Billing and Coding for Nurse Practitioners: 2021 Updates
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Billing and coding clinic office visits are probably not the first thing nurse practitioners think of when they graduate. It's probably more like:
Phew! I’m so so so glad that's over.
What comes next?!
How am I going to find a job?
I’m not going to worry about that right now because...
...I'm finally done with NP school! 👩⚕️🦄💪
But unfortunately, the skill set of medical billing and coding is one of the first major frustrations that new nurse practitioners encounter on the job.
And doing it right makes a big difference -- there are serious consequences with chronically under or over-billing!
It tends to feel really hard for new grads at first, but once you get the hang of it, it's much simpler than you think.
Start with the Basics of Billing and Coding for Nurse Practitioners
We did our first episode on Billing and Coding for Nurse Practitioners over here. I refer to it a few times in this episode, so definitely go and check it out first, if you aren't familiar with how it works.
In both episodes, I'm talking about the bread and butter of coding -- new and established office visits, E&M codes. I don't get into procedures or coding for physical exams or coding modifiers. If you're interested, I'd totally be into hosting a Billing and Coding workshop to get more into those!
The Good News About Billing and Coding
Once you've watched that episode, I need you to head straight back here because we’ve got some good news —
The 2021 CMS updates for billing and coding just made life a LOT simpler for nurse practitioners.
They've streamlined it quite a lot — it's still relevant to know the more "complicated" billing and coding method (from the previous episode) since it can help you more accurately code and get reimbursed for all your hard work. But hopefully, this will overall give you back some time in your day.
In this episode, we chat about:
✅ Main branch points for determining strategies for billing and coding in-office visits
✅ Choosing the appropriate documentation to support coding
✅ Options for billing based on levels of decision making OR time spent with a patient
✅ And other significant updates!
Plus, grab your Billing and Coding for Nurse Practitioners Cheat Sheet below! 👇
Get your updated Billing and Coding Cheat Sheet here!
Resources mentioned in this episode:
If you liked this post, also check out:
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Hey there, welcome to the Real World NP podcast.
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I'm Liz Rohr, family nurse practitioner, educator, and founder of Real World NP,
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an educational company for nurse practitioners in primary care.
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I'm on a mission to equip and guide new nurse practitioners so that they can feel confident,
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capable, and take the best care of their patients.
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If you're looking for clinical pearls and practice tips without the fluff,
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you're in the right place. Make sure you subscribe and leave a review so you won't
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miss an episode. Plus, you'll find links to all the episodes with extra goodies
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over at realworldnp.com slash podcast. Well, hey there, it's Liz Rohr from Real
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World NP. You are watching NP Practice Made Simple, the weekly videos to help save you
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time, frustration, and help you learn faster so you can take the best care of your patients.
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In this week's video, I'm going to be talking about the billing and coding updates for 2021.
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If you haven't watched it already, I've actually made another video about billing and coding,
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really the foundations of choosing an office billing code for primary care.
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Definitely go back and watch that if you haven't already. I'll link to it down below
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this video and at the top right if you're watching on YouTube. Definitely check that out
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because I'm going to be referencing those foundational elements in this video.
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Jumping in, very brief refresher. Again, if this is confusing, then please go back
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and watch the other video. As a quick refresher, the way that the billing and
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coding guidelines have worked so far, very, very large overview. In primary care,
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there are three main buckets of visits. There are office visits. Those are things like
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urgent care visits, like urgent complaints rather, chronic care conditions, follow-ups,
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et cetera, et cetera. There are physicals, which have their own billing and codes,
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which I'm not talking about in this video. I'm really going to focus on the office visits
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themselves. The other one is procedures. They have their own considerations. I'm really just
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focusing again on office visits in this video. General approach to billing and coding. Again,
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a little bit of a refresher, but there's two major branch points. When it comes to choosing an
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E&M code, evaluation and management code, you need to look at whether somebody is an established
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patient or a new patient. New patients are any patients that are brand new to the clinic
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and you've never seen them before. They also could be a new patient or an established
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patient that hasn't been seen in the last three years. If it's been more than three
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years since you've seen them, they're technically considered a new patient. The reason that's
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important is that new patients typically reimburse at higher rates than established
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patients. They're more work involved. There's more thought involved.
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The other branch point is established patients. If they've been seen any time in the last
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three years at your clinic, they're considered established. The next point of decision making
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is that you want to think about how medically complex this patient is. Depending on that
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level, it's levels one through five. 99201 to 99205, 99211 to 99215. This is historical.
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This is a refresher. There's some changes with that. Typically speaking, there's levels one
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through five for both new and established patients. Historically, this is still relevant,
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so I'm going to do a quick refresher. Historically speaking, the way I recommend
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choosing a billing and coding guide number one through five is by first thinking through
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the medical decision-making thought process. It's called MDM. It's part of the guidelines.
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Again, go back and watch that video that I did originally on this topic if you're not
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familiar or haven't watched it already. I talk about how you come up with your medical
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decision-making. Basically, straightforward medical decision-making through high-level
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medical decision-making and the steps really walk you through. Also, on that note, there's
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a cheat sheet down below this video, an updated cheat sheet to print out and keep
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as a reference for billing and coding guidelines. Again, if you want to think more about medical
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decision-making thought process, please go back and watch that. I don't want to
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do a full refresher in this video, so go back and watch that. Once you've chosen that,
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the next step after that is to choose the appropriate documentation to support that level
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of coding. That's the simplest way to break it down is that there's different rules
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of what you need to document for every levels one through five, depending if they're a new
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patient or an established patient. That's in that cheat sheet and it's in those guidelines.
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I actually have the guidelines linked down below. One other disclaimer I forgot to say
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is that I'm not a billing and coding expert. I'm a nurse practitioner. This is based on
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my review of the updated guidelines as well as my current clinical practice.
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After you've determined if they're new or established, you've determined the level
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of medical decision-making level one through five, then you can make sure that you document
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the appropriate things. Enough in the HPI, enough things in the review of systems,
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enough things in the physical exam, enough social history questions, etc. Again,
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goes into depth in that. Then you come up with your code. That's a very brief refresher
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on the way it's been. Most of that is still relevant. I want to tell you about the changes
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of what has been changed since, and I have my notes down here so you might see me peeking
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down so I don't misspeak. First thing that has changed for office visits is that level one,
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99201 for new patients, no longer exists. For new patients, you have to choose levels two
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through five. That's just gone. The next really exciting change is that, like I said,
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typically the branch point has been newer established level of medical decision-making
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one through five and then making sure you document those things appropriately based on
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that billing code. The thing that has changed, like a really core thing is that you can either
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choose your level one through five based on the level of medical decision-making or the total
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spent on the encounter for that day. I'm going to read you the exact verbiage so you know what
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I'm talking about. I'm not misspeaking. I want to talk about time. Again, it's total time spent
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on that visit. From this documentation, from the guidelines themselves, it includes both face
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to face and non-face to face time personally spent by the provider on the day of the
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encounter. What does that even mean? Basically, instead of doing that whole one, two, three,
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four step process, you still have to determine if they're new or established,
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but you can choose your billing code based on the amount of time you've spent with that
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patient. I want to talk about the things that are included and not included. The things that
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are included, obviously direct patient care face to face time is included. Non-face to face time
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includes preparing to see the patient, for example, review of tests. The next one is obtaining
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and or reviewing separately obtained history. If you look at, I'm not sure exactly what that
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means, but I'm intuiting that it refers to if you had somebody room the patient first,
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the medical assistant or a nurse, depending on the staffing at your clinic, you're reviewing
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that history. Maybe you're reviewing previous notes from another provider. Maybe you're
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reviewing specialist notes before going into the patient visit. The next thing is counseling
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and educating the patient, family and or caregiver. I have a note about that, so just hold that
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thought. Ordering medications, tests or procedures. How much time do we spend outside of patient
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visits, taking care of them, doing these things, right? Referring and communicating
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with other healthcare professionals. I have a note about that too. Documenting clinical
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information and the EHR. That's pretty cool or regular health record, whatever you use.
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The next thing that's also included in time is independently interpreting results
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and communicating results to the patient, family slash caregiver in the context of the visit
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that day. Then the other piece is care coordination. If you're doing a lot of care
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coordination related to that visit at that day, that counts for that visit.
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The kind of caveats I want to make about education and about a couple of other things
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I mentioned. When it comes to education, the things that are not counted as part of time,
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the caveat in the guidelines say that teaching that's general and it's not specifically related
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to that specific patient case does not count. I don't really know what the hair splitting is
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on that piece. I think as long as you're educating you yourself as the provider or
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educating the patient from your level of expertise, then that's relevant to that
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versus general health teaching. It's really hard to say, but that's how I'm interpreting that,
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but that's verbatim what it says. Again, those are linked down below if you want to peruse those
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yourself. Very riveting. Then the other thing that's not allowed is travel, which we probably
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knew that, but the other thing that's not allowed in terms of time is including services
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performed separately from the visit that you've billed for separately. What does that even mean?
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I talk about the basics of primary care and then the fancy part of primary care.
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I think it makes sense to the people that I work with when we've talked about fancy tests
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and fancy whatever, but when it comes to billing and coding, there's a lot of basics that we
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all need to know. Then there's those quote unquote fancy ... The more you know, the more
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you develop your knowledge about a topic, you can expand your scope of how much fancy
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billing you're doing. I don't know. That's not very clear, but that's the general gist
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of what I'm talking about. Basically, I do not do this in my current practice, but theoretically,
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there are certain things you can perform and bill for outside of a patient visit. For example,
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care coordination done separately from a visit that day, theoretically, there's a billing code
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associated with that. I am not savvy about that, but that is something to talk about with your
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supervisor and or your billing department if they have recommendations of the common things
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you're doing outside of regular patient care and what you're allowed to bill for.
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Theoretically, according to these guidelines, care coordination, communicating results,
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and collaborating with other healthcare professionals could theoretically be billed
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for outside of a visit that day. That's what I'm talking about. If you're billing for ...
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If you're doing that fancy billing and you're billing for coordination with a specialist
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and communication with them, and then you see them that day, and then you also include it
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in time, that doesn't count. It's not like double documentation. Those are the two notes
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of things that were not included. You can't bill for a separate service and then include
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it in the time, and then all of your teaching needs to be specific to that patient related
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to your level of expertise as the provider versus a nursing level care, potentially.
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That's how I'm interpreting it. The other updates I wanted to share
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is again, if we kind of just a recap, when it comes to choosing a billing code,
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are they new or established? The next step is you can either do based on time
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or medical decision making. You don't have to do it by medical decision making anymore.
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You could just choose by time. There's time ranges for each of the levels,
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which actually is in the cheat sheet down below, so definitely download that if you
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haven't already updated. You can choose it based on the time. Then the other piece,
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typically before, what I'd recommend is looking at your level of medical decision making and
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choosing the appropriate documentation to go with it so that you're billing at a level four and
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you're documenting at a level four. The new guidelines say verbatim, it says history and
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physical are only performed medically as only as medically appropriate. I'm assuming that's
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performed and documented, because if you don't document it, then you didn't do it.
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But yeah, it seems like it's really kind of lightened up on those strict rules about
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what needs to be documented for what, specifically as it relates to the history and exam.
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There are other components, and like I said in the other video about review of systems
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and family history and social history, et cetera, et cetera. The only thing that it
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says in the guidelines as far as I understand is history and physical only as medically
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appropriate. One last thing that I wanted to add, and again, I'm not a billing and coding
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specialist, so those are the biggest changes. There could be potentially some other ones,
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including extended time, which I'm not going to talk about in this video,
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but it's in the guidelines down below. If you go beyond either 75 minutes as a new patient or
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beyond 55 minutes as an established patient, there are special codes for extended visit times,
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which I have not used, but something to consider. For Medicare-specific patients,
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there is a new code GPC1X. I'm looking down at my notes so I don't misspeak. But
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basically, it's an add-on code that you add for patients who are more medically complex.
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It describes the work associated with visits that are part of, quote,
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ongoing comprehensive primary care and or visits that are part of ongoing care related to a
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patient's single, serious, or complex chronic condition. That's all I know about that code.
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I have not used it myself yet, but just a little side note there. But yeah, those are the
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things that you can really account for the amount of time that you spend with a patient.
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When it comes to the medical decision-making, if you apply that table and you look at all
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the different factors, you might come up with a three, but because of a variety of other factors,
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your time may actually match up with a four. You can do either or. You might spend a level
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three amount of time with a patient, but address a four level worth of problems and
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decision-making and risk. So then you choose that one, right? So you just, you have options.
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And I didn't see anything specifically about time documentation, but for my personal practice,
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I have a quick text where I say this amount of time was spent with this patient in this visit
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to help support if I've chosen a billing code based on time versus medical decision-making.
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Hopefully this video was helpful. Let me know what questions you have.
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If you haven't grabbed the ultimate resource guide for the new NP,
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head over to realworldnp.com slash guide. You'll get these videos sent straight to your inbox
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every week with notes from me, patient stories and bonuses. I really just don't share anywhere
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else. You will also get the ultimate resource guide, which is a compilation of my favorite
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resources to really save you that time of weeding through all of the different myriad
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of options and assessing whether or not they're evidence-based and or trustworthy.
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So hopefully that will be very helpful for you as well. But thank you so very much for
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hanging in there and I'll see you soon. That's our episode for today. Thank you
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so much for listening. Make sure you subscribe, leave a review and tell all your NP friends
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so together we can help as many nurse practitioners as possible give the best
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care to their patients. If you haven't gotten your copy of the ultimate resource guide for
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the new NP, head over to realworldnp.com slash guide. You'll get these episodes sent straight
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to your inbox every week with notes from me, patient stories and extra bonuses I really just
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don't share anywhere else. Thank you so much again for listening. Take care and talk soon.
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