Top Takeaways from the 2025 Final Rule

Welcome, everyone, to AAPC business solutions webinar, top takeaways from the twenty twenty five final rule. My name is Cordell Hammond, and I'm gonna be the facilitator today. I have just a couple of items to mention before we begin.

Today's presentation will be about sixty minutes followed by a q and a session if there's time. We've got a lot to cover in this roughly three thousand page rule.

So we're gonna try and hurry through it and get to your questions. If we don't get to them, don't keep that from having you send them in because we may be able to, write up your blog post that answers all the questions in a different format at a different time.

But if you do have questions, please send them to the q and a module and not the chat module. That way, we can keep track of them a little bit better.

Also, please note we'll be sending out a copy of the PowerPoint presentation and an on demand recording of this presentation in just a couple of days, so keep that out or keep an eye out for that in your inbox.

Also, as, made mention when you registered for the webinar, this has not been approved for any AAPCC use.

Today, I am happy, and excited to introduce a friend of mine, Lori Cox.

Lori has over twenty years of experience working in the business side of medicine. She began her career in patient accounts, then moved into billing and coding for multi specialty clinics. Lori is promoted to billing supervisor and then to compliance officer. And in two thousand five, she received her MBA from Quincy University in Quincy, Illinois. Laurie has traveled the country educating coders and physicians on complex coding topics such as hematology oncology and e and m guidelines.

Laurie is an active member of our AAPC chapter and is the director of client engagement for AAPC audit services. And with that, I'm gonna turn the time over to Laurie.

Thank you. Thank you, Cornell. Hi, everybody. It's great to be with you today. I was looking at the chat as we were waiting to start.

I see lots of fellow Missourians and some Illinoisans. I'm right on the Missouri, Illinois border. So welcome, everybody. Welcome, everybody else.

Hopefully, some of you are in sunny places, and some of you I know are in the snowmageddon places. So, we have a lot of people joining us today, which is one of the reasons I'm not sure if we're gonna get to questions. But as, Cordell said, please put your questions in the q and a, and we will do our very best either to get to those in a blog post or or maybe on a podcast. For those of you who like podcast, you should know that AAPC has a podcast, and you should get out there and subscribe to that.

But like I said, we have a lot of slides.

We're gonna jump in our we're gonna take a brief look at the overview of the final rule, and then we're gonna go into telehealth. I think I anticipate that is where most of your questions are gonna come from because everybody's kind of up in the air as of today, and I was researching before a webinar to see if there were any updates.

I think a lot of us are having some concerns about telehealth.

But there are a lot of new codes in the final rule. Some of them may apply to you. Some of them may not, but we wanna get through those. We have a few slides on RHCs and FQHCs and then a few other changes we wanna talk about.

Alright. So here are some of the main topics that were in the final rule. Now we're not gonna cover all of these. That would take forever.

As as you might know, the final rule, if you go to the PDF version and not the federal register version, it's like three thousand and eighty eight pages. The federal version is just as long. It's just that they put it in little bitty print and three little columns, and it's a lot harder to read. I prefer the PDF.

But, yes, three thousand and eighty eight pages, is a lot.

So if any of this information pertains to you, and there are some other things in there, you wanna go look at that PDF version, do some searches for the things. Like, if you're looking at one of the codes that we talk about today and you want some more information on it, download that three thousand page document and then just search for that code and find the pieces that you need. Okay? But these are just some of the things that are in there.

I think one of the concerns, especially for the physicians, that this should be a concern for us as well of being auditors and coders because the company's bottom line affects us. Right? It affects our salary, our bonuses. It affects our staffing.

So if this pay cut that Medicare is proposing goes through, it could be drastic.

Right now, a lot of the what the consensus is is that physicians and I know people think, well, you're a doctor. You get paid a lot of money.

But the reality of it is that some of them really don't, not for what they do. And this pay cut is going to affect them even more. Now there is a bill out there that will stop the cuts, and anybody can go write your senator, write your representative.

You can go to this website called fix medicare now dot org and tell them to push this bill through because we don't need this pay cut. We certainly wouldn't like it if our, pay got cut by two point eight three percent, would we? So we definitely don't want this for our physicians.

So we really want this to not happen.

Like I said, you can go out there and, go to that website or write your senators and have your physicians do the same thing to get this stopped.

But it might be beneficial. That's why I put a lot of the new codes, that are coming out because you're gonna wanna take a look at those. If this pay cut goes through, then maybe some of the new codes that are out there will help you regain some of that back.

But let's go into what I feel like is the bane of our existence right at the moment. Honestly, I feel like we are going back to pre COVID telehealth days when it very first started. Remember how when we we first got word that telehealth was gonna be allowed for COVID? But every day, they changed the rule. I'm not kidding. I wrote a article for, like, the magazine or something about the telehealth rules, and the very next day, the rules changed, didn't they? And I feel like that is what we're going back to unless Congress steps in.

So Medicare does not have the option to change the rule. It has to be an act of Congress, and there is a telehealth modernization act. There are, I think, even a couple others. This one was the one that seems to be the most common. Again, you can write your senators and your representatives to get this through. However, it's likely not going to happen before January first.

And as of January first, Medicare patients cannot be in their home and get telehealth services unless it's a mental health. Okay? And so we're gonna talk about that a lot more. But that is the rule that is coming.

Okay? No longer can a Medicare patient be at home and get telehealth, and that is sad. We don't want that, do we? We want telehealth to continue.

Now remember, this is a Medicare rule. We don't know what the payers are gonna do. I am hopeful that many payers are gonna continue to allow it. I was on, my UnitedHealthcare, which is the plan that I have earlier, and they have not said anything, about discontinuing telehealth.

It seems like the virtual visits are gonna continue.

So let's hope and pray that even if it doesn't happen on January first, that somewhere along the line, it's gonna get changed to where patients can once again get telehealth services from their home.

If you remember before COVID started, you had to be in what was called an originating site.

This is the location where the patient is when they receive their telehealth service.

A home is no longer an originating site as of January first.

First of all, you have to be in a valid area such as you cannot be in an MSA.

You should be in a rural census track area or a HPSA, and both of those are determined both of the first two are determined by the Census Bureau, and then the HRSA determines if you're in the shortage area.

So first of all, you can't be in New York City or in St. Louis, which is where I originate from.

That's not gonna work. You've gotta be in a rural health area.

Second of all, you have to have the patient go to one of these places.

So the likeliest, example that I could think of here is a patient, is in a rural health area. They go to their clinic and telehealth with a specialist in another area, but they have to go to the physician's clinic in order to do telehealth. They can't sit at home and do telehealth anymore. Again, unless it's mental health, which we'll talk about in a minute. So you can see how, desperate we are here to get this changed. Right? Now to even further complicate our situation, the AMA has deleted our telephone codes.

So as of January first, nine nine four four one through nine nine four four three, those were the telephone only codes. Correct? The ones where there's no video, we're just on the phone or, you know, doing phone over the Internet, but no video.

Gone.

So they created these new codes, which, honestly, I think the new codes are great.

So we now have telehealth codes for audio and video new patients, for audio and video established patient. Then audio only, new patient. Audio only, established patient. Now I didn't go into detail about these codes because that's a AMA and that and we wanted to focus on the final rule. But they're basically broken down just like your office visits are. You've got straightforward, low, moderate, high decision making, and you've got time attached to all of these.

But these are just your telehealth visits.

Medicare says, nope. We're not gonna pay them. So even if Medicare allows the patients to be at home for mental health services, we can't use these codes any longer. So you can just see the confusing just multitude of problems that we're gonna have going in, and you know that that's what Medicare is gonna audit on. It has to make sure we're following the rules, but we're not really sure what the rules are right at the moment. So it's going to be very confusing.

Stay tuned with ABC. Stay tuned with your networking, your local chapters.

We'll try to keep you as updated as we can.

As of right now, CMS will not pay the Nutella health codes. However, they are going to pay for the new AMA code, which is the virtual check-in. So CMS always had a code for the virtual check-in. You know, this is that brief, five minute I think it has to be at least five minute check-in with the patient.

Hi. How you doing? Just making sure everything's okay type of thing. Do we need to have a visit, something going on? That's what that was at g twenty twelve.

It's deleted, and Medicare will allow the nine eight zero one six for those virtual check-in codes.

Here's a couple exceptions. So if you're an RHC or an FQHC, you can use the g twenty twenty five, which is the payment for the distant the telehealth distant site service. So that code has been in effect. You can still continue to use that for patients that come in to the rural health clinic and receive telehealth services.

For behavioral or mental telehealth, all patients can continue to get telehealth services with no originating site. So telehealth, mental telehealth, behavioral telehealth can be at home. That's it right now. And what codes are we gonna use?

So CMS says you're gonna go ahead and continue to use the office visit codes for that. And so then we're gonna need to get our place of service right on the plane. And then you really wanna watch your MAC carriers to determine, are you gonna need that ninety five modifier, the telehealth modifier, because those are no longer allowed per the AMA on the office visit codes because we have the new telehealth code. So, again, you can just see the multitude of conditions that we have with the telehealth concerns.

Let's hope we can get that resolved.

So what Medicare did say, even though this seems to be a bit confusing because, they said they weren't gonna allow telehealth, but then they turn around and say, if a provider intends to use telehealth so they have every intention of using video services. And that's what I mean when I say telehealth, but we know all those words are interchangeable.

If they intend to use video, they can go ahead and use the telehealth, the office visit codes even though they didn't use video. So maybe the patient's video wasn't working or the patient did not want to be on video for their service. That's fine, Medicare says.

We can still allow that as telehealth and use the office visit codes. Because remember before, if there was no video used, we had to use the telephone codes. Well, those are gone now, and Medicare doesn't pay the new telephone codes. So what they've said was if you are providing you have every intent to provide audio video, it's okay to go ahead and use the office visit codes. Again, check with your payers to see if you're gonna need a ninety five or making sure you have that correct place of service, like the two or the ten, that we get those that we get those correct. So I know we're gonna have a lot of questions on that, but let's get into some of the new codes because there are a lot. Now some of these won't apply to everybody, but, again, I think this is worth knowing about because it's going to decrease, hopefully, that that pay cut, that is coming.

Right? Alright. So we do have a code. This is an add on code.

Now this is a well, it's kinda funny because in the final rule, they say this new device however, I did some research. It's been around for a few years now, but we all know how, innovative technology kinda falls behind. I mean, it falls ahead of our coding trends. Right? Our codes lag when we get the innovative technology. But, this device is used in the office, but it's rather expensive.

It delivers that ear tube, okay, so that tympanostomy tube, also known as a vent tube, through the tympanic membrane of the patient. It's used in the office usually for pediatric patients six months or older.

This allows the device to be furnished to patients without general anesthesia, and it can therefore be performed in the office setting. But the device itself was a little expensive.

So Medicare created a code, g o five six one. You're still gonna use the six nine four three three, which is the code for the vent tubes being placed, but you can add on this code. Now, again, this is a Medicare, a little confusing because not a lot of pediatric patients have Medicare, but older children may. And maybe this means that Medicaid might also allow.

Again, you'll have to check with your states to see if they're gonna allow this, and we don't know if the payers are gonna allow it. My suggestion is if you're using this device, no matter what the payer is, put the code on there. And then if they deny it, you know, that they they're not gonna allow it. But, hopefully, maybe you'll get some money out of it.

Now there was no in the final rule, there was no work RVU published, so we don't know exactly yet what the reimbursement rate's gonna be.

So stay tuned on that.

Now this is the new code that's very similar to g twenty two eleven, which we're gonna talk about g twenty two eleven here on a couple slides. We also have a webinar next week that's coming just on g twenty two eleven. So that's next week. You could find that by, going through the AAPC website and looking for webinars on g twenty two eleven. It's a free webinar as well.

This code is very similar. The work RVU is the same. However, this is the add on code for the complexity of services that are done in the hospital for infectious diseases.

Now it's suspected or confirmed infectious disease such as COVID, but there is no stipulation.

It just has to be an infectious disease.

They it's usually by an infectious disease consultant, but I don't think that that was stipulated that it has to be because you could have a a hospitalist, but maybe they just know infectious disease. So in that case, it would be okay. This is a add on code. So you add it on to your hospital visit codes, either your initial or subsequent codes.

And it's supposed to describe that intensity, that work that has to be done in order to manage infectious diseases. So on the next few slides, you're gonna see there are some components to this. Now there are a lot, in the final rule. I think it was, like, three pages worth of components, but it could be worth that extra money to do this. Get a template designed for your providers that has all the necessary information in it so that they're using the correct template. They're getting the right information that needs to be obtained to use this code.

But you can see the first component is risk assessment and mitigation. So we have to follow these things. We're gonna develop, follow the protocols. Right?

Coordinate with human resources, counseling the family if needed, or caregivers, and then managing infection and protocols and treatment protocols for those complex patients. That's the first part. The second piece is public health because if you remember, we had to report COVID, to our health departments, and then there was that whole contact tracing, which none of us really probably care to hear about again, but it's still there. We still have COVID out there.

So, and, again, it doesn't have to be COVID. It can be any infectious disease. But in this piece of it, you're doing an in-depth patient chart review. You're communicating with the labs.

You're co coordinating with federal, state, and local public health organizations.

All of this needs to be documented in order to build this code.

The third piece of it is the complex therapy counseling and treatment. So this is how are we fighting it. What are we using to fight the disease? Not just medication wise, but how are we using anti vaxx, and all the other sanit wipes and things that need to be done to prevent the control of this disease.

And it's assumed that you're gonna have complex medical decision making in these cases.

So these things are, again, all the items that need to be you can get to the final rule and get the exact details to build your template from, or contact us at AAPC, and we'll happily build one for you.

Okay. Our next set of codes is caregiver training services. That's CTS, caregiver training services.

We have several new codes in this area, and I think that these are gonna be really good because it's always kind of been something that's been done, but we never really had any reimbursement real reimbursement for. But you can see, the very first code for the caregiver training, this is an ongoing condition or illness to or to reduce complications, such as ulcer formations, wound care, infection control without the patient because this is just us training the caregiver. It's one work RVU, which could be pretty significant, and it's thirty minutes. And then we have each additional fifteen minutes, which is point five four work RVUs.

The GL five four three is group caregiver training. So this is where we have a set of caregivers, and we're training all of them at once in a group setting, but there's still the same guidelines. And then each, each person or each patient that's associated with that group caregiver training gets point two three work RVs for billing that code.

So unlike the other caregiver training codes that are already paid under the fee schedule, These codes are for direct care service and support on focusing on those special skills that are needed for, like, you and me. We could we could be a caregiver for somebody. It's usually more of someone who has a nursing background, and I am definitely not a nurse. I don't even care to be. I prefer to sit in the background of things. But that is what this is for. We want for for one example that they gave is that a caregiver could be taught how to properly change wound dressings, so that we have that promoting that healing and preventing infection or preventing the wound from spreading to other places.

So these are some of the things that, CMS put out there saying that these would be things that we would see documented in the patient's note about the training of the caregiver.

Of course, it has to be the plan has to be clearly identified. We need to know exactly what's going on, and it's not billable for patients that are already under a home health plan of care, receiving at home therapy, or receiving DME services for the involved medical equipment and supplies.

They're also going to add new coding and payment for caregiver behavior management and modification training.

So this is more of the mental health side of things.

These, current CPT codes, nine six two zero two and nine six two zero three, allow for multiple family group behavior, modification services.

These are more one on one.

So we have the behavioral management for caregivers of a patient. They just have to have a mental or or physical health diagnosis, but it's more of an overall one on one training of that patient with either be that needs behavioral management or modification. So even though they might have a physical health diagnosis, this training is how we're not necessarily managing that physical diagnosis, but we're doing that behavioral management.

An example might be a patient who is at the end of life due to, cancer or whatever the case may be, but we're using behavior modifications to help support them through that end of their life. So that's what these codes are for.

Now advanced primary care management services. We have three new g codes that describe a set of care management services furnished under a broader application of advanced primary care. Now these new codes are supposed to reflect the recognized effectiveness at growing adoption of the advanced primary care approach to care.

So these are good things, but they're a little confusing, and, they encompass quite a bit of information. So let's take a look at g o five five six. This is the first one.

As the code reads, this is a APCM service. This is by clinical staff that is being directed by a physician or other qualified health care professional.

They're responsible for all primary care and services. They are the focal point for all health care services per calendar month with the following elements, and then that's where it goes into more detail, excuse me, in the final rule.

These were the most important ones that I found. I put the page numbers. Again, this these page numbers are the ones if you download the PDF document that you can get from the federal register. I think we probably have a reference link to it at the end of this presentation, but, the PDF file, not the actual federal register with the little bitty words in the three columns.

If you're going to initiate starting to do these codes, you've gotta get to those pages on the final rule and see the three pages, four pages, almost of listing of things that needs to be done. You have to have consent, first of all. They have to have an initial visit.

You have to be able to provide twenty four seven access to care. So your office has to have some way of providing twenty four seven access to care, and then there are so much more. And I just could not fit it all on these slides.

So this first code is for provided by clinical staff per calendar month. Our next code, g o five five seven, is for a patient with multiple chronic conditions expected to last at least twelve months or until the death of the patient. The patient is at significant risk. These are very ill patients, again, probably towards the end of their life.

That's per calendar month again, clinical staff, but you have to have all of that, elements that we just talked about that are in the final rule have to be done in order to support this code. But the work RVU is point seven. It's seven seven. It's pretty decent.

So but the patient does have to have the at least two chronic conditions expected to last twelve months.

The third rule is the same thing, includes the same elements. However, in this case, it has to be a patient that is a qualified Medicare beneficiary.

So what a QMB is is a patient that has both Medicare and Medicaid.

So they are not only just on Medicare, either due to a disability or due to age, they also have Medicaid.

And so if that's the case, you'll use this code instead of the g o five five seven, because this patient also has to have multiple chronic conditions expected to last at least twelve months or until they're passed, but all of the other elements stay the same.

Now in the, AMA CPT Symposium that I was on a couple weeks ago, there was a lot of discussion about how are are we supposed to know if there are QMBs. So that's where you gotta it's gonna be a group effort. If you have, like, a coordination of benefits department or if you have a registration department, you can go into your MAC. Here in Missouri, we use, SNAP or c SNAP, but what's called WPS, to look it up, and we can tell. And then we use, like, emo med, which is our Medicaid site to go in and see if they have Medicaid too. And that will usually tell us that they also have Medicare. So it's gonna take a little bit of back end work, working with your registration or your pre op or your coordination of benefits department, whoever it is that does those authorizations to make sure that the patient is a QMB.

And then, you know, that you will bill this code instead of one of the other two for your Advanced Primary Care Management Services.

Okay.

The million hearts model, I think it was called, is where this information came from. It was a study that CMS did over a few years, I believe, because heart disease is one of the leading causes of death. Right?

And so this is a standardized tool that you can go over with the patient or get to them in advance to fill in. They bring it in. You go through it with them.

It has to be a tool that has been tested and validated through research, and it includes the following domains. You have to have a ten year estimate of the patient's heart risk, demographic factors, modifiable risk factors for cardiovascular disease, possible risk enhancers for CVD. The work RV is point eighteen, so a few dollars can be. This is for administering the tool for five to fifteen minutes, can only be done every twelve months. And then this next code, g o five three eight, is for the risk management of a patient.

Doesn't have to have a current diagnosis of heart disease, but they have been determined to be at medium or high risk for heart disease as was determined by that tool that we just looked at. And this is the clinical staff time. Again, they're directed by a physician or other QHCP per calendar month. So this is the management of a patient that's at high risk.

Now this originally was going to be an add on code. So if you were with us for the webinar we did back when the proposed rule came out, we talked about this a little bit.

But we and we always encourage our attendees when we do that proposed rule webinar. Get on to the CMS to the federal register where this is published and submit your comments. Because what happened was this was proposed to be an add on code. But so many people commented and said, no. This needs to be a stand alone code.

So they changed it. So see, it does work to submit comments into the proposed rule.

What this is is a patient is being, it it's safety planning interventions.

These are patients that are coming in.

We're we're contacting them.

We're we recognize that they have a mental illness, and we're looking at those interventions per twenty minutes, that include all of these pieces, recognizing those warning signs, talking to them about coping strategies, what social contacts and settings can be used, what family members can we get involved.

So and it's one point o nine work RV is that's pretty decent.

So, yes, this is now a stand alone code that can be used when you're doing these types of safety planning interventions with patients.

Now, there was a lot of research that was done, and common sense kinda tells us this too. When a patient comes into the ER with mental health illness, they are at significant risk in a period of time after their ED visit of actually going through with their plan to commit suicide.

So if we do some type of follow-up, maybe we can prevent that. So research showed that, patients that have some type of outreach later after their ED visit were at less risk of following through with their plans, than were patients that had no contact at all. So this is for a it could be a phone call. It is a phone call.

Post discharge phone call, from a person in the ER following up with that patient after their crisis. So in some time period after the crisis, we follow-up with them. It can be performed by clinical staff under the direction of the practitioner, and it's one work RBU. So, this is something I think that is much needed.

I work part time in an ER sometimes, and I see it so much. And so I think that this will be really helpful.

Okay. There are mental health digital treatment devices or DMHTs out there.

It has to be a device that is cleared under the FDA.

The billing practitioner has to incur the cost of furnishing the device to the patient, and the patient I mean, obviously, they have to have some diagnosis of mental health.

They're diagnosed. The patient gets the device.

This is for the supply of the device itself, and it's I believe there was no RVU value listed in the final rule yet.

And then this is for the monthly management of the patient that is on the the device. Now from my little research, I was trying to find, like, a picture of this device. Is it an actual device? Like, is it something that you carry around with you, or does it stay at home?

Like, there wasn't a lot. Most of it was on this good old device that's in my hand right here. You know? The telemophono, which has everything on it these days, seem to be.

So I guess it would be as long as it was something that was cleared by the FDA, it could be an app, but, you know, it's probably something you have to pay for. So maybe it's something that your provider, subscribes to per patient and has to incur that cost.

It can't be a free device. You know, it has to be a device that they purchase. And then these codes you use to manage that patient. So somehow the provider is getting that information from that device or from the app that's on the phone and is evaluating it and contacting a patient.

You know? Maybe we need to come in. Do we need to change your meds? So you have to have at least one interactive communication with them per month.

And then the first code is for the first twenty minutes per month, and then the second code is each additional twenty minutes.

Alright.

Lots of new codes for behavioral health services, and I think we're just hitting the tip of the iceberg with these.

But the first code here is for telephone Internet, electronic health record assessment, and management by a practitioner who is a mental health specialist. You see it says, their covered services are limited by statute to services for the diagnosis and treatment of mental health. So we're talking about psychiatrists and social workers and licensed, CSWs and things like that.

The first code is for the verbal and written report to the patient's treating or requesting practitioner.

So this is just for communicating the what you found when you met with the patient back to the physician or the patient's PCP.

Five to ten minutes. And then you have eleven to twenty minutes, twenty one to thirty minutes, and then more than thirty one minutes.

Again, this includes the time for the verbal discussion and the written report. You have to do both. Notice that says and, not or.

If you only do the written report, then you use the g o five five o of five minutes or more. That's it. That's all you get, one code no matter how long it takes you to do that written report. But this is just to reimburse for that time that it takes to do it. And then the thirty minutes is kind of like, all of this overall.

Thirty minutes with the patient, covering those services limited by statute. You know, you have to be that certain provider, and you do thirty minutes of work per calendar or per time, I guess it is. Not calendar month. Sorry.

That code was a little confusing the way they worded it in the final world. I'm not gonna lie, because it was kind of like, okay. What's the difference, right, between some of this? But alright.

Now we have a code for the post op follow-up complexity.

So this has to be for a practitioner who is not in the same group, same specialty. So this has to be a different specialty.

Per once only, that's all you get for that ninety day global period.

When there has not been a formal transfer of care, and then there's a whole bunch of elements we're gonna look at on the next slide. But but keep in mind, post op care is included in your global surgical package unless it's a provider.

Again, it has to be a different specialty or in a different group practice, so maybe that's the case.

And you have to have all of these components involved. So you've got to be able to read this the op note, Research the procedure. You're gonna evaluate the patient and communicate with the surgeon.

You list this code in addition to the E and M code that you're billing to see the patient, and then you get a little bit of a bump. Again, I'm not sure how much. I think that was on the previous slide, like, sixty one or something for getting this information done.

Just remember, you can't be in the same group, same specialty.

And remember that same specialty means APPs as well in the AMA role because APPs that work under a certain provider considered to be the same specialty. Correct? So Medicare may also consider that to be same specialty.

And if it really just is typical post op care that you would be doing anyway, that's not what this is. This is something outside of that. It's above and beyond what you would normally do.

Alright. Just four slides on RHCs and FQHCs. So if this doesn't apply to you, you can tune out here for just a couple minutes.

But we're they're really trying to beef up, rural health and federal health centers because and I feel like these these locations are underpaid.

So what they're trying to do in this case is is they have this code g o five eleven for rural health or FQHCs only, general care management, twenty minutes or more of clinical staff time for chronic care or behavioral health integration services, per calendar month.

So they are gonna allow them to build this code that or they allowed them to build geo five one one. But now what they're saying is that they're gonna allow you to split up and bill things out separately. So think of it as like bundling. Okay? So before we had g o five one one, for, you know, just as general care management of the patients.

And now what they're saying is, you know, there was a lot of services involved, and this code did not adequately reimburse for all the services that were paid under it. So if you look in, and I put the page number here, page eight hundred and forty two, again, at the the PDF file of the final rule, you can see all the different codes that were bundled up into this g o five eleven. Now you can unbundle them and bill each one of them separately that you actually perform, and you'll get more reimbursement.

Now, again, because of the proposed rule and the comments that were made, they said, hey. We might need a little bit of time to put this into play because, you know, the final rule gets released, like, the end of November, and it gives us a month to put it into place before January first, and that just doesn't always happen. So they're they're saying you have until July first to implement this. But go ahead and start getting it ready to go. Okay? Go ahead. Get that table pulled up if you're an RHC and find out what services you can bill separately.

They're also gonna allow payment for those APCM services that we just talked about in the RHC or FQHC setting.

Now they did make a note, though, if you're gonna report those, they are per calendar month bundles. And so in that case, you bill those, you can't bill for those certain other services that may have been billed for under that g o five eleven that we just talked about. So you're gonna have to decide which is gonna be more cost beneficial to you, reporting the APCM services if they apply to those patients, or is it going ahead and billing them out, you know, kind of un unbundling it and billing the different pieces out separately.

The other good thing that they put into play is that RHCs and FQHCs are finally gonna be able to bill for part b preventative vaccines. And before, this was kind of one of those things that was all rolled up into your cost bundle. But it includes all four of them, the pneumococcal, influenza, hep b, and COVID nineteen vaccines. So you'll be able to bill the codes for these beginning January first. You can build those codes out separately. So if you're not as familiar with those codes because you've been in an RHC setting for a while, you wanna reach out to your network and or to us again at AAPC, and we can help you get those codes. Okay?

They're also saying that in certain circumstances, patients come in, they see your rural health care provider, and they also need some kind of dental care.

And before, they didn't allow those on the same day. Now they're saying, it can be if it's inextricably linked to a covered service, which we'll talk about that here in a couple slides. I think maybe even on the next one. I'm not sure.

But you've gotta get the KX modifier, which means I followed the policy like I'm supposed to, that it was medically necessary that you have the documentation in your record to support both of these being done the same day. But what they did say was that they know that this is something that's really new. They're going to provide additional instructions in the future. So this may be not something that you're gonna implement right away.

You might wanna wait and see what comes out in some future guidance like a MLM matters or something like that.

Okay. A few other changes.

The assistant at surgery, these codes are not new. Okay? But now we can bill for an assistant when we have these, procedures and we have an assistant with some stipulations.

So we can't just always bill an assistant, excuse me, for these codes. We can only bill it if it was medically necessary to have an assistant, and we have been saying this for quite a while now. Most of you know I work for AAPC audit services. I do a lot of auditing and coding and that type of work for AAPC.

And we have been telling providers over the years, it's not enough to just say assistant at surgery was, doctor Smith or John Doe, PA. That's not good enough anymore. We need a medically necessary reason to have an assistant in this day and age because if the insurance company wants to deny it, we have nothing to fall back on. We as auditors don't know why an assistant was necessary.

And I know the doctors say come back to me and they say, well, we always have an assistant for this surgery. Well, that means absolutely nothing to me. I and I hate it when people say things like, we've always done it this way. You know?

I hate that.

You should really have a reason anytime you use an assistant surgeon of a medical necessity for that. In these codes, you definitely will have to. If you're gonna use an assistant for these codes, you've gotta document the medical necessity, and it's supposed to only be used in particularly challenging cases. Okay? So that needs to be in the documentation.

One thing, and I'm a hemonc coder auditor, so this has always driven me crazy driven me crazy, is when you have these, we call them the mAb codes because they end in mAb, like rituximab and things like that.

They're very complex drugs. They're not chemo necessarily.

They're usually used in, like, a rheumatology setting, but they're very complex drugs. And we've always said we feel like those chemotherapy admin codes are the ones that should be used for these, Mav drugs, but not all payers were going along with that. They would change it over to what we call the therapeutic diagnostic, those types, not chemo. And we've never felt like that should have been correct.

Well, now CMS is coming in and saying, they're going to well, they realize that some MACs have developed LCDs and LCAs that restrict the payment on that. And so they're updating the IOM saying that you can use those chemotherapy admin codes for these very complex drugs. Now is there a listing of drugs out there that you can absolutely use those with? No.

And they're not like the j nine codes, which we know those are chemo, but they usually end in mAb. I would just, if you're in a rheumatology practice, go down and talk to, like, the usually have a a technician that's in responsible for administering these drugs or several, and talk to them and say, okay. Which one of these would you consider to be just as complex as having to do, like, chemotherapy administration?

And then once you're on with that information, go back and at least try to bill your chemo codes and appeal them if you get a denial from a payer.

Use this information. It's right here in this chapter, the IOM that Medicare says these complex drugs can be used with chemo, and then maybe have your provider draft a letter, a template that you can use to appeal those.

Okay. G twenty two eleven. I feel like has been so confusing to everybody.

How do we use it? When do we use it? And like I said, there is a webinar coming next week just on this code. And we're also planning a podcast and a bunch of other things, to try to, raise awareness on the use of this code. Because even when I'm auditing, I'm still not seeing it as much as I would expect to.

You know, there aren't that many restrictions on it. It's just that you're providing the longitudinal care for the patient. Right? And just having some kind of documentation in your note that supports that.

What they are saying now, because there was a lot of pushback, You know, if a patient comes in, they not only have a sick visit, but they have, like, a AWV or they're welcome to Medicare visit, that we should be able to add this code on to those. And in the beginning, Medicare said no because you can never use this code with modifier twenty five. Well, we always had that modifier with our sick visit when done on the same day as an AWB. Right?

Now they're saying, okay. We will allow you to bill g twenty two eleven on the same day as a part b preventive service.

You have to still bill a e and m, so you better have a reason, for billing that separately identifiable e and m, and then you can bill the g twenty two eleven. And what they're saying is that they expect that there's supposed to be some information such as the diagnosis, the assessment, the plan of care, or other codes reported that would report that would support this code.

There were also some revisions to therapy supervision for PT and OT.

What they're just looking at is that they're changing this from direct supervision of the assistants.

So your, OTPPs and your PTPPs, your your assistants can be generally supervised now instead of directly supervised, and they're just hoping that that opens it up, to accommodate more patient availability and to ensure that there's more access to these types of therapies.

Okay. Back to the dental and oral services.

Medicare is slowly getting on board with paying dental services. It's still not great, because I feel like everybody needs dental services, but Medicare just isn't going along with that. What they're saying they will pay it is when it is linked to ESRD or patients that are on dialysis.

Then they can have screenings, oral treatment for oral or dental infections.

We've gotta put the KX modifier on there, but they decided they would postpone that for now. I would recommend going ahead and using that KX modifier. This one, again, is the one that said, hey. I followed the rules that you said I have to follow.

So you can get payment for dental services, again, only if linked to ESRD or dialysis services.

Now this one, I will say, was a little confusing to me because in my opinion, modifier fifty fours, fifty five, and fifty six have always been supposed to be used this way. But what they kinda did is change the wording of it a little bit. What they're doing is they're saying there doesn't have to be a formal transfer of care now. So modifier fifty four means I am only doing the surgery. I'm not doing the pre op, and I'm not doing the post op. I am only during doing the surgery.

But sometimes there isn't a formal transfer of care from one provider to the next. You know, maybe the patient's traveling or there's just not a formal transfer of care. And so what Medicare is saying now, there doesn't have to be a formal transfer of care.

You can go ahead and use the modifier fifty four when you're only doing the surgery. You're not doing for your post op services.

They did the study because you would expect there to be a correlation. Right? If we have modifier fifty four build so many times, we should also be seeing fifty five and fifty six. Right? Because somebody's seeing that patient for pre and post op care, but it wasn't happening.

They said modifier fifty six is very rarely used. So that means that either we're just really doing a lot of globals, but there was still no correlation between the fifty four usage and the fifty five and fifty six. So we need to really start using these modifiers as expected.

Fifty five and fifty six does need a formal transfer of care, though. So the pre op doctor is gonna say, I'm transferring the patient to doctor so and so who's only gonna do the surgery, and then that doctor so and so does the surgery with the fifty four, and then they go back for their postop care with another provider. Again, it has to be something outside of the global package different specialty or a different practice. Right? Because regular pre and post op care is included in the global surgical package.

So beginning with January first, you have to use modifier fifty four on all ninety day global surgical package where the provider only plans to do the surgery and nothing else. They're not gonna do the pre and post op care.

Alright. And it looks like that is the end. I do have some reference slides here to share with you all.

Gosh. We ran right up against time, I figured. And I know there's a lot of questions out there. What are you guys seeing, Cordell? You seeing all the questions that are showing up? There's a lot. Yeah.

There's well over a hundred questions there.

I figured.

And that doesn't even account for the hundred or so that came through the chat.

I don't know how to tackle this with only three minutes left and be impartial or fair. Yeah. I think we're good.

I'm gonna have to do something fun with it.

Yeah. Because there's very little time and so many questions.

So So many questions.

So let's, let's let's end it there, and I will thank you, Lori. I know how much work that entailed to go through all three thousand pages and find what was most important to our audience.

So thank you very much for all the work that you've put into it. And to our audience, again, we will be sending a copy of the presentation slide deck as well as a recording of this presentation.

And knowing the complexities that you will be facing in twenty twenty five, if you're interested in talking to an AAPC expert about the business solutions we provide to help you through, and navigating through these these challenges, there's a survey, just as soon as we end this presentation that you can let us know. We'll be in touch. Thanks again, everyone.