309 is actually its own packaged vaccination. If you aren't sure or just to keep track of all these vaccine code, new vaccine codes, Appendix Q can be looked up online. If you just search the CMS Appendix-- I'm sorry. AMA Appendix Q, it will give you the table that has all of the codes. It gives you the NBC numbers I think also, but it's a great way to keep track of these. Now, you also want to make sure whoever is doing your chargemaster knows about the new codes. You're educating physicians coders on the new codes as well. (DESCRIPTION) New slide titled COVID-19 Vaccines. The new ICD-10-CM codes for reporting COVID-19 vaccination status effective April 1, 2022, are: Z28.310, Unvaccinated for COVID-19, Z28.311, Partially vaccinated for COVID-19, Z28.39, Other under immunization status The 2022 Official Guidelines for Coding and Reporting are updated at Section I.C.1.g.(1),n to include this guidance: Code Z18.310, Unvaccinated for COVID-19, may be assigned when the patient has not received at least one dose of any COVID-19 vaccine. Code Z28.3111, Partially vaccinated for COVID-19, may be assigned when the patient has received at least one dose of a multi-dose COVID-19 vaccine regimen, but has not received the full set of doses necessary to meet the Centers for Disease Control and Prevention (CDC) definition of “fully vaccinated” in place at the time of the encounter. Code Z28.39, Other under immunization status would be reported for non-COVID vaccinations. CDC Definition of “fully vaccinated”: Fully vaccinated means a person has received all recommended doses in their primary series of COVID-19 vaccine. Up to date means a person has received all recommended doses in their primary series COVID-19 vaccine, and a booster dose when eligible. People who are moderately or severely immunocompromised have specific COVID-19 vaccine recommendations for the primary series and booster dose due to their different immune response following COVID-19 vaccination. (SPEECH) And then as far as new codes go, I wanted to talk a little bit about the new COVID-19 vaccine code. As we stated, they will go into effect the day after tomorrow, and there are three new ICD-1-CM diagnosis codes. The first one is Z28.310, and it's unvaccinated for COVID-19. It would be assigned when the patient's not received at least one dose of any COVID vaccine. So that's pretty clear cut when we would use that. The next code, Z28.311, that's for partially vaccinated for COVID-19. And this would be a sign when the patient's received at least one dose of a multi-dose COVID-19 vaccine regimen but has not received the full set of doses necessary to meet the CDC's definition of fully vaccinated. That is in place at the time of the encounter, and that is a key part of that sentence. On the right hand side of the slide, I do have CDC's definition, and this may change now that FDA has approved new doses, but this was, at the time, the definition of fully vaccinated, and it means a person who's received all recommended doses in their primary series of a COVID-19 vaccine. Up to date it's also a definition that CDC has on their site, but up to date doesn't affect our assignment of the status codes for COVID vaccines in any way. Up to date, this includes all the booster shots. The booster shots aren't included at this time in the fully-vaccinated definition. The fully-vaccinated definition also changes for patients who are moderately or severely immunocompromised. So there's a different vaccine recommendation for those primary series and also the booster doses due to that immune response. So think about that and what kind of documentation do we need to see in order to assign these codes appropriately. So hopefully, our physicians can document fully vaccinated or partially vaccinated. In some cases, that may even change from one visit to the next depending on if you're immunocompromised patient. We just got an additional dose approved for those immunocompromised patients. Now, last week, they may have been fully vaccinated. Now, this week, they may be partially vaccinated. It's just going to depend on the CDC's definition at that time. That third code, Z28.39 is the code for other under immunization status, and that code isn't going to be reported for COVID-19 at all. It would be reported for any other measles, mumps, those chickenpox, those types of vaccinations when patients are under immunized. And so, again, these code are not going to be in our current ICD-1-CM manual. So it's important that your providers are aware of the new codes, and what supports those codes as well as your coders. I think that's everything for this slide. (DESCRIPTION) New slide. Text, Monoclonal antibodies for pre-exposure prophylaxis of COVID-19. CMS created new code, Q0221, effective February 24: Long Descriptor: Injection, tixagevimab and cilgavimab (EVUSHELD™), for the pre-exposure prophylaxis only, for certain adults and pediatric individuals (12 years of age and older weighing at least 40kg) with no known sars-cov-2 exposure, who either have moderate to severely compromised immune systems or for whom vaccination with any available covid-19 vaccine is not recommended due to a history of severe adverse reaction to a covid-19 vaccine(s) and/or covid-19 vaccine component(s), 600 mg. Use the existing administration codes — M0220 and M0221. The FDA authorized the use of this monoclonal antibody combination for the pre-exposure prophylaxis of COVID-19 in adults and pediatric patients (12 years and older weighing at least 40 kg) under these conditions: They aren’t currently infected with SARS-CoV-2. They haven’t had a known recent exposure to an individual infected with SARS-CoV-2. One of the following apply: They may not mount an adequate immune response to the COVID-19 vaccine because their immune system is moderately or severely compromised due to a medical condition or because they got immunosuppressive medications or treatments. They aren’t recommended to get vaccinated with any available COVID-19 vaccine, according to the approved or authorized schedule, due to a history of severe adverse reaction (for example, severe allergic reaction) to a COVID-19 vaccine. (SPEECH) And then lastly, we have a new code, which was effective February, 24. It's for a prophylaxis for monoclonal-- I'm sorry. For COVID, it's a monoclonal antibody, and it's to be used for pre-exposure. So it's the first emergency-use authorization approval for a prophylaxis for COVID. It was first approved back on December 8 of 2021. But the FDA just recently approved a different dosage, and at that time, CMS created the new code Q0221. This is actually called the brand name currently is Evushield. It's administered as two separate consecutive intramuscular injections. There's one injection per each type of monoclonal antibody, and I'm not going to talk to you by trying to pronounce those two antibodies, but they are given in immediate succession. It's to be effective for pre-exposure prevention for six months. It's not authorized for individuals for the treatment of COVID-19 or for post-exposure prevention of COVID-19. So my question here would be, how do you define pre-exposure since you don't know if you had it, but this code is also not in the HCPCS 2022 manual. So we want to make sure that we're making our coders and our providers aware that these codes are available. And at this time, I'm going to turn this table over to Colleen Deighan. (DESCRIPTION) New slide. Text, Public Health Emergency (PHE) (SPEECH) Good afternoon, everyone. This is Colleen. I'm just dialing in via the phone. I apologize for not being on the internet today. Sue, if you could advance the slides for me, I'd appreciate it. And now you have Colleen. (DESCRIPTION) New slide. Text, Public Health Emergency. First issued 1/31/2020, effective 1/27/2020. Duration of the emergency or 90 days. Renewed eight times. Last renewed January 14, 2022. Effective 1/16/2022, expires April 16, 2022. Will HHS extend? CMS 1135 Waivers as a result of PHE: Flexibility for Medicare Telehealth Services, Emergency Medical Treatment & Labor Act (EMTALA) enforcement, Verbal orders, Reporting requirements, Patient rights, Physical environment, Nursing services. Public Health Emergency declaration: The Secretary of the Department of Health and Human Services (HHS) may, under section 319 of the Public Health Service (PHS) Act, determine that: A, a disease or disorder presents a public health emergency (PHE); B, or that a public health emergency, including significant outbreaks of infectious disease or bioterrorist attacks, otherwise exists. Duration and Notification: The declaration lasts for the duration of the emergency or 90 days. (SPEECH) Thank you. Sorry, so I can't also see the slides, so I apologize. So I wanted to talk a little bit about just the public-health emergency, reminding us of this process. So this is what we refer to as the PHE. It was a declaration and is a declaration by the Secretary of the Department of Health and Human Services. And when a PHE is declared, there's an opioid crisis declaration right now as well, and as Bobbie mentioned, sometimes there's local declarations around the Gulf oil spill as one example when she talked about the CS modifier. So this public-health emergency that HHS declared when a disease or disorder presents a public-health emergency, or a public-health emergency, including significant outbreaks of infectious disease, bio-terrorist attacks, et cetera, that declaration can be made. And it's made for a duration of the emergency or 90 days. So if you recall, just on the slide here, this was first issued back in January of 2020, and it was effective 1/27 2020. And this, again, the duration of these is the duration of the emergency or for 90 days. So this is a 90-day declaration that was renewed so far up to eight times. Last renewed on January 14, which made it effective January 16th of this year, and it expires in mid-April in a few weeks here on April 16. So the question there-- I've brought a lot of information-- yes or no? So will the Department of Health and Human Services, the Secretary, extend this again. If it does get extended, it will be for an additional 90 days and expire on July, 16. So I've read that there's likely an extension that will happen, but I've also read that this will be the last extension. So I point that out to just to really be aware of that, and then what are we going to hear in the next couple of weeks about the extension of the PHE for an additional 90 days. And I also wanted to remind everyone that as part of that declaration, CMS created some flexibilities. So 1135 waivers that CMS declared as a result of the public-health emergency. There were many in there. I've highlighted a few of them here. So expansion, what they refer to as flexibility of telehealth services. There's also relaxation of the EMTALA enforcement in the emergency department, relaxation of verbal orders, reporting requirements related to different breakout events. How we notify patient rights, waivers and flexibility around that. Even the physical environment, which was, again, when they created different ways that patients could receive care without being in the hospital. So the physical walls of the hospital, the flexibility related to that. And the nursing services is just one other example around the requirement for care plans for all patients. So all of those flexibilities and many other ones are part of this declaration that's PHE, and they're set to expire whenever HHS declares the public-health emergency-- I guess, we could use the term over. So I think with relation to this, I wanted to talk primarily about telemedicine. I think that was-- if there's anything that I would say as a silver lining, I've used this term before, I think telemedicine is-- could be considered a silver lining of COVID-19. There are many, many people for many years behind the scenes that have been trying to advance telehealth or telemedicine services. There are many things in the way of that that will relax as part of this waiver 1135. So telemedicine in just a brief definition is the delivering of care at a distance. So using technology to deliver care at a distance, and CMS and its prior to the public-health emergency only allowed telehealth services to be covered for their Medicare beneficiaries. If the patient lived in a rural area, or a particular service was not available to that patient. The patient did have to travel to a local medical facility and then receive those services from a medical doctor at a remote location. So very narrow window, and I wanted to share that CMS wanted to expand. It was a very important expansion in the PHE. Remember, it was around access, making sure their beneficiaries had access to care. They wanted to keep their beneficiaries safe at home, avoid travel, contain the spread of COVID-19. And this was and still remains in its PHE status, regardless of the patient's diagnosis. So this isn't just for treating COVID. It's for treating any patient condition during the public-health emergency. And statistically, I found some statistics on the HHS, the Department of Health and Human Services website that said in 2019, there were approximately 840,000 claims for telehealth services. And then in 2020, the year 2020, during that main year of that first year of the PHE, there were 52 million claims. So we went from 840,000 claims to over 52 million, and this is just the Medicare population that's in the traditional Medicare services. So that was a 63-fold increase reported by HHS, and they also reported that 92% of those patients received telehealth services in their home. We saw telehealth being delivered in physician setting in the hospital. There were many different areas, at 92% in the patient's home. So the question that I have that I think is important to think about is what's going to happen. So telehealth really, the expansion of this was successful. There were many things that were wavered as part of this regarding licensure as one example. The state licensure requirements for physicians, the relaxation of those requirements, the payment of them. Many of our commercial carriers went online. So with these changes that CMS really encouraged to have happen during the pandemic. So you as we think about the public-health emergencies and the end of this declaration, what's going to happen to telemedicine. And I think that there's still today many behind the scenes working on post the PHE. The American Medical Association, Congress, physician bodies have been working, I say, to define the new normal. And I also wanted to say is part of this, one of the key things that happened last week was the-- excuse me, sorry. That as part of the Consolidated Appropriations Act of 2022, that omnibus funding bill that President Biden signed into law last week, there were some telehealth flexibility extensions for the Medicare program as part of that omnibus funding bill. And the key thing that it did was it allowed the continuation of a broad range of telehealth services for 151 days beginning on the first day after the end of the PHE period. So whenever the PHE period ends and is declared by HHS as ending, that then begins the 151 days that this omnibus funding bill is creating the extension of those telehealth flexibility. So Medicare wants to continue to provide those services post the pandemic, and what does that look like. So there isn't a gap. There has to be a clear transition here. So this is the initial steps of that transition. So again, keeping in place any sites, including the patients home, is eligible for delivering of telehealth. The other key thing is telehealth initially pre the pandemic was for services by professional services. What we refer to as physician services, and it did not include occupational therapists, physical therapists, speech, language, audiologist that provide key care in patients home. So the extension of those eligible practitioners will be included as well in this. So I think those are the things that I think about. I guess I have more questions than I have answers, but I really wanted to bring this to everyone's attention because telehealth is really-- what's going to happen to telehealth post the pandemic. And I think what we really see is that telehealth works, and it meets the patients literally where they are. It does exactly that. So I wanted to keep those dates in your mind for your providers of services and making sure that telehealth gets to continue post the pandemic in its current fashion, almost the whole degree that it's available during the public-health health emergency. And with that, Sue, I will turn it back over to you. OK, and I'm going to turn this to Cheryl, who's going to wrap up with our last mini topic, I'll say. (DESCRIPTION) New slide. Text, COVID-19 and quality metrics (SPEECH) Thank you, Sue. So I did see a question about post-op sepsis, and COVID was not listed as an exclusion, because HRQ uses their data for, specifically, it would have been time periods 2017 and 2018. COVID was not a diagnosis. So COVID cannot be an exclusion in an HRQ world. Now, in terms of CMS, CMS per the final rule last year, so we're almost up to the proposed rule this year. But final rule last year, CMS indicated they would remove COVID-19 claims. Any patient who had it listed as principal or secondary, any U071 on a code, those claims would be removed from any of the quality reporting programs meaning the half reduction program, value-based purchasing, and the hospital re-admissions reduction program. So CMS has already done their best and did some specific exclusions also during this time period, during our public-health emergency. The provider's profiling system. The merit-based incentive payment system did allow physicians to apply. So you notice the key there. The physicians had to apply for an emergency exemption, an extraordinary use exemption, meaning that they could not participate in their quality-improvement activities because they were working under the pandemic. That was extended from the first year into the second year, and CMS did indicate that by tomorrow, the providers can also request an exemption for 2022 for that Emergency Hardship. Now, what's going to happen next year? How HRQ is or isn't going to include COVID or CMS? As Colleen said, I'm waiting with bated breath. I would not hang my hat on what the proposed rule says. Many times, they do change their mind before the final rule comes out. I think sometimes it's a good indicator, but many times, they propose some radical changes that don't fall through. So we really won't know until August what CMS is going to do. And as for HRQ, they typically have been releasing late July, early August. So we won't know until then how HRQ is going to address it. And again, the challenge for HRQ is it would need to be in both the baseline, and it would have to be in the current period for them to determine how much it's affecting the complications, although we clinically understand that it probably is having an increase in the number of complications those patients with COVID that they're not going to make any decisions until they have both. So this is a big question mark that we didn't want to not address what's happening to quality. I think CMS has done a decent job, to be honest with you, in how they've handled it this year, and I'll be curious to see how they do it for the upcoming years. And with that, Sue, I'm going to turn it back to you. (DESCRIPTION) New slide. Text, Q&A. (SPEECH) OK, well, thank you, everyone. This was, I think, a great smorgasbord of COVID information. So we hit it from many different angles. So Lisa, I think you've been monitoring the questions that are coming in on the chat. So do you want to throw some of them out to our group here and try to address them? Thank you. Yeah, absolutely, there's a ton, so I'm going to try to get to a couple of them. We will have to follow up after with any questions that we don't get to. Just a quick reminder, the resources section does now have the slides. So if you don't see them, do a quick refresh of your browser, and they will populate at that point. There have been a couple questions on CEUs. We do not provide CEUs. That's what the certificate of attendance is for. So if you do download that certificate, you can always submit that to an accredited association to obtain CEUs. This is recorded. We will add it to our website in the next couple of weeks, as well as the handout as well. So if you still aren't able to get the handouts, then it will be available on our website soon. OK, so with that, let's get to some questions. I hope I don't hit any repetitive ones. So I'm just going to kind of start down at the beginning and work my way up to get to as many as we can. So what code would you assign if the provider answers unable to determine. This was on slide 13, whether the COVID was current versus-- oh, I'm going to butcher this-- Sequela. I think that's right. So Audrey, tag. I saw that question come through. I mean, that is always the option that the provider can answer unable to determine. It is highly possible. As we are learning more and more, is the virus current or not. I mean, you have to take it based on the documentation that's available on the record and stop and consider, well, how long ago was the initial diagnosis? Was it last week? Was it last month? What's the corresponding treatment towards the COVID-19 to help maybe decipher that as well. I mean, obviously, a code has to be assigned, and you're going to be taking it based on the documentation. Cheryl, I'm kind of floundering, because I'm not quite sure where to go when the provider can't answer. Do we escalate it? Do we have another peer review look at it? I think if, ultimately, they cannot tell you if it's current or sequelae, I think we just have to code the history of COVID, because we can only code confirmed conditions. And if they can't confirm it to me, I would just be doing history of COVID, because I don't know how else I would assign it. That might also be a very good example to submit to coding clinic, that specific example, and how a situation like that should be handled. And Linda did make a note, and I think Linda was responding during this time. She said, you would need to say clinically UTD. Linda Gavellin, does that ring a bell of anything with that? Well, clinically unable to determine is what she is saying with that. Yeah, I just think, as Audrey said and Sue said, I do think it's appropriate to-- I'd love to see coding clinic answer this one, because heaven forbid, and many times Audrey and I have given advice, and then coding clinic comes out and says the opposite. And we kind of smile and go, we're giving it our best guess, but I do agree that having a physician advise on these difficult ones because the data integrity is so important. I think it might be important to go through an escalation process and have those providers have their conference and say, what is your best guess Dr. Jones? What are we going to put on this record? What do you believe is the clinical truth? And usually, from what I have seen, when those difficult conversations do occur, they do give us some sort of definitive answer. But I can appreciate the fact that this is kind of a wild one. Absolutely, and so because we are so close on time, I am going to pause, because there are a lot of questions left. And so after the webinar, I will collect all of the questions and get them over to our panel to reach out, and it might be worthwhile, and this is something we'll discuss too, do we combine it and put it into a document to send, because there's just so much. So (DESCRIPTION) New slide. Text, That's a wrap! (SPEECH) as you can see, and as you heard today, there is so much information that this team knows, and it's just so impressive to hear all of you talk and just the knowledge that you provide is just wow. (DESCRIPTION) New slide titled 3M Education boot camps. Text, 3M experts offer a variety of education boot camps to keep you informed and meet the growing need for more specialized trainings in the clinical documentation integrity (CDI) space. Our educators include clinicians, documentation specialists, and coding experts with decades of industry and education experience, they will deliver the insights you need to make an impact on your CDI programs. Virtual Advanced CDI training: The Advanced CDI training week offers comprehensive CDI education addressing fundamental CDI skills and the clinical and coding concepts behind key major diagnostic categories (MDCs). This training week is a crucial starting point for any inpatient CDI or coding professional before moving to other more advanced topics. Upcoming Advanced CDI training week: November 1 through 5. Virtual Advanced quality training: Discover how CDI, coding and quality efforts can impact the quality of care across various value-based purchasing initiatives. The quality training is a great follow up to the Advanced CDI training and is great for seasoned professionals and multidisciplinary CDI teams looking to take their programs to the next level. Upcoming Advanced quality training weeks: November 15-19. Dates are subject to change. Learn more at go.3m.com/cdibootcamps. (SPEECH) And so with that, in the resources section, again, if you are not able to download the presentation slides, if you did not refresh your browser, the slides will be available in the next couple of weeks on our website. And usually, during the promotion of our next webinar, which you can actually register for. We already have that one, part one in the series that Cheryl is going to be presenting on. Cheryl, do you actually want to talk about that one, kind of give them a quick preview, because that registration is in the resources section. Not necessarily. Sorry, I wasn't prepared for that question. No, that's OK. Don't worry about it. No, that's OK. I can comment. I am so sorry. I am looking forward to it, and I think similar to today, we'll probably have a lot of questions and probably need to tabulate those and get you all some feedback on them, but I do look forward to meeting with you all next month. Yeah, the registration is there. It's up, and so if you are interested in registering for the next one, you can do that. You also can see that there are educational boot camps that we have coming up. So a lot more of this information is available to you. You can get to those resources. The links are in that section as well, as well as that certificate of attendance. And so if you have any questions, like I said, in those engagement tools, there's a little envelope there if you do want to send us a direct question, that does come to me directly. And I'll try to get your questions answered if there is any follow up. And so with that, again, this panel is just incredible to hear. We've had a lot of great presentations. Thank you for the information. So we do appreciate your feedback as well in that survey. So if you could complete that as well, that also helps us to provide good webinars. And so with that, again, thank you for joining us today, and don't forget too, we do have our CDI innovation webinar coming up in April. You can register for that on our website as well. So thank you all again, and we look forward to hosting you next time. Thank you.

(DESCRIPTION) Presentation. 3M Quality Webinar Series, O.P.P.S. and C.P.T., What you need to know in 2022. January 26 2022, Colleen Deighan, R.H.I.A. C.C.S. C.C.D.S. O. (SPEECH) Hello and good afternoon, and welcome to our first quality webinar of 2022. My name is Lisa Paulenich, and I will be here as your host. If you were with us last year, you may have noticed that we are using a new webinar platform. We are excited for the new enhanced user experience. So, before we kick things off, I wanted to go over some of the new features and layout. Because this is a web-based platform, there is not a dial in number to participate by phone. If you are having audio issues, please check your speaker settings, clear your cache, and refresh your browser. If you have joined from your computer, you can move and minimize the different sections in the portal. Also, if you're needing closed captioning, you can turn it on in the Live Stream section. As always, we encourage you to answer-- oh, I'm sorry, ask questions throughout the webinar. We have a lot to get through today, so we will get to as many as we can at the end. Those we don't get to, we will follow up with after, and you can add those questions to the Q&A box. We will provide a Certificate of Attendance to you that you can submit to obtain credits. This can be found in resources section as well for download, as well as the handout for this presentation. There are engagement tools at the bottom of your screen. If you have questions about the webinar, please contact us using the Contact Us feature. If you would like to learn more about our products and solutions, click on the Learn More button and complete the form. Again, the handout is in the Resources section if you would like to follow along there. As always, we appreciate your feedback. You can complete the survey in the portal or you can complete the survey when it launches at the end of the webinar. So enough about all of the housekeeping. Like I said, we have a lot to get through today. And so my first question to all of you is, can you list all of the 329 code updates for 2022? And so today, we're going to welcome Colleen Deighan, one of our favorite consultants to discuss the OPPS and CPT updates to kick off 2022. So we welcome you, Colleen. (DESCRIPTION) Slide, Meet our speaker. Colleen Deighan, R.H.I.A., CCS, CCDS-O, Outpatient consultant. Colleen is a consultant with 3M Health Information Systems where she provides advisory services on outpatient CDI, clinical coding, and revenue cycle management to 3M clients. She has more than 25 years of technical and managerial experience in medical coding, clinical documentation integrity, compliance and revenue cycle management. (SPEECH) Good afternoon, everyone, and thanks for joining in. (DESCRIPTION) Slide, Learning Objectives. (SPEECH) Today, as Lisa mentioned, we're talking about everything Outpatient Prospective Payment System in CPT. We actually have 405 changes. I think I might have given Lisa a mistake there. But, as we get underway here, a couple of learning objectives, of course. We hope you'll have an increased understanding of CMS's policy for calendar year 2022 related to the Outpatient Prospective Payment System and Ambulatory Surgery Center, payment system final rule, really focusing, of course, on what impacts coding and quality reporting. Also, I want to address, not all, but highlight some of the key changes to the over 400 CPT changes for this year. Particularly, spend some time in the surgery section of CPT. And we have some revisions, not as significant as last year, but I still consider them significant related to E/M services. (DESCRIPTION) Slide. (SPEECH) So just a quick overview. I know there's a variety of titles and job responsibilities dialing in today. So when we talk about the Outpatient Prospective Payment System, you might hear me refer to it throughout this as OPPS and ASC payment system. Of course, outpatient care is becoming increasingly important. Medicare beneficiaries receive a wide range of services in the hospital outpatient departments, something as simple as an injection to complex procedures requiring anesthesia. So in the outpatient setting, Medicare originally based payments for outpatient care on hospital costs. But CMS began using the outpatient prospective payment system in August of 2000. So it's been a while, a long while, and I am happy to say, or are willing to admit, I've been here for the whole journey. The OPPS sets payments for individual services using a relative weights, a conversion factor, and has typical adjustments for geographic differences. Hospitals can receive additional payments in the form of outlier payments for extraordinarily high-cost services and pass-through payments for some new technologies. Within OPPS is the inventory payment classification, also known as the APC classification, and services that are classified into APCs based on clinical and cost similarity. In recent years, CMS has revised some payment policies adding the Advent of Comprehensive APCs that do further packaging in an expanded number of services. I always point out the Outpatient Prospective Payment System uses the calendar year, or the CY, along with American Medical Association who updates the CPT book. So the changes to both CPT and OPPS are effective each year on January 1. I say this in contrast to the Inpatient Perspective Payment System and ICD-10, which uses the federal government's fiscal year, or FY, of October 1 annually. And in the next few slides, I'm going to be addressing two items of the OPPS, the changes to the Inpatient Only List, also known as the IPO list, and the updates to the quality measures adopted into the final rule. (DESCRIPTION) Slide, Inpatient only I.P.O. list. Bullet points. (SPEECH) Let's start with the Inpatient Only List. This was a-- Medicare created this list over 20 years ago, and it designates surgeries that require inpatient care. And are then not payable in the outpatient setting. And certainly this designation affects how hospitals are paid as well as the patient's financial responsibility because outpatient is covered under Part B at 80% versus Part A where hospital inpatient payment is made at 100%. So I want to compare last year to this year. So last year for calendar year 2021, CMS's final rule they finalized the decision to eliminate the Inpatient Only List starting with January 1 and as part of their efforts really around increasing patient choice around surgery. The Inpatient Only List is a series of over 1,700 procedures for, again, which Medicare will only pay when performed in the hospital inpatient setting. But CMS, at that time, raised some concerns around the list. They felt it restricted patient choice when it comes to where they would have their surgery. So, as you can see here, I see a typo here, and so I apologize, for calendar year 2021, again, they made the decision in the final rule last year to eliminate, and that would take over the course of three years starting with last year, completely eliminate the Inpatient Only List. But one of the challenges, or concerns, that were addressed was they had a long standing criteria. CMS did and how they made the determination of removing something off the Inpatient Only List and they did not use that last year. Last year they took almost 300 codes off the Inpatient Only List. The majority of them are musculoskeletal related, again, to increase patient choice, encourage site neutrality. And there was a lot of concern about that, not only in the medical community, but also in the medical device industry. Overwhelmingly, really backed reversal of that decision in 2021. And CMS did say in the proposed rule that they, and I'm quoting, say "The unprecedented removal of 298 codes from the Inpatient Only List transpired too quickly." And they also said the procedures addressed were not addressed using their long standing criteria. So CMS stated, while they understand that physicians should help determine if a procedure location is safe for their patients, CMS can make that overarching decision on the broader Medicare population. So, for calendar year 2022, CMS has halted the elimination of the Inpatient Only List. They've added back almost all of those 300 or 298 codes, with the exception of five of them. And, in addition to that, they stated they will reinstate their long standing criteria in determining what should be removed off the Inpatient Only List. and just another point to note that when a procedure as part of this decision is removed off the Inpatient Only List for two calendar years, it is exempt from site of service and noncompliance two-midnight rule retrospective audits. (DESCRIPTION) Slide, Inpatient only list. Table. (SPEECH) So let's take a look quickly at the five codes that remain off the Inpatient Only List for 2022. You see Arthrodesis, but note it's a single interface in the lumbar area. You see the J1 status to those, which is that new, somewhat new. It's been around for a number of years, but that comprehensive APC status indicator is J1. And then some arthroplasty total shoulder, arthroplasty ankle, and a few other open procedures. So all essentially musculoskeletal procedures, five of them related to-- we'll see, again, what happens in the future. But the elimination of the Inpatient Only List is off the table. (DESCRIPTION) Slide, Criteria for assessing procedures for removal for the I.P.O. list. (SPEECH) Just quickly the criteria that I mentioned. So this long standing criteria that is utilized, there's five items that are considered as part of the criteria. You don't have to meet all five of them to be removed from the Inpatient Only List. List. But, in consideration, can this procedure-- can most outpatient departments, are they equipped to actually provide this service to the Medicare population? Is the simplest procedure described by the code first in most outpatient departments? Number three, is the procedure related to codes that have already been removed from the IPO list? And is determination made that the procedure is already being furnished in numerous hospitals on an outpatient basis? And finally the determination is made that the procedure can be appropriately and safely furnished in an inventory surgery center, and that it's on the approved list of ASC services or has been proposed by CMS as addition into the AFC list. So those are the five long standing criteria that are used. And again, don't have to meet all of that criteria, but reinstating this criteria as part of the decision making process. (DESCRIPTION) Slide, How familiar are you with C.M.S's Hospital outpatient quality reporting O.Q.R. program? (SPEECH) So that brings us to our first poll question. And we're going to talk in a few moments here about the hospital outpatient quality reporting program so I'd like to ask you how familiar are you with the hospital outpatient quality reporting program? So you have five options there, extremely familiar, very familiar, moderately familiar, slightly familiar, or not familiar at all. I'm going to pause here for a few seconds while you answer that question. And I'd like to ask this question. I'm, personally, have been in the HIM field for over 25 years. Most of that career, I really was in the hospital outpatient prospective setting for almost all of those years. And I've historically paid very close attention to the CPT changes, the changes to OPPS as part of my daily job function, either as a coder or a coding analyst, a coding leader. And I have to admit, I really didn't pay that much attention and didn't have a lot of insight into these hospital outpatient quality reporting programs. So I've spent a lot of time over the last three years really learning about this program and how these different measures are reported and how the data is used by CMS. I'm going to pause there just for a few more seconds and allow our listeners to answer the poll question. And, Colleen, while we're finishing up on that poll, there have been some questions about the Certificate of Attendance. I believe it should be updated now within the Resources section. Initially, it looked like it was the presentation slides for today. But it should be the right-- it should be the right certificate now. So I just wanted to pause real quick to let people know that as well. (DESCRIPTION) Slide, Results. Slightly familiar 46.6%, not at all familiar 28.8%, moderately familiar 20.5%, very familiar 2.6%, extremely familiar 1.5%. (SPEECH) And I'm going-- we've got about half our listeners have answered the poll question. Actually, well over half of our listeners. So let's take a look at the answers. And, again, not surprised because I think I was right there with all of you, there's some slight familiarity with about half the listeners today. Some moderate familiarity, about 20%, 28%, 29% not familiar at all. So I'm encouraged and discouraged to hear that at the same time. But I think, again, not surprising at all, and just have a few items of interest here in this program. (DESCRIPTION) Slide, Outpatient quality reporting O.Q.R. program. (SPEECH) So the hospital Outpatient Quality Reporting Program, it's actually been over 10 years that CMS mandated this. And it's a Pay for Quality reporting program implemented, again, by CMS for Hospital Outpatient Services. The hospital OQR program was mandated by the tax relief and Healthcare Act of 2006. And it was, again, it became effective for payments beginning in calendar year 2009. Within this program, hospitals are required to report a subset of data on measures that affect quality of care furnished in hospital outpatient settings. Those measures of quality can be of various types, including those of process, structure, outcome, and efficiency. Under the hospital OQR program, hospitals must meet administrative, data collection, submission, validation, and publication requirements, or be subject to a 2% reduction in payment for failing to meet these requirements. And that's by applying a reporting factor of 0.098 to the Outpatient Prospective Payment System and co-payments for all applicable services. Of note, in addition to providing hospitals, of course, with a financial incentive to report their quality of measures, the hospital OQR Program does provide CMS with data to help Medicare beneficiaries make more informed decisions about their healthcare. Hospital quality of care, information gathered through the hospital OQR program is available on the Hospital Compare website, same place you would see inpatient data. (DESCRIPTION) Slide, New information. (SPEECH) So just quickly, the Quality Reporting Program, again, it focuses on reporting measures that have high impact and also, at, the same time support national priorities around improved quality and efficiency for Medicare beneficiaries. The current measure set includes measures that assess processes in care, imaging efficiency patterns, transition of care, emergency department throughput, the use of HIT, care coordination, and patient safety and volume. (DESCRIPTION) Slide, O.Q.R. Program Measures for C.Y. 2022. (SPEECH) This is a snapshot a slide that shows the current outpatient quality measures for calendar year 2022. I do have an asterisk that I wanted to point out against OP measure 31 because that does have some change this year. So cataracts are currently voluntary collected information. So that measure measures the improvement in patient's visual functions within 90 days following cataract surgery. And the last two on the list, their OP measured 35 and 36. Those were actually added last year, and it kind of was in conjunction with definitely the OP 36 that the Inpatient Only List removal of items off the-- or services off the list. So admissions and emergency department visits for patients receiving outpatient chemotherapy. So measuring what percentage of patients that have chemotherapy in the outpatient ultimately within 30 days need to present to the emergency department or have a hospital inpatient admission, and same thing with hospital outpatient surgery, having surgery in the outpatient setting and needing additional care related to those surgeries. (DESCRIPTION) Slide, O.Q.R. Program O.P.P.S. slash A.S.C. Final rule. (SPEECH) So a couple of changes for this year, there's actually pretty significant changes, what we see is as finalized, again, as part of the OPPS and ASC final rule three new measures. The first one is COVID-19 vaccination among healthcare professionals. It's OP measure 38. Certainly given the time sensitive nature of this measure, considering the current public health emergency, CMS proposed that hospitals would be required to begin reporting data on their COVID-19 Healthcare Personnel Vaccination Measure. So this is beginning January 1. So here we are almost at the end of this month, believe it or not, but this began on January 1. It affects payment beginning in calendar year 2024, but reporting this year. And in this measure, hospitals are collecting the numerator and denominator of their vaccination employees. It's in one self-selected week during each month of the reporting quarter. And they submit that data through the National Health care Safety Network Personal Safety Components. They have to do that before the quarterly deadline. So it's a basic numerator-denominator in a given week. At least one, I would call it, a shift, one shift, during that week. What's the total population of employees and what population percentage has been vaccinated? Interesting, of course, in relation to other things around vaccination, but thought that was very interesting. The second measure is the breast screening recall rates. It's the measure 39 beginning on January 1 and for payment determination in 2023. This is what we call a Claims-based measure. It's measured to document breast screening recall rates at the facility level. It calculates the percentage of Medicare fee for service beneficiaries who had traditional mammography or digital breast tomosynthesis screening study that was performed and then followed by a diagnostic mammography, a diagnostic BPT, an ultrasound of the breast or an MRI study of the progress of the breast performed in the outpatient setting or the office setting either on that same day or within 45 days or those initial images. It's really looking for a good recall rate. Medicare states have facilities with performance rates that are less than 12%, but greater than 5%, are likely recalling the appropriate number of Medicare beneficiaries for breast cancer screening. And the third measure there, the ST Segment Elevation Myocardial Infarction, this is the part of the Clinical Quality Measure are the eCQM. It's measure 40. And it's measuring the percentage of emergency department patients with a diagnosis of a STEMI who received-- and making sure-- checking for, obviously, appropriate treatment. And that's defined as having received tribalistic therapy within 30 minutes of arrival to the emergency department, having PCI, or percutaneous coronary intervention, within 90 minutes of arrival to the emergency department, or a transfer within 45 minutes of arrival to the emergency department. And that measure is intended for use at the facility level in what CMS refers to as their Accountability Program. Although it will also be publicly reported. And this begins with voluntary reporting in 2023 and mandatory reporting in 2024. And with that third new measure, the measure 40, the removal of two measures that are currently in place, which is the OP 2 measure, which is the fibrinolytic line therapy within 30 minutes. And then also that transfer time, OP 3, for cute coronary intervention. Those two measures will no longer be needed beginning in the calendar year 2023 with this new measure, OP 40. And as I mentioned earlier, they made mandatory the reporting of the cataract measure OP 31, which, in prior years, has been voluntary. And they continue to update the validation policies for the OQR program. There is some provider burden improve processes. There's different ways this information makes its way to Medicare. So trying to continue to refine that process as well. (DESCRIPTION) Slide, 2022 C.P.T. Updates. (SPEECH) So we're going to move into the CPT changes for 2022. There have been over 400 code updates. And, for today's session, I want to focus on some of those key changes. I certainly can't address all of them. Time does not allow for us to do that in this hour. I'm sure many of you are aware, the American Medical Association, the authors of the CPT book, do hold an annual CPT symposium in November. It's actually over three days. There are some Medicare administrative contractor, or CMS, medical directors that also attend and provide discussion related to application of these codes within the physician fee schedule and the Outpatient Prospective Payment System. There's also a great resource that the AMA publishes. It's called the CPT Changes book. It's updated annually. It's a terrific resource. And if you're interested in all the updates, that's a great source to study and learn about all the changes. And as I mentioned, there's actually over 400 changes this year. (DESCRIPTION) Slide, Who has joined us today? (SPEECH) So before we go onto the next portion of this webinar, I do have my second poll question I'd like to ask you just to get a sense of who's in the audience with us here today. So if you could let us know, are you a CDI specialist on the inpatient side, a CDI specialist in the outpatient or ambulatory side, or do you work in quality improvement, a quality analyst or a quality coordinator? Are you a coding professional, or is your title in another realm? So I'm going to stop there for a few minutes, or a few seconds actually, and give you an opportunity to answer some of those-- that poll question for me. Again, I think 3M has been providing these types of quality webinars for many years. And we've seen the evolution of CDI from DRG, certainly to MSCRGs to value-based payment models, APR, DRGs, quality reporting, those different components of inpatient CDI, but we've also seen the evolution to the outpatient or ambulatory setting and more and more coding professionals certainly working together with CVI and listening in to those webinars. So whether it's gaining more insight into coding and reporting or applying the changes each year into your role, we certainly appreciate you listening today and each month when we hold these webinars. A couple of seconds for folks to finish answering those. (DESCRIPTION) Slide, Results. Quality improvement coordinator analyst 4.4%, clinical documentation specialist ambulatory 4%, clinical documentation specialist inpatient 12%, coding specialist 53.4%, other 26.2%. (SPEECH) I'm just going to move on to the next slide and see what we have here. So super excited to see that 53, 53 and 1/2% coding specialist. Great to see. A large variety of others, but we have CDI inpatient. I know for myself I was in CDI inpatient back in the day, and I used to get a lot of questions about CPT or E/Ms. So nice to see that. And we see some inpatient CDIs also working in some of the outpatient settings. Small percentage, we're still low in percentages, but those in the CDI business that work on the ambulatory side and some quality folks. So thanks again for all of you dialing in today. (DESCRIPTION) Slide, Summary of changes, 405. Additions 249, Revisions 93, deletions 63. (SPEECH) So let's take a look at the updates. As I mentioned, there's over 400 changes. They're in, what we call, three categories. So what's been added to the CPT code, what's been revised within the code set. So the code remains the same, but the official text has undergone some revision and what has been deleted from the CPT code. So very typical to see more additions than revisions and deletions. So those we're going to kind of go through some of those today. This next slide shows those changes by what we call CPT section in the code book. And (DESCRIPTION) Slide, Table. (SPEECH) as you can see here, most of the changes occurred in the pathology and laboratory section followed by the category three codes which are the temporary codes for emerging technology services and procedures. There is a really great appendix in the CPT books. It is Appendix B, like boy. It is a detailed summary of all the changes for the year. And some of those pathology changes, as you might guess, include some COVID-19 testing. But there's also some new codes in that section. I'm not going to address them here today, but if you work for a pathologist, there's some new pathology clinical consultation services that mirror the medical decision-making changes that we saw in the office visits last year. So nice to see that work a pathologist is required during the consultative services. (DESCRIPTION) Slide, Surgery Guidelines. (SPEECH) All right. So let's go here to the CPT. I'm going to start in the surgery section. There's a new heading that I just wanted to quickly point out. It's a new definition or, again, I think probably more of a clarification of a definition of a foreign body versus an implant. And this is really defining that an intentionally placed object is an implant, and an unintentionally placed object due to either trauma or ingestion, as example, is a foreign body. But, for CPT coding purposes, if an implant has migrated from its originally place position, if it's broken, it's no longer needed or it presents a hazard to the patient it qualifies as a foreign body from a removal perspective, unless CPT instructs otherwise or there is, in some cases, a particular code that describes the removal of the implants. (DESCRIPTION) Slide, Cardiovascular system. (SPEECH) There are a number of changes in the cardiovascular system, I would say, within the surgery section. This area had the most changes. Some appear in the surgery section, actually the majority do. I did bring in the medicine section where we have a few changes with the congenital cardiac catheterization codes located in the medicine section. But the next 16 slides address some of the changes in the cardiovascular system. What you'll see here is, as you note, within the CPT book, there's instructional notes throughout the code book. And if you have an actual copy of the CPT book, you would see any changes to those instructional notes to be in green versus in black text. So whenever you see text, if it's an existing text, it's in black and new text would show up in green. So you could see this at the beginning of a section, within a subsection, at the code level. And I just always point out that it's critical to read and understand and incorporate these notes into the decisions for your CPT code assignment. And this first slide here that I have on the screen around the cardiovascular section begins with the added instruction for electrophysiological, or EP, operative procedures. There's some new codes in this section. So with those new sections, some introduction notes have undergone some revisions. On this next slide here, there's three new codes, actually, in this section. And for the exclusion of the left atrial appendage, which can be done by excision. So they use the term exclusion, that could mean excision, isolation via stapling, oversewing, ligation, plication, or a clip. And this procedure is performed to treat atrial fibrillation and mitigate post-operative thrombolytic complications. So a surgical left atrial appendage, or LAA exclusion, can be performed as a standalone procedure via a sternotomy, a thoracotomy, or arthroscopic approach. And that first code there, CPT 33267 with the red dot in front of it, again, in the CPT book, anything with a red dot in front of it is a new code for that calendar year. So this new code is used for reporting the exclusion of the left atrial appendix as an open procedure and as a standalone procedure. The code right underneath it, 33268, one thing to notice there, not only does it have the red dot, but it has a plus sign in front of it, which indicates it's an add-on procedure. So similar procedure exclusion of the left atrial appendix open, but the key there is when it's performed in conjunction with another open procedure. So it's a procedure that would not be recorded on its own. So if it's being done on its own, it's 33267 in conjunction with another open procedure, 33268. On the next slide then is the last of the three codes in this section is exclusion of the left atrial appendix via thoracoscopic approach. Any method, meaning excision, isolation, plication, and et cetera. (DESCRIPTION) Slide, New information. (SPEECH) We do also have some changes in the heart section, the heart valves, great vessels area. This slide, again, is around some of the added instruction due to the addition of a new code, 33370. And this instruction, very typical to the CPT book, a lot of the instruction describes when it can be reported, and which codes can be reported with, and typically what additional services are included or excluded. (DESCRIPTION) Slide, New information. (SPEECH) So if you look at the next slide here, this is the code. It does have a plus sign in front of it, so it is an add-on procedure. It's used along with the three CPT codes for transaortic valve replacement, also known as the TAVR procedure. This new code has been established to report percutaneous transcatheter placement and subsequent removal of a cerebral embolic protection device. So during a TAVR procedure, materials such as valve tissue, embolic materials can break free. Calcified fragments break free and block the blood vessel, creating the potential for a CVA, Cerebrovascular Accident. This device then captures such embolic material to prevent that CVA. That's why it says replacement and subsequent removal because it's placed-- the procedure's performed-- and it's subsequently removed all within that setting. (DESCRIPTION) Slide, New information. (SPEECH) Also within the cardiac system mitral valve areas-- some important, revised instructional notes for transcatheter mitral valve repair. This is really just pointing out-- I shouldn't say simply-- but pointing out simply when it's appropriate to separately report a diagnostic heart catheter that's a right-heart or a left-heart or a combined left- and right-heart cath in addition to the transcatheter mitral valve repair. So some very clear examples of when it's appropriate because this diagnostic cath is typically done in advance, which then leads to the decision that the mitral valve can be transcatheterally repaired. But there are instances, such as when no prior study's available, there's a prior study available but there's inadequate visualization of the anatomy is several examples of when it would be appropriate to report that diagnostic cath. A lot of times, we see this as a standard of care within the operative setting that a cath is being done. But very clear, just because it was done doesn't mean it meets medical necessity or reporting purposes for payment. So again, that direction there is very important to understand. So within this area also of valves, we have the tricuspid valve and what's called the Category III Code, which are, again, the emerging new technology or services. And this is a transcatheter tricuspid valve implantation. So you can see, again, from those parenthetical notes, there's existing category III codes to describe transcatheter valve procedures, such as reconstruction of the valve or repair of an existing valve using a clip. But this new code describes the transcatheter procedure in which a valve prosthesis is implanted or an existing prosthesis is replaced within the tricuspid valve. So we certainly started with the TAVR, right-- the transaortic. Oh, it's probably at least 10 years now we've been doing transcatheter aortic valves. Moved on to pulmonary valve and mitral valve and tricuspid valve. So over time, the evolution of that procedure, again, encompassing all of the valves. So new code for reporting what we would call a transcatheter tricuspid valve replacement. (DESCRIPTION) Slide, Pulmonary valve. (SPEECH) So similar to the mitral valve that I mentioned on the other side, very similar information here related to pulmonary valves. And when we're performing a transcatheter pulmonary valve implantation via a percutaneous approach, when is it appropriate to separately report to the diagnostic cath in addition to the valve procedure? So again, often seen as a standard of care. Very clear to understand when is it appropriate to ask for additional payment for the physician work involved in that versus what we would call the standard of care. (DESCRIPTION) Slide, Endoscopy. (SPEECH) We do have one new code in the endoscopy area of the heart that I wanted to point out. It's 33509 there at the bottom of the screen. It's been established to report an endoscopic harvest of an upper extremity artery for coronary bypass grafting. Notice those parenthetical notes there, right underneath the code, that direct you to a different code if performed open. And also direct you that if performed bilaterally, it's appropriate to report the code with modifier 50. So very important code decisions around the assignment and appropriate, of course, always appropriate code. So we've had, of course, the endoscopic harvesting of the veins for a long number of years. And open upper extremity artery, now we have a procedure for an endoscopic harvest. (DESCRIPTION) Slide, Endovascular repair of congenital heart and vascular defects. (SPEECH) Couple slides here. I'm going to go past some of these endovascular repair codes just in interest of time, but there is a new subsection for endovascular repair and some congenital heart defects. The last area that I wanted to cover here was the cardiac caths. (DESCRIPTION) Slide, Cardiac Catheterization. (SPEECH) So there were some changes to the cardiac cath for congenital anomalies. So they've created, actually, a new subsection with new guidelines and six new codes. I'll show you those on the next screen. They've been added for cardiac catheterization for congenital heart defects in accordance with advances in treatment for congenital heart defects. I'll show you those on the next slide because what you'll see is those codes being deleted and this new set of codes, really organized based on what we would call treatment of normal native connections versus abnormal native connections. So you see a right-heart cath for normal native connections. Underneath that indented, abnormal native connections. Same thing with the left-heart cath and the right- and the left-heart caths. So when blood flows through the expected course, through the right- and left-heart chambers and into the great vessels, that's considered a normal native connection existence. And in some patients that have atypical cardiac anomalies, such as a hypoplastic left heart or a hypoplastic right heart, they have what's called the abnormal native connection in existence. So that change was really to show that important advancement in how we treat congenital heart defects. (DESCRIPTION) Slide, New information. (SPEECH) So you see the new codes there, the six new codes-- five new codes, excuse me. And then this is the sixth of the five codes. Again, add-on-- a plus sign in front of the code. So this is an add-on code that you'll see for measuring cardiac output during these congenital caths. The guidelines in the sub section for cardiac catheterizations for congenital heart defects, I did want to point out. You see a number of parenthetical notes here, but you'll also see a full discussion of normal and abnormal native connections within those guidelines. And application of them is, of course, a must for proper code assignment. (DESCRIPTION) Slide, Digestive system. (SPEECH) OK, that wraps me up into the cardiac system. In the digestive system, we have a new code. It's 42975, and it's been established to report flexible and diagnostic drug-induced sleep anatomy endoscopy. So the current CPT codes that exist didn't actually have a way to accurately capture the work involved in sleep anatomy, drug-induced sleep endoscopy. So this new code describes drug-induced sleep endoscopy designed to evaluate sleep disorder breathing. And you see the parenthetical notes right underneath that provide, again, additional instruction on how to report this code in conjunction with other services. (DESCRIPTION) Slide, New information. (SPEECH) We have a new code in the digestive system, 43497. It's been established to report transoral lower esophagel myotomy. And this procedure is performed for disorders such as achalasia, which is the inability for food to pass from the esophagus into the stomach. So prior to 2022, there was no CPT code to report this service. It would have been reported with an unlisted code, an unlisted CPT code. (DESCRIPTION) Slide, Category 3 codes. (SPEECH) And finally, in the digestive system, we have three new category III codes. It's 0652T through 0654T. And these new technology codes were established for the use of transnasal EGD services. You can see, again, there's three codes. You see the parent code and what we call a family of codes. So EGD flexible transnasal diagnostic-- the second code is EGD flexible transnasal with biopsy and that third code with insertion of a transluminal tube or catheter. I was actually particularly intrigued by these new codes. Just thinking to myself, why would you perform a transnasal EGD versus a typical oral EGD? Then I learned-- I looked, I'm curious-- that a transoral approach is much more comfortable for the patient. Apparently there's quite a bit of gagging reflex. This procedure is actually done a lot on children and young people. So the gagging that they experience is very uncomfortable for the patient. There's actually better recovery time as well because there's no use of sedation. When a transnasal is performed, they use just topical anesthesia when they perform this procedure. So I thought that was just a little tidbit of interesting. It caught my eye when I was reading through those. (DESCRIPTION) Slide, Urinary. (SPEECH) We do also have, in the urinary section, four new codes for periurethral, transperineal adjustable balloon incontinence device. This procedure is for urinary incontinence post a prostatectomy. These four new codes are in what we call category I of the CPT book, or standardly just called CPT. And that is because there were several category III codes, 0548T through 0551T, that have been retired/converted into these new CPT codes or category I codes. So you just see the distinction of bilateral insertion versus unilateral insertion, removal of each balloon, and then adjustment of the volume in those balloon continent devices. (DESCRIPTION) Slide, Category 3 codes. (SPEECH) This I also found very interesting. We have some new category III codes for uterus transplantation. This procedure is performed on any woman with Uterine Factor Infertility, or UFI. They have this condition due to the lack of a uterus or the presence of a non-functioning uterus. This is a promising new procedure that helps some women overcome uterine factor infertility and carry a baby. If the woman is approved for the procedure, the process starts with creating an embryo in vitro. Next, a healthy uterus is then transplanted into the patient. And about six months after a successful transplant, a single embryo is implanted into the uterus. And if the uterus leads to successful pregnancy, the pregnancy is treated as a high-risk, and the baby will be delivered via c-section. One might guess or wonder, but a woman with UFI cannot successfully vaginally deliver a baby. And then, as with other organ transplants, the woman must take immunosuppressive medications to prevent the body rejecting the transplanted uterus after the baby's born. So I read that a woman can have up to two pregnancies, currently, with a transplanted uterine. If, after their first pregnancy or following the second successful pregnancy, the woman doesn't want to have any more children, the uterus is removed via a hysterectomy procedure. Of course, then, that results in the woman no longer needing to take anti-rejection medication. So I just point that out. When we think about other transplants, this is not transplanted for the patients' remainder of their life but for use in carrying a baby to term. But pretty interesting, so you see you have the donor hysterectomy and interestingly, that could be a cadaver. It could be a living donor in an open procedure. It can be laparoscopic in a living donor and then, of course, recipient allograft transplantation from that cadaver or living donor. And then very typical within transplant services are backbench prep. So there's usually two groups of surgeons or they're working in two ORs. One is doing that donor hysterectomy from the donor and then transplanting with that backbench prep group that's preparing that cadaver or living donor for transplantation. So there's some backbench work, backbench reconstruction, that some time is needed to ready that transplanted organ, to make that organ ready for transplantation. So very promising for women that have this condition. (DESCRIPTION) Slide, Nervous system. (SPEECH) And I would say, I guess, enough are being performed that they're creating a category III code. And then within the nervous section, we have some new codes, 61736 and 61737. They've been established to report laser interstitial thermal therapy, also known as LITT therapy. And this is for treatment of intracranial lesions. This procedure involves stereotactic placement of a laser fiber into an intracranial target and is followed up by thermal treatment of the target under real-time MRI thermographic monitoring. So the difference in distinction between these two codes-- 61736 is reported when LITT is performed for a single trajectory for one simple lesion. And then 61737 would be used when LITT is performed for multiple trajectories or multiple or complex lesions. As noted, several inclusion parenthetical notes there that guide the users when it's appropriate to report other services along with this service. And also important to note that it's these two procedures would never be reported together. It's one or the other. It's a single lesion, or it's multiple or complex lesions. We also have some category III codes that were deleted. So with the deletion of category III codes 466OT and 468T, some new codes, 64582 through 64584, so three new codes established to report hypoglossal nerve stimulation services. Although the hypoglossal nerve is considered a cranial nerve-- which there's codes for cranial nerve stimulation that exists today-- the work necessary for placing a hypoglossal nerve stimulator is much more extensive with this work, and thus the need for new codes. It has to do with dissection of the nerve that's needed and identification of the branches that protrude onto the tongue. So these new codes capture that extra service of placing the inspiratory sensor as well as its replacement and removal. So you'll see those distinctions of open implantation, revision or replacement, and removal of the device. This stimulator is implanted to reduce the occurrence of obstructive sleep apnea by electrically stimulating the hypoglossal nerve, which causes the nerve that causes tongue movement. And this stimulation is timed with breathing to relieve upper airway obstruction. (DESCRIPTION) Slide, New information. (SPEECH) Finally, within the nervous section, we have two new codes, 64628 and 64629, for thermal destruction of intraosseous basivertebral nerve. These codes have been added to the somatic nerve subsection of the nervous section to describe new surgical procedures that provide treatment options for patients who have not responded to conservative therapy. It says it provides durable relief for chronic, vertebral low back pain. So it's a procedure for back pain. (DESCRIPTION) Slide, Eye and ocular adnexa. (SPEECH) There is a couple of new codes-- let me just go back one slide here real quick. OK, so we have a couple of new codes in the category III sections. So you'll see it down at the bottom of this in the green parenthetical notes. So there were actually two category III codes removed, a new category III code and two new category I or CPT codes. So they're on the next couple of screens here. So this new CPT code you would see listed here with the red dot, 66989. There's also 66991, which I'll show you on the next screen. And these codes have been added to report various insertion procedures for the placement of an interior segment aqueous drainage device into the trabecular meshwork without an external reservoir. So 66989 nine describes the performing of this procedure. It's listed as complex in the sense of the cataract extraction. So 66982 is a complex cataract extraction. So when performing a complex cataract extraction and also inserting this aqueous drainage device, you would report 669889 with a complex cataract. (DESCRIPTION) Slide, New information. (SPEECH) And then, on this next slide, if you were doing what would be called a routine cataract, which is the famous 66984, one of the most reported CPT codes, that's considered a routine cataract. The same exact procedure code definition, just with a different code at 66991 to be reported with a routine cataract. So two codes-- they have the same exact text to them. One's reported along with the complex cataract. One is reported along with a routine cataract. And on the following slide, this new category III code, 0671T, when this exact same drainage device would be placed without a cataract procedure being performed at the same time. (DESCRIPTION) Slide, Evaluation and management. (SPEECH) So moving on to evaluation and management. I just wanted to point out some new services in this area. So we have five new codes under the section called Care Management Services. Most of these services are time-based codes. Some of you may be familiar with some of them, which are the Chronic Care Management, or CCM codes, and the Complex Chronic Care Management, or CCCM codes. Those are two existing sets of codes within the E/M section and, in particular, the subsection of care management services and chronic care management and/or complex chronic care management for the management of two or more conditions that are expected to last 12 months until the death of the patient. So this care management is intersecting chronic conditions that place the patient at risk of death, acute exacerbation, or functional decline. So with the beginning of this these new codes, you start with revisions to the guidelines. So I show, here, a good example of text in black that's existing, some crossed-out text that's no longer, as they revised this. And then the text in green is the new text here. So I'm certainly not going to read through all of that for you, but pretty significant, I won't say, changes to the care management services, overall, but just the addition of a service called principle care management. (DESCRIPTION) Slide, Table. Care management services. (SPEECH) So I like this slide. It shows a nice table. This is actually in the CPT book. So it shows the three categories. So we see chronic care management and four codes. We see complex care management, and we see principle care management codes. And what you'll notice in the column on unit duration-- these are all what's called time-based CPT codes. So the clinical indicators are in minutes. And they also show the frequency in that very far right column of how often these can be performed per month. One of the other distinctions here is that these time-based codes-- there's code sets for clinical staff which performs those services directed by a physician or a qualified healthcare professional and code sets for the providers which are physicians or what AMA calls QHP. So I always stop and say, you see this term qualified health care professional in the CPT book around E/M sections in particular. So when we think about physicians and we think about APPs, Advanced Practice Providers, or NPP, which Medicare refers to them as Non-Physician Practitioners. And then the AMA refers to them as QHPs. It's referencing nurse practitioners and physician assistants that are licensed and able to establish diagnosis independently. They work in conjunction with some version of supervision of a physician, but they are independent practitioners. So whenever you see that term, APP, NPP, or QHP, they all mean the same thing. And it's referencing nurse practitioners and physician assistants. So some of these services could be performed by a physician or by a QHP. So I think this is a great reference if you happen to work in-- again, this is about longitudinal care. So we don't just take care of sick patients. We want to reduce hospital readmissions. So chronic care management, principle care management, is a way of longitudinally managing a patient and the quality of their care and their life. So these are very common services in certainly, primary care, of course, cardiology to name a few of them. But it's not designated for any particular specialty. But this is the management of that patient. And this, again, either the clinical staff, the nurses and other ancillary members of the care at the direction of the provider and/or the provider themselves. So again, I stop always and talk a little bit about this because it's a pretty nice table. So (DESCRIPTION) Slide, New information. (SPEECH) within there, there were some revisions to the care management services codes, under chronic care management. You see that with a triangle in front of the CPT code. And this code has a triangle in front of it to indicate some of the text has been revised. And it's actually one word that's underlined. So instead of chronic conditions, they forgot the word "that" in the past. So that triangle indicates that the word "that" was added to that. So this is official text of these CPT codes. So I don't want to underscore the importance of that. It's very important that the official text be noted. But then you'll see, on the next slide, the reason for some of that care revision in green, that you see in the slide, is because, within these codes, that first code is 33490, which is, again, very clearly defines what it is. It's managing a care plan, establishing a care plan, monitoring a care plan, additional minutes, and then the first two codes were for the clinical staff. And then the next two codes are personally by the physician or QHP. And what I note here is that there was two codes for the clinical staff. Prior to this year, there was only one code for the first 30 minutes by the physician or the QHP. And so then there's a new code in this section. So when a physician provides chronic care management services or a non-physician practitioner does, each additional 30 minutes by the physician or the QHP per calendar month. So these services are recognized to take more than 30 minutes, similarly as they would for the clinical staff. (DESCRIPTION) Slide, Table. (SPEECH) And then onto this very last topic here, in the last couple of minutes, is the new subsection for principle care management. So this service is a brand new service, sort of. There were some G codes last year from CMS, and those were retired. And the establishment G codes are in the HCPCS code book, but the establishment of four new codes. And as you can see here, again, we have a service that focuses on the medical and/or physiological needs manifested by a single, complex chronic problem expected to last at least three months. Same as the others, it includes establishing, implementing, revising, and monitoring a care plan that's specific to that single disease. And also like chronic care management and complex chronic care management, these are time-based CPT codes. So you can see the range of codes, then on the next slide, I will show you those codes. There's two sets of them, so 99424 and 99425, and again, note the plus sign in front of the second code there. These are the single, high-risk or principle care management of a single, high-risk disease. These are provided personally by the physician or QHP. And then the second set-- first 30 minutes of clinical staff time and each additional 30 minutes of clinical staff time directed by a physician or QHP. So very common theme, again, to see the parenthetical notes that describe what can be reported with what, giving you direction. So I always just say, the CPT book is organized in a very different fashion than the ICD-10 book. So these parenthetical notes in these chapter guidelines are critical to code assignment. So I think that is my last slide. So I'm going to turn it back over to Lisa. (DESCRIPTION) Slide, Q & A. (SPEECH) We only have a few minutes left, but I will turn it back over to you, Lisa. Great, thank you Colleen, and yes, as you said, we are just about at time. And so for the questions that we do have, we will follow up with you after, just to make sure we get to all the questions. There were a couple of questions about the certificate of attendance. And so that certificate can be submitted for CEUs to the accredited associations. (DESCRIPTION) Slide, That's a wrap. (SPEECH) And so if you were not able to download it at the beginning, as I mentioned before, if you do a quick refresh of your browser right now, that PDF of the certificate should be updated at this point. But because we have so many questions, Colleen, if you're OK with it, we will contact everyone that did attend with the answers to those questions as well as the certificate, just to be sure that everyone did in fact get it. I'll personally answer those, so you'll get an email from me. Perfect. No problem, yep. Great, well again, thank you so much for your time today, Colleen, and kind of being my first speaker utilizing this new platform. And so we really appreciate your time today with your knowledge. As (DESCRIPTION) Slide, 3M Education boot camps. Virtual advanced C.D.I. training, April 11-15. Virtual advanced quality training, March 7-11. (SPEECH) a quick reminder to everyone, we do also offer educational boot camps. And so in the resources section, as well, there is a link to get to this web page if you are interested in learning about more. And so, again, we appreciate your time as we kicked off this year on the quality webinar series. We will be doing this bimonthly, like we did last year. And we will be kicking off the CDI Innovation Series next month, and so we hope you all could join us there as well. And so again, we always appreciate your feedback, and so at the end of the webinar, the survey will launch if you haven't already done it within the platform. And we do appreciate your feedback. So again, we always appreciate your time, appreciate us on this new webinar platform journey. And we look forward to joining you again. So thank you. Have a great rest of the day, everyone. (DESCRIPTION) Slide, Thank you.