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Healthcare Econ 101 - Ep. 3: Decoding the Black Box (Billing & Coding) · Behind The Knife: The Surgery Podcast

• Healthcare Econ 101 - Ep 3 (edited)-esv2-51p-bg-10p-music-10p === [00:00:00] Everybody, welcome back to Behind the Knife. I'm Nina Clark. Joined again by Dr. Chris Childers, a surgical oncologist at the University of Washington. We are now in episode three of our little miniseries on healthcare finance, and I think this is gonna be our last episode in this initial series. We would love your feedback and questions from any listeners about what they wanna hear about more. And if we can generate additional episodes, we would be happy to do that. So let us know what you think. We've covered a ton of ground in these first few episodes. The first, we did a deep dive on insurance and how healthcare is financed in the us and in the second episode, we've explored how this money then flows to surgeons and to hospitals and how this translates into somebody's paycheck. This last episode, we are gonna spend a little time covering billing and coding. This is not the sexiest topic, but it is actually critical for almost any surgeon entering the workforce, and I will definitely count myself as one of those because I know nothing about this topic. Dr. Childers's, big picture. How do you want to approach this as we go along this episode? [00:01:00] Gosh, I can't think of a more boring topic, and so we're gonna try through enthusiasm and energy to get through this. Primarily. I think the way we should break it up is that we should start, we should start with probably the highest yield area, which is gonna be a. Evaluation of management coding, e and m, coding for short, because I think most people are gonna be responsible for that. That's gonna be the coding that you do for your clinic Patients, individuals are gonna be variably responsible for their inpatient coding, and they're probably not gonna be directly. Responsible for coding their OR cases, but they are gonna be instrumental in terms of figuring out and generating what that coding structure looks like. So I think we should start with e and m coding. Then we can do, or coding and, and we'll talk about some modifiers. Along the way, I think kind of general principles that I would emphasize now and we'll emphasize throughout the episode, is that you really wanna get to know who your coders and billers are. Very early on in your career. You wanna meet them, you wanna review cases, you [00:02:00] wanna review things and get their feedback 'cause they're gonna have a wealth of experience. At the same time, you're also gonna know more about these patients and these operations than they ever will and making it a two-way street and kind of emphasizing the work that's involved in operations can be. Beneficial 'cause they can then go back to their coding community and see if there are alternative ways of doing things. So get to know them early and make sure that you're getting appropriate credit for the work that you're doing. Yeah, it's funny, the majority of that I've dipped my toes into this space is in looking up CPT codes mostly for case logs. And I feel like every time I Google a CPT code, I get these blogs of coders asking what they should bill for. So I'm excited to dive in and get a little bit of a better understanding of this whole system. Uh, let's start with office visits and that ENM coding that you mentioned. So this is like a patient that you're seeing in your clinic or a patient that you're seeing in the hospital, I assume. How do you approach these patients and these codes? Yep. So. Let's start on the outpatient side. I think that's, [00:03:00] that's the easier side. By and large, you're only gonna be billing a few codes here. There's one big stratification. Is it a new patient or is it an existing patient? And then if it's a new patient or an existing patient, what level of care did you provide to that individual? A few things that we should touch base on, and probably the one that is the most important for trainees and new grads to understand is that ENM. Billing is entirely based on how you determine which level to bill at. And there are two ways to do that and you can do it based on time and you can base it off of what's called medical decision making or, or MDM. There are tons of good resources out there. You do not need to memorize any of this stuff. This is not AB site studying. What I have, and I, I study this stuff, but I still have on the whiteboard next to my desk in my office, a printout of the different time cutoffs [00:04:00] for these inpatient, outpatient new established patients, because they're slightly different for some reason, depending upon the setting. One of them has a cutoff of 30 minutes. One has a cutoff of 35 minutes, and there's no way that you should or could expect to figure out what those time cutoffs need to be. The other table, I would encourage you to print out the a MA has a table. If you just look up MDM levels of coding, you'll find a chart that basically outlines how you assign something to the different levels of these office visits. A couple things to know. Number one, starting in 2021, they changed all of these things, and so if you ask anybody. For about how they did this. Before that it was very different. They had to have like their 12 review of systems and their nine things in the physical exam. All of that stuff is gone. You need none of that. You can write a three sentence progress note as long as you document the appropriate time or MDM and you can bill whatever level of code your, the length of note has nothing to do with billing at this point. [00:05:00] If you're billing based on time, you need to bill you. You can include. All of the time you spent seeing that patient, but also all of the time you spent thinking about that patient in that calendar day. So as a surgical oncologist, if I look up the patient in the morning, maybe I then go to a tumor board and talk about them. I then go and see the patient, maybe discuss it with the resident, maybe call somebody, maybe call radiology. All of that time and then document on them appropriately. All of that time can be included in your, in the time that you're allocated to that person, and that can determine the level of care. MDM tables have no time requirement. It's just based on where does it fall in these three columns. And I'm not gonna go through the entire table. It's relatively self-explanatory as surgeons we're dealing with generally pretty high complex issues. Most of the time they are, the low and kind of moderate [00:06:00] levels are, are really designed for patients who are being seen predominantly by their primary care provider and maybe they're titrating a hypertension medication. If as a surgical oncologist you're seeing somebody with a new pancreatic cancer diagnosis. And you're deciding whether or not to take them for a Whipple, that's a very different patient. And I think most people agree that that is a much higher complexity patient. Whether you're billing based on MDM or based on time, I think you're gonna be airing towards those higher categories. The level fours and the level fives pretty consistently. And this is not just me saying this, there's pretty good data that after the 2021 office visit updates that all specialties. Are shifting upwards in terms of how they're coding these things because you no longer need the nine exams and the 12 review of systems, and it really is just based on either time or complexity. And so pretty much across the board, regardless of specialty, most physicians are billing level four and five for both new patient encounters and for established encounters. I see this a lot in [00:07:00] my attendings attestations of my progress notes or, or my ICU notes or h and ps or what have you. And I feel like a lot of the time I do see time still used. This is more in the inpatient setting, but is one of them better than the other? And also how does this actually play out for you as a staff in real time? Do you like actually pay attention to how much time you have spent charting when you're pre-read for clinic patients and then, you know, sitting in the room with each person, how do you actually keep track of this? Or is the MDM decision making kind of style a little bit easier to just think about how much effort I put into this clinic appointment overall? Yeah, so, so lots of good questions. Number one, you do not report to the payer. Which technique you're using in the sense that when you submit a bill for an office visit, all they see is 9 9 2 1 4 or 9 9 2, 1 5. They don't see like a 9, 9, 2, 1 4 based on 45 minutes of time or anything along those lines. So we really actually have no idea at a national level what people are using predominantly. If it's time or if it's MDM. [00:08:00] What I've heard. Is that oftentimes early in your career you're building based on time and maybe later in your career you're building based on MDM, and that might just be a reflection of just getting a little bit more efficient with your time, but still seeing the same level of complexity of individuals. I don't think many physicians and surgeons are quite at the point of lawyers where you have a timer and you're hitting start, stop from when you're doing these things. You know, I, I do think though that. You know, if you're spending 45 minutes reviewing nine charts and it took you about the same amount of each time, you're about five minutes there and you can kind of do the same thing for tumor board and you can actually get some feedback from the EMR in a lot of situations. So Epic can tell you how long you spent in a patient's chart. Now did you step away for 10 minutes and go and see the patient and come back? Well, you, if you saw the patient, that's still time that counts. And so Epic can actually also give you some insight into how much time you've been spending. The [00:09:00] MDM is certainly useful in, you know, kind of high acuity, short timeframe things, especially on the inpatient side, which we'll talk about in a second. To get to some of the time cutoffs, you're dealing with pretty high numbers, like 75 minutes in order to be able to build a highest level and. Whether or not you're actually spending 75 minutes in order to kinda work up somebody that is acutely needing to go to the operating room, you may or may not be right. So I think the, the general advice, and I don't think I'm gonna get in trouble for this, is you should bill whichever one is higher. As long as you're billing accurately, you should not overestimate or underestimate the time that you're spending. And, and likewise, you should not do so on the MDM side, but if you find that you're doing high MDM and it only took you 35 minutes. You should build a high MDM. There is one other kind of subtlety, which I think is important for. Trainees and and faculty to remember is that if you end up spending a lot of time with a patient, well, more than kind of the time cutoffs that we have, so a [00:10:00] new patient's about 60 minutes, an established patient, I think it's 40 minutes. If you're spending an hour and a half or two hours with those patients, you're probably gonna wanna bill based on time because if you get over a certain threshold, you can actually bill for prolonged services with that individual. There's this weirdness in the fee schedule where. Medicare actually has a different interpretation of prolonged services than pretty much every other payer, which is a subtlety that we don't probably need to get into. But the basic idea is that. Medicare thinks that if you are saying, I'm gonna spend 60 minutes with a patient, that you should not get any additional credit until you get to 75 minutes. And then you can only get credit for the prolonged services if you then spend in another 15 minutes with a patient. So basically, Medicare is saying you need to get to 90 minutes in order to bill prolonged services, whereas the CPT manual, which is adopted by most. Other payers says that you can do it at 15 [00:11:00] minutes past 60, which is 75 minutes. That's a lot. But basically whenever you look at these charts, you'll often see two different codes for prolonged services, and that one of them is like a G code and one is a normal number, and that's the reason why is because of weirdness in Medicare payment policy. What a surprise, another weird complexity of the system that we all work in. As a future trauma surgeon, I imagine a lot of what I'm gonna see is those highly complex patients that we have to make a decision on pretty early in their hospital course. And so I imagine that will probably more frequently hit high MDM than I do high time requirement for a lot of those acute consults. So it's good to know. A couple other things on this topic. What about modifiers? What are they, which ones are most relevant, especially in the outpatient setting? Yeah, let's, let's run through a few that are relevant to kind of the ENM codes. So anybody that works at a teaching hospital needs to be familiar with the GC GC modifier. And so that is something that is supposed to be appended to any bill that has a resident involved. [00:12:00] So any time you're supervising a resident, you're supposed to put that on there. So I just have kind of an auto template that basically everybody I see has a GC modifier on them. And actually you'll see this both on the OR side, if you ever look at the actual detail of what your coder is. Billing, since I work at a teaching hospital, every single CPT code for my gallbladder, for my Whipple procedure will have a GC modifier in it because there was a resident that was involved in those cases. GC is a common one that you need to know if you work in a teaching environment, and you'll get bugged about it by your coders if you don't put it in early these days. With telehealth being very common, there's a modifier for that, and actually there's a different modifier if it's video and audio, as opposed to if it's audio only. Right now, just as a random aside, you will get paid the exact same amount for a telehealth visit as you will for an in-person visit, and that's kind of a moving target with Congress. Two other modifiers that are actually really important for surgeons. 57. None of these have any rhyme and reason [00:13:00] to them. By the way, they're just probably the order that they were created. 57 decision for surgery. So we talked in, was it episode two? Episode two. We talked about global periods, right? And we talked about the 90 day global period and when does it start? When does it start, Nina? Does it start the day of surgery? No, it starts the day before. That's exactly right. So let's say. You are a surgeon and you saw somebody the day before their operation and you saw them in your clinic and you just had a conversation and you document that they're doing fine and they're ready for surgery tomorrow. Can you bill for that? Probably not based on that being in the global period, or did I just walk into a trick question? No, you're you're absolutely right. So technically the answer is no, but. Everybody now recognizes that you should be able to do that, right? If you're seeing somebody in clinic the day before and you're make, and you're doing a full [00:14:00] evaluation, and actually probably when this happens more often these days, as an acute care surgeon, you're seeing the patient in the er, you're working them up, you're spending, you're 75 minutes figuring out whether or not they have X and Y diagnosis. Looking at the imaging, doing all of that, counseling the patient and making a decision about surgery, you should be able to bill that ENM visit. And so the modifier that you have to apply though, so that it doesn't just get swamped into the global period is modifier 57. And the reason why. The whole global period started the day before surgery. The reason why is because back in the day, most patients undergoing major operations were admitted the day before surgery to undergo their like final workup. And that was the argument is that that's still part of their surgical period. That was not the decision to make surgery. It was you were just getting them teed up for an operation. And then lastly, another really important one for surgeons, modifier 24, you asked. Last [00:15:00] episode, oh my gosh. I have somebody in the hospital for like three months, and obviously they have complications from the surgery, but they have other things that happen. They have a pe, they have a heart attack, they have other things that I'm having to manage. Can I not get any credit for that 90 days worth of rounding on them every single day that I've done? And the answer is modifier 24. If you provide evaluation and management services. During the global period, this is specifically after the surgery that are unrelated to the operation. Now there's a little bit of judgment in what that means exactly, and I'll leave it up to you and your coders to figure that part out. But if it's unrelated to the operation, then you should be able to bill for that evaluation of management code. I think that's the main codes for. ENM visits. Yeah. There's no way I'm ever gonna remember these random numbers and letters, but super helpful to know that these things exist. And I think this is, you know, to your point of getting to know your coders so that you're, you're doing this [00:16:00] the right way when you start out. What if you have an a PP if you're working with a, a nurse practitioner or a pa, how does that fit into all of. Yeah, good question. And just one other kind of tip and trick that I had when I kind of started out in practice is I had just like a little note on my phone that had a lot of these ENM modifiers and, and the inpatient modifiers just so that I had a kind of a quick reference service for, for when I was doing this. So some something that might be helpful. Apps really important, obviously, growing number of apps, supporting surgeons both on the inpatient side and on the outpatient side. So apps are, are providers by Medicare, and so they can bill for anything that they perform independently. The only, and the only difference is that Medicare will pay them 85% of what they would pay for a physician, but that's a totally reasonable thing for them to do. You can also bill for a PP services as a physician, and there's kind of two ways to do this. One [00:17:00] is. Very is gonna be uncommon for most surgeons who listen to this. So if you were that non facility surgeon, the surgeon that has their own shingle, so to speak, and you had an a PP in that clinic. Then you can do what's called incident two billing. Basically, the A PP sees the patient, they do like the actual work with seeing that patient, but they're your patient. They're your patient in your clinic, and you're immediately available to take care of that patient. So you're working alongside them. Maybe then technically that a PP can bill under your MPI number and they can get. Full credit, a hundred percent credit for that service. That's uncommon because most surgeons don't operate in that model anymore. But what you will probably have is if you have an a PP on the outpatient side, and it's a hospital owned clinic, you can still do what are called split or shared visits with an A PP. There's some more subtlety to these. When you do this, you can kind of get credit [00:18:00] for the totality of the work that both of you provide. So if your a PP goes in and sees them and spends half an hour with the patient or does half an hour's worth of work for that patient, and then you go and see them for 35 minutes, then you can technically bill as a split visit for 65 minutes under your NPI number. You, the, the subtlety. You can also do this on the MDM side. You can say that the combined effort of us was a high MDM. There's a couple of subtleties to this. Number one is if you see the patient with the NP or pa, that's overlapping time. You can't bill for it separately. So if you. Together. Went in and saw a patient for half an hour. It's only 30 minutes total, assuming that you don't do any work outside of that. The other thing is that in this model, you have to claim that you are doing kind of the substantive [00:19:00] portion of that visit. You have to be doing 51% of that visit, either in terms of the medical decision making or in terms of the time. If it's less than that, technically it goes under the app's NPI number, and they get to claim your time as part of theirs, but then it gets billed at 85%. The other thing that I think is important and residents don't realize a lot of time is that this does not apply to residents. I don't get to claim any of the time that you spend with a patient. I can only claim the time that I spend either with the patient or thinking about the patient or working on the patient. And the reason for this is because resident time is already paid to hospitals through GME funds, and so otherwise it would be kind of double-dipping to claim any payments for the residents time. This really highlights, I think, the discrepancy in how much time and effort residents put in over seven years. I can't even count how many [00:20:00] hours I've probably put into clinic prep that doesn't, you know, count in quotes toward anything specific. And it also just brings up some questions of we, I think especially in academics, hear a lot about apps as being. Cost reducing measure for hospitals and for healthcare systems. And I can see why you splitting a visit with an A PP saves everybody time because you've got somebody else looking up the patient and spending their 35 minutes, and then you only have to spend the 35 minutes of super high level decision making. Is that the main argument? I feel like it often comes down to pay too, but is, is there something I'm missing there? I mean, every institution's gonna have kind of their own calculus that goes into that. I can speak to, for example, I have, I have some friends who do work in private practice where in those models, which are kind of that eat what you treat collections based model, you have to [00:21:00] pay for your a PP out of. The revenue that you generate, right? And so for those individuals, there's a real calculation that goes into these things. And for those individuals, it's not saving them money, right? You're not trying to reduce your salary, you're trying to actually. Ideally generate some more revenue, if that's possible. Right? Maybe you can shorten your visit time. Maybe you can see a few more patients. Get more patients into the operating room. Right? And more importantly, you're also just reducing the amount of work that you're having to do. Right. And there's real value in that, especially for individuals who are in this model where. Their collection space and they're really trying, having to hustle in order to be able to make ends meet. There's value in not having to be responsible for seeing the 38 patients you need to see in clinic by yourself. Yeah, that makes a lot of sense. Alright, let's move into the operating room. How does everything work there? Yep. So. Most in [00:22:00] institutions, most individuals that I know usually have a coder that is responsible for kind of going through your operative note and generating a bill for your operation. Certainly there are different models around there. You may be asked to put in your own code. You may have to send what you think are the codes that they should be related to it, but I think most typically it's. The model I've heard is that you write your operative note and then a separate coder is responsible for that. You know, it sort of makes sense when you think about some of the other things we've talked about in this miniseries, that they would have a coder because what do we care about? We care about the DRGs. We care about the APCs on the inpatient side. Well, what determines a lot of those assignments is the CPT codes from the procedures that you're performing. And so they wanna make sure that they're getting the right CPT codes 'cause that's what leads to that. $15,000 paycheck as opposed to the 200, $350 paycheck. So I think the questions that people often ask me. Is, you know, how do I, how do I improve my [00:23:00] operative billing or my operative coding? The first things first, it cannot be under emphasized that your documentation needs to be thorough for what you're doing in the operating room. Providing a list of procedures that you think that you're performing is certainly valuable. But describing it in the bulk of the text is also extremely valuable. I can't tell you how many times I've written in the procedure, like I used intraoperative ultrasound and then forgot to mention it in the body of the text. And that means I have to, either they can't bill for it because it's not described in the operative text, or I have to go back and amend my operative notes. So being thorough with your documentation from the outset is gonna be extremely valuable As you're getting into this, nobody's expecting you to know the millions of nuances about the billing and coding for your individual specialty. Some things that I think are useful resources for finding codes and finding out what procedures exist. Ai, great tool these days. Ash Chat, GPT or Claude or whatever your favorite [00:24:00] AI is. They're not perfect by any means, but they seem to be getting better and better. Google as well has also found a lot of things. There are, as you mentioned, kind of these coding blogs that will help you kind of figure out which codes to be assigned. You mentioned A-C-G-M-E. Those are actually a great way to find CPT codes because it provides you a list of the relevant codes for general surgery. Ask your partners. That's probably the most valuable thing you can do early on in your career. And then there are some other resources that might be useful. You can actually get the CPT manual. There's a CPT professional manual that comes out every single calendar year. It's released by the A MA. It's not cheap, it's a couple hundred bucks, but. If you work at an academic institution, I can almost guarantee you, you have a copy through your library that you can get access to either electronic or, or a print version. And then your specialty society is also should be a wealth of resources as it's related to billing and coding. Some specialties are better than others, but many organizations, the American College of Surgeons as well has a list of kind of hot topics and [00:25:00] difficult areas to, to figure out coding. There's a great resource as a surgical oncologist. There's a great resource for, how do I bill. Wed resections versus partial hees for liver, and how many of them can I bill? And how do you do it when you've got ablations and things in different locations. So those resources are out there, you just have to kinda look for them and start tucking them away in a folder on your computer so that you have access to those resources when you need them. And frankly, it doesn't take too long. I'm obviously a little bit more embedded in this space than the average person, but within just a few months, you're gonna be doing kind of the same operations over and over again, and you're gonna get pretty, pretty familiar with it. This makes me a little worried as a future trauma surgeon, where I will not necessarily do the same sort of procedures every day, at least for the first bit there. But you know, hopefully I'll have good partners. A couple of quick hits as we kinda get to the end here. First off, robot versus laparoscopic versus open. Does it all matter when it comes down to coding? The short answer is [00:26:00] robot and lapar identical. There are no codes that separate robotic from laparoscopic operations as far as CPT codes and as far as the RVs assigned to them, they have, the robot has been viewed as a tool to perform laparoscopic surgery, so you're not going to make more or less doing a robotic operation. The difference is between minimally invasive and open, and there are. Often two different codes for minimally invasive operations compared to open operations. Back when they created the RV system in 1992, laparoscopy was very much in its infancy. So laparoscopy was not a commonly performed procedure, especially for anything that was complicated. And so those codes got added later and they have not been added for everything. So as a surgical oncologist. Distal pancreatectomy doesn't have a laparoscopic code. None of the gastric resections have a laparoscopic code. But the bariatric versions, of course, all do because those were, you know, operations that were introduced a little bit later on. So you'll need to look up and become familiar with your specific specialty as to whether or not there are laparoscopic versions of these procedures, [00:27:00] and there are ways of still describing minimally invasive operations. Compared to open operations. But typically what will happen is that it'll end up in what's called an unlisted code. And so you might see that something that ends with like 9, 9 9 is being billed for your laparoscopic distal pancreatectomy. And the reason for that is because you didn't do an open distal pancreatectomy. And so what hopefully is happening behind the scenes and, but this is again where you gotta talk with your coder and biller, is that they're creating some sort of a crosswalk. They're basically saying. We don't have a code for this. We're listing it as an unlisted code, but we're gonna provide information to the payer that this is very similar to the work done for an open distal pancreatectomy. You should pay us based on the open distal pancreatectomy code, and that's probably the most common way for doing that. But I'll be honest with you, this is where you really have to know your billers and coders because unlisted codes by definition have zero work RVs [00:28:00] associated with them. The hospital is still gonna get their DRG. And get their money. But if you're not paying attention and the billers and coders don't have guidance, otherwise, you may find out that all of your distal pancreat ectomies are zero rvu and you've been getting no credit for those. And that's when you need to go back to your department, your billers and coders, and make sure that you're getting credit for that value. That's fascinating. I can imagine that would be a very sad day in a junior attending's career to realize that. What about operations? When you're doing multiple procedures at once? I'm thinking about our hip surgeons or debulking operations where we're doing a ton of things or bilateral hernias even. How does that work? Yep. So again, document everything that you're doing is probably the most important thing. Just a, a general rule that is probably worth mentioning is that Medicare and most other payers, the way that they do this is, again, with a modifier, which you don't need to memorize, but essentially you'll get credit for. The [00:29:00] first procedure, and we'll talk about that in a second, and then you will continue to get credit for the subsequent operations, but they usually don't give you full credit. You usually don't get a hundred percent of the RVU value by convention. Most of the time you're getting 50% of the work RVU for all of those subsequent procedures. And the reason for that is because presumably there is some overlap both in terms of the work that you're doing in the operating room. Like if you are doing. A splenectomy as you're a trauma surgeon, so you're doing something to the liver and you're doing something to the spleen. Well, you only needed to make one incision, so you shouldn't get credit for making that incision separately. You're also probably have overlapping global periods, right? You're gonna have work that's gonna be overlapping between those two. So that's where the 50% kind of multiple procedures modifier comes from. The one thing, another kind of tip and trick though, is that you wanna make sure that you're getting credit. For the highest RVU value for that first one, I early on did a [00:30:00] hepatic artery infusion pump placement, and I think the highest. You take the gallbladder out as part of that. And that actually, ironically, is the highest value part of that operation, which is insane. But that's a different story. And I think they listed the pump as the most important one, but the pump is only worth eight RVs, whereas the gallbladder's worth a little bit more. And so it ended up reducing the amount that I was getting paid overall for that procedure. And so little things like that are again, important to keep track of and make sure your coders are on top of. Alright. Last question I think is, are there other common modifiers? I'm thinking of one in particular, which is the modifier 22, but what are some other modifiers that we should just know about and breeze through and talk about quickly? Yep. Yep. So we talked about modifiers on the outpatient ENM side. Let's talk about a few kind of quick hits on the OR side. Modifier 22. Is described as unusual procedural services. It does not have a great definition, but basically the [00:31:00] idea is that if you think a procedure required increased exceptionally increased services for that patient, then you should be able to identify it in some way, shape or form, and get renumerated a little bit more for that procedure. The idea being that in general, the way that our RDU system is structured, you're getting paid for a typical patient. So what is a typical patient? Who knows? But there are gonna be extreme outliers, right? Patients with tons of adhesions, extreme obesity, patients who have altered anatomy operations, where things are wrapped around blood vessels. And you should be able to identify those patients and get paid a little bit more for them. That's what Modifier 22 is supposed to do. As an aside, we did a paper on this a couple of years ago that looked at Medicare data and whether or not modifier 22 when it's appended to a claim actually does increase your reimbursement. And unfortunately, the results of that paper kind of suggested. Doesn't on average, because what ends up happening is that those claims are much more likely to get denied, [00:32:00] and then your hospital system has to go back and try to appeal it multiple times. Attach your operative note, maybe get more information. If you're doing it for a gallbladder and it's only $350, that's a lot of work to go through to try to get a few extra dollars. I don't have any hard data to support this, but modifier 22 is, is roughly supposed to be about 20% of cases. If you want to think about it in terms of outliers, and you're roughly supposed to get paid about 20% more if you claim the modifier 22. How your hospital accounts for this is gonna be highly variable. They might account for it on the backend just in the dollars that they get paid. They get paid 20% more than $350, in which case doesn't matter to you as a surgeon. If you're being measured on work RVs at other institutions, they might bump up your RVU by 20%. And so you wanna know that when you go to your new institution, because that might make a difference in terms of identifying these cases and being more persistent about [00:33:00] identifying these cases and making sure the appeals process goes through. I still think it's worth doing if nothing else, just because it's the right thing to do and you should know which patients required extraordinary effort. A couple other ones that we should dive into. Residents have seen this on operative note all the time, and I've had some residents get. Terribly offended when I said there was no qualified resident to help with an operation. Most of the time, this is not a insult to the resident. It is a coding facet. So you'll see modifier 80 or 82 are kind of the common ones that you'll see. So we're all used to kind of the teaching hospital environment, but a lot of. Institutions don't have, aren't teaching hospitals, they don't have residents involved in every operation, and so you might have your partner come and help you with an operation and it's totally normal and expected for that to happen. That person should be able to bill for their services and so they bill modifier 80 and they get about 20% credit. So if a gallbladder's 10, they get. Two RBU's, which is [00:34:00] frankly less than most office visits. So it's not a ton, but at least it's something. If you're at a teaching hospital, your assistant is a resident. Your resident, as we already talked about, can't bill because that would be double dipping because the hospital was already getting paid for their services because GME. But there are certainly situations where you might need to have another attending in the operating room. Maybe the residents are at education and you need another attendant to come help you with an operation. Maybe it's a really hard operation and you do actually need another attending in order for that attending to get any credit for being in that operation, they have to apply modifier 82 and they have to specifically document that there was no qualified resident available to help with that operation, and that's why you will see that in operative notes. And then lastly, modifier 62 is when you're doing a two surgeon operation. So this is different from what we were just talking about with an assistant. So I'm the primary surgeon doing a Whipple, and I have my partner come and help me. That's an assistant at surgery. If I'm doing a case with thoracic [00:35:00] surgery. And it's taking out a spleen and stomach, and chest wall and ribs, and it really does require two surgeons, maybe from distinct service lines. That's a true two surgeon operation. That's where modifier 62 comes into place, and what usually happens is you create a total RVU for whatever that procedure is, and each of you gets 60% of it. Is usually how that works. There are classic examples of this. So you've probably heard of people who do spine exposures, right? You'll have a vascular or a general surgeon come in and do the spine exposure, and then neurosurgery does it. They will split the, uh. Rbu is using a modifier 62 VP shunt cases are another great example. You get laparoscopic access to the abdomen and you can bill a modifier 62 for the combined effort of that operation. So those are the other kind of key modifiers that I think you should at least be familiar with. Awesome. Yeah, I'll have to take it up with the coders because no qualified resident was available is just a savage way of putting that. [00:36:00] I'm one of the people who gets insulted when I see it, but that was great and really I think eyeopening as to. Kind of how the sausage gets made. This has been a really nice series. I think I've learned a lot just in recording these episodes. So thank you for listening and, and thank you Dr. Childers for providing your expertise here. We are really looking forward to listener feedback on this series and are open to developing future podcasts. If you guys have other follow-up questions that you want us to address going forward, and Dr. Childers, thank you for your time and I will let you do the honors. All right. I've been wanting to say this for a number of years. The day. Thanks everyone.