Volledige transcriptie van Procedures and Postpartum (June 30 recording of Town Hall series)

the hospital and the patient is later admitted, the time period begins upon hospital admission. 00:06:26.319 --> 00:06:30.639 For outpatient postpartum visits, there are four MDM levels. 00:06:30.800 --> 00:06:34.240 There is straightforward, low, moderate, and high. 00:06:34.560 --> 00:06:41.040 And to the codes at these levels, as you can see on this table, there are three groups of factors that you need to consider. 00:06:41.680 --> 00:06:49.360 The problems being addressed, the amount and or complexity of data to be reviewed and analyzed, and the risk of management. 00:06:49.680 --> 00:06:53.519 And I'll be going through these three factors in the next few slides. 00:06:54.800 --> 00:07:02.560 So as seen on the table, problem complexity is categorized as minimal, low, moderate, or high. 00:07:02.800 --> 00:07:14.720 Minimal complexity includes a minor problem, while high complexity includes a severely exacerbated chronic condition or a condition that poses a threat to life or bodily function. 00:07:16.560 --> 00:07:20.000 The second factor in medical decision making is data. 00:07:21.600 --> 00:07:26.959 For the minimal category of data, that would include zero to one tests, documents, or orders. 00:07:27.279 --> 00:07:40.879 For the low category, you must meet the requirements of at least one of these two categories, which is any combination of two tests, documents, orders, or an assessment that requires an independent historian. 00:07:41.759 --> 00:08:04.000 For the moderate category, you must meet the requirements of at least one of these three categories, any combination of three of tests, documents, orders, or hysterion, independent interpretation of tests, discussion of management or test interpretation with external physician or other qualified healthcare professional. 00:08:08.319 --> 00:08:15.920 Risk at the visit is categorized as minimal, low, moderate, or high based on the risk associated with the patient's management. 00:08:16.319 --> 00:08:22.560 The table here provides examples of activities and conditions that fall into each risk category. 00:08:24.639 --> 00:08:30.399 So when coding based on time, consider the total time spent on the date of the encounter. 00:08:30.879 --> 00:08:40.240 This includes time spent with the patient, communicating with family or caregivers, ordering services, reviewing results, and coordinating care. 00:08:41.919 --> 00:08:51.840 When selecting an office or outpatient EM code based on total time, choose the code that corresponds with the total time personally spent on the date of the encounter. 00:08:52.639 --> 00:09:09.360 For new patients, use CPT code 99202 when the total documented time is 15 minutes, 99203 for 30 minutes, 99204 for 45 minutes, and 99205 for 68 minutes. 00:09:10.159 --> 00:09:28.159 For established patients, you use CPT code 99212 for a 10-minute visit, 99213 for 20 minutes, 99214 for 30 minutes, and finally 99215 for 40 minutes of total time documented on the date of the encounter. 00:09:39.279 --> 00:09:50.000 It signals to payers that the service being billed is part of maternal care, distinguishing it from general medical services that may use the same CPT codes for ENM visits. 00:09:52.159 --> 00:09:56.720 So that concludes the overview of the new procedure and postpartum ENM codes. 00:09:56.960 --> 00:10:07.600 Before we jump into the QA portion, I'm joined today by two of our coding experts from the Committee on Health Economics and Coding, or Chuckford short, Dr. 00:10:07.759 --> 00:10:09.120 Lisa Hoffler and Dr. 00:10:09.200 --> 00:10:10.559 Adrian Zertucci. 00:10:11.200 --> 00:10:13.440 Please go ahead and introduce yourselves. 00:10:19.600 --> 00:10:20.960 Hi everyone, I'm Dr. 00:10:21.039 --> 00:10:22.080 Lisa Hoffler. 00:10:22.480 --> 00:10:28.559 I'm one of the CPT advisors for ACOG to the CPT editorial panel. 00:10:29.519 --> 00:10:34.639 I was part of the maternity care services work group that helped create this code. 00:10:35.039 --> 00:10:45.919 And in my day job, I'm a complex family planning subspecialist and I also provide inpatient labor and delivery at the University of New Mexico where I'm faculty. 00:10:47.600 --> 00:10:48.720 Good evening, everyone. 00:10:48.799 --> 00:10:50.240 I'm Adrienne Zertucci. 00:10:50.320 --> 00:10:55.279 I'm a general OBGYN in Atlanta and a former member of ACOG's coding committee. 00:10:55.360 --> 00:10:58.559 And I currently serve as the chair of the Georgia section of ACOG. 00:10:58.720 --> 00:11:00.240 Good to be here with y'all. 00:11:01.120 --> 00:11:01.600 Great. 00:11:01.759 --> 00:11:03.360 Thanks for those introductions. 00:11:03.840 --> 00:11:06.559 Now we can jump into the QA portion. 00:11:06.799 --> 00:11:10.399 So we can start with the hemorrhage, the new hemorrhage management code. 00:11:10.639 --> 00:11:11.039 Dr. 00:11:11.120 --> 00:11:16.960 Hoffler, can you walk me through the scenario where the uterine tamponate code would be used? 00:11:17.120 --> 00:11:18.879 And how would it be documented? 00:11:19.039 --> 00:11:21.759 And also, is it different than medical managements? 00:11:24.159 --> 00:11:26.559 Thanks for starting us with this question. 00:11:27.440 --> 00:11:35.200 I would like to say of all of the new codes, the uterine tamponade code is by far the most exciting one to me. 00:11:36.320 --> 00:11:39.200 So you already know what uterine tamponade is. 00:11:39.279 --> 00:11:42.639 This is the procedural management of postpartum hemorrhage. 00:11:42.879 --> 00:11:49.279 And it's called uterine tamponade because CPT is for procedures and postpartum hemorrhage is a diagnosis. 00:11:49.519 --> 00:11:56.879 And so we will all get used to saying uterine tamponade when we mean, you know, procedural management of postpartum hemorrhage. 00:11:57.919 --> 00:12:01.360 So this is work that you already do all the time. 00:12:01.519 --> 00:12:03.360 You're very, very familiar with. 00:12:03.519 --> 00:12:08.159 And it's been really challenging

that we have not been able to report this work before now. 00:12:08.399 --> 00:12:12.879 As you know, a postpartum hemorrhage is pretty intense, scary. 00:12:13.120 --> 00:12:14.240 Um, it's a big deal. 00:12:14.320 --> 00:12:18.879 It's one of the reasons uh, you know, the most common obstetrical emergencies there is. 00:12:18.960 --> 00:12:23.600 Um, and so it's very exciting that we now have a code to be able to report this work. 00:12:24.639 --> 00:12:28.720 So you know clinically when you would use a uterine tamponade. 00:12:29.039 --> 00:12:34.480 It's when you place a device during a postpartum hemorrhage that's not responsive to medical management. 00:12:34.720 --> 00:12:44.240 So medical management of postpartum hemorrhage by itself is included in the delivery code, which makes sense because we routinely give uterotonics after delivery. 00:12:44.320 --> 00:12:51.600 And so it's hard to say, you know, when is our oxytocin just our prophylactic versus when is it hemorrhage management? 00:12:51.679 --> 00:12:58.320 Um, and so all of the medical management of hemorrhage is included in a vaginal delivery code or a cesarean delivery code. 00:12:58.639 --> 00:13:12.960 Um sometimes, you know, we have to give a little bit more medicines if there's a little more bleeding, but often if there's uterine acne that's not responsive to medications, the next step in hemorrhage management is uterine tamponon. 00:13:13.039 --> 00:13:22.080 So this is the code we use to report the work of placing that device or even packing, if you don't even have a device, into the uterus for hemorrhage management. 00:13:22.159 --> 00:13:28.720 So this would be your, you know, your big intrauterine balloon that takes, you know, 500 milliliters of fluid. 00:13:28.960 --> 00:13:34.559 This would be, you know, maybe a smaller catheter that you would fill up if you don't have a big balloon. 00:13:34.799 --> 00:13:49.840 It would be one of those vacuum devices that you hook up to suction and that has a gentle suction to remove any clot and sort of reduce the hemorrhage that way, or packing that you might put, you know, thrombin soaked packing, whatever you have. 00:13:50.080 --> 00:13:57.919 All of that work of placing a device or packing into the uterus for hemorrhage management is uterine tamponade. 00:13:58.879 --> 00:14:04.960 I want to say also that this code, 59623, is only for the work of the tamponade procedure. 00:14:05.039 --> 00:14:09.600 So placing that, you know, device or packing, balloon, vacuum, whatever it is. 00:14:09.919 --> 00:14:22.159 Postpartum dilation and curatage, which we already do have a code for, for, for example, retained products of conception, uh, is still coded with the existing code, which is 59160. 00:14:22.480 --> 00:14:25.840 And so if clinically indicated, you can report both together. 00:14:26.000 --> 00:14:34.879 And I certainly have scenarios where I need to place a uterine tamponade device, but the uterus itself is empty and it's just

at me. 00:14:35.039 --> 00:14:42.879 And I have scenarios where I need to do a postpartum dilation and curatage, and I don't need to place a uterine tamponade device. 00:14:42.960 --> 00:14:44.320 And sometimes I need to do both. 00:14:44.879 --> 00:14:53.519 If the person has hemorrhage because of retained products, I do the postpartum dilation and curatage, they're still bleeding, and so then I do a uterine tamponade. 00:14:53.759 --> 00:14:57.840 So those are reported separately if they both occur. 00:14:58.559 --> 00:15:08.639 In terms of documentation, you probably already have a documentation process for uterine tamponade because this is a procedure that's been in widespread use for a very long time. 00:15:08.879 --> 00:15:13.120 And the challenge that we've had is there hasn't been a way to report it before now. 00:15:13.440 --> 00:15:26.080 So using your usual documentation practices for when you place a vacuum or a balloon or a hemorrhage management device, that procedure of uterine tamponade, you know, usually the device stays inside the patient. 00:15:26.159 --> 00:15:28.000 So you need to have documentation for that. 00:15:28.159 --> 00:15:31.200 Often the devices require some amount of fluid in them. 00:15:31.360 --> 00:15:39.279 So you need to document how much fluid is there in order that you or the next person knows how much to remove when you go to take down that device. 00:15:39.440 --> 00:15:43.840 Um, and so a procedure note or an operative note would be appropriate. 00:15:44.000 --> 00:15:47.679 It's likely though that you're already documenting what you need to. 00:15:47.840 --> 00:15:54.080 Um, and so so continuing to document that procedure of uterine tamponade, now we've got a way to report it. 00:15:54.240 --> 00:15:58.000 Again, for me, this is the most exciting code in the whole new set. 00:15:58.960 --> 00:15:59.600 Amazing. 00:15:59.840 --> 00:16:01.440 Great, thank you so much for that. 00:16:01.679 --> 00:16:01.919 Dr. 00:16:02.080 --> 00:16:09.360 Zertucci, what are the differences between billing for first, second, third, and fourth degree lacerations? 00:16:09.759 --> 00:16:16.960 And what should be document documentation, what should the documentation show to distinguish between the degrees? 00:16:18.320 --> 00:16:18.720 Sure. 00:16:18.879 --> 00:16:19.919 That's a great question. 00:16:20.080 --> 00:16:29.679 I think what's most important to understand about these new codes is that the usual best practice regarding our obstetric lacerations is unchanged. 00:16:29.840 --> 00:16:43.519 You know, at every delivery, each clinician should describe the laceration and any other relevant findings, make a diagnosis that is explicitly name the degree of the perineal laceration, and then document their approach to the repair. 00:16:43.840 --> 00:16:54.639 The key thing to remember as it pertains to billing, however, is that the work, quote unquote, of a first or a second degree laceration repair is included in the vaginal delivery service. 00:16:54.879 --> 00:17:11.200 Although a small asterisk to that is that is that is that if it is performed by a clinician that is not the delivering clinician or of the same specialty or part of the same practice, then the work of that first or second degree repair is separately reported as a five nine three zero zero. 00:17:11.599 --> 00:17:21.119 But more importantly, and what I'm more excited about for third and fourth degree laceration repairs, these newly announced codes make these lengthier procedures separately billable. 00:17:21.359 --> 00:17:33.119 So a clinician should code a third degree epesiotomy or laceration repair as a 59433, as was listed in the slides prior, and a fourth degree repair as a five nine four three four. 00:17:33.440 --> 00:17:38.160 Generally, for any of the lacerations, a separate procedure note is not required. 00:17:38.319 --> 00:17:42.480 That is, the description of your repair can be included in your original delivery note. 00:17:42.640 --> 00:17:49.359 However, if you move to the operating room for repair, you might want to consider a new note or certainly if it's required by your payer. 00:17:50.960 --> 00:17:51.440 Great. 00:17:51.599 --> 00:17:52.160 Thank you. 00:17:52.480 --> 00:17:52.799 Dr. 00:17:52.960 --> 00:18:00.559 Hoffler, what if the patient delivers vaginally, is admitted as an inpatient, and hemorrhage during the inpatient stay? 00:18:00.799 --> 00:18:03.279 Describe the stages of hemorrhage management. 00:18:03.519 --> 00:18:08.000 Can you build the uterine tamponage code days after the delivery? 00:18:09.519 --> 00:18:11.519 This is a great question. 00:18:11.599 --> 00:18:16.079 It's a less common scenario, but this is still a scenario that we're familiar with. 00:18:16.559 --> 00:18:34.000 So, for example, probably the most common manifestation I would say is that the person delivers in the evening on one day and then is transferred to postpartum care and then has some excessive bleeding on the postpartum floor early the next morning. 00:18:34.160 --> 00:18:42.319 So it's on a different calendar date, or they're in a different unit, for example, and then you're called for hemorrhage management. 00:18:42.559 --> 00:18:45.359 And so clinically, again, you know what to do. 00:18:45.440 --> 00:18:48.640 And this is a scenario that many of us have all seen before. 00:18:48.880 --> 00:18:53.680 So if there's a delayed postpartum hemorrhage, you know how to evaluate and manage it. 00:18:54.400 --> 00:19:06.480 You know, commonly this would include, for example, a an ultrasound, um, you know, a pelvic ultrasound that if you document and capture the images correctly, you could potentially bill that ultrasound. 00:19:06.640 --> 00:19:16.000 Um, if there's retained products of conception, you might need to do a postpartum dilation and curatage, that 59160 we talked about before. 00:19:16.240 --> 00:19:24.240 Uterotonic medications, of course, for postpartum hemorrhage

management, um, are definitely indicated. 00:19:24.319 --> 00:19:33.680 And then uterine tamponade, if indicated, again, if there's um some clot or some acne that has come out, and now you want to place that device. 00:19:33.839 --> 00:19:42.960 And this again would be a balloon, a vacuum, a catheter, even packing, whatever is needed to manage that hemorrhage. 00:19:43.359 --> 00:19:58.240 Um, and so the secondary or delayed postpartum hemorrhage is less common, but certainly you still do similar work and you can report the uterine tamponade code anytime that you need to place a device. 00:19:58.400 --> 00:20:01.519 So it's not restricted to immediately after the delivery. 00:20:01.680 --> 00:20:12.720 It's not restricted to the same date of delivery, um, but really uh whenever you need to manage that postpartum hemorrhage through uterine tamponade, that's what this code is for. 00:20:14.000 --> 00:20:14.640 Great. 00:20:15.119 --> 00:20:15.599 Dr. 00:20:16.000 --> 00:20:21.759 Zertucci, let's say I have a patient with a no placenta accrita and a team in place. 00:20:22.000 --> 00:20:25.359 How are the new codes used for this type of situation? 00:20:26.319 --> 00:20:26.880 Sure. 00:20:27.039 --> 00:20:32.240 Um, delivering deliveries in the setting of a placenta accredita can certainly be scary. 00:20:32.480 --> 00:20:43.039 Um, but thankfully for all the stress that we endure in those situations, we now have these new codes to help ensure appropriate payment to the appropriate clinician. 00:20:43.200 --> 00:20:59.279 Um so to begin and to review from our session earlier this month on delivery codes, remember that the delivering physician in this scenario will still bill a 59502 for a primary C-section or a 59503 for a repeat C-section. 00:20:59.759 --> 00:21:01.759 And again, a small asterisk on that. 00:21:01.839 --> 00:21:12.400 Remember, for a primary C-section, you should also add the initial or subsequent inpatient services code because this work is not included under the guise of the primary C-section code. 00:21:12.640 --> 00:21:14.240 But back to the question at hand. 00:21:14.480 --> 00:21:30.000 So the C-section is performed, and if an accreto is confirmed interoperatively and a hysterectomy is decided upon, whether subtotal or total, then the 59504 hysterectomy after C-section code may also be billed for this additional procedure. 00:21:30.319 --> 00:21:36.480 The nice thing is that 59504 may be separately billed by an intra-op consultant. 00:21:36.559 --> 00:21:44.559 So for instance, if one of your gynecologic oncologist colleagues comes in or maternal fetal medicine subspecialist, they can bill that separately. 00:21:44.799 --> 00:21:52.720 Or it may also be billed by the same physician that performed the initial C section, although in that circumstance, a modifier may be required. 00:21:54.319 --> 00:21:54.799 Great. 00:21:55.200 --> 00:21:55.839 Now, Dr. 00:21:55.920 --> 00:21:59.359 Hoffler, let's say I have a patient that continues to hemorrhage. 00:22:19.519 --> 00:22:19.759 Dr. 00:22:19.920 --> 00:22:21.359 Hoffler, you're muted. 00:22:22.799 --> 00:22:23.359 Thanks, Dr. 00:22:23.519 --> 00:22:24.319 Zertucci. 00:22:24.640 --> 00:22:26.160 I was trying to be so kind. 00:22:26.480 --> 00:22:38.160 Um so in this scenario, I could envision actually two different scenarios where a uterine tamponade is performed and then a hysterectomy is needed. 00:22:38.319 --> 00:22:43.519 Um and the I think the question you might be asking is the scenario of Dr. 00:22:43.680 --> 00:23:01.839 Zertucci's patient where there was a high likelihood of needing a hysterectomy after cesarean and the patient, you know, really wanted you to try to not perform one, or maybe it isn't an expected or a planned hysterectomy after cesarean. 00:23:02.000 --> 00:23:06.160 Um and again, like this is a really high stress situation. 00:23:06.400 --> 00:23:18.640 But in in the first scenario that we'll talk about, say the patient has a cesarean delivery, and then there's uterine acne and a hemorrhage that's unsuccessfully managed with medications. 00:23:18.799 --> 00:23:29.839 So this might be a primary cesarean, often is a time when there's the person's been laboring for a while, say they've had um interuterine inflammation and infection there. 00:23:30.000 --> 00:23:38.559 Um they might have been on uh having you know labor induction medications or augmentation medications for a while. 00:23:38.720 --> 00:23:42.559 And so the risk of hemorrhage with acne is really high. 00:23:42.799 --> 00:23:53.279 So the person has a cesarean, there's some acne, and there's hemorrhage unsuccessfully managed with medications, and you decide to do a uterine tamponade as the next step. 00:23:53.440 --> 00:23:58.640 So then the device isn't working to manage the hemorrhage either, and the patient needs a hysterectomy. 00:23:58.880 --> 00:24:01.440 So in that case, you could bill all three codes. 00:24:01.599 --> 00:24:04.480 You would have the primary or the repeat cesarean. 00:24:04.720 --> 00:24:09.359 You know, in the scenario I gave I gave 59502 as the primary cesarean. 00:24:09.440 --> 00:24:17.039 That's I think the most profound uterine atne often that we see, a repeat cesarean's 59503, as you heard. 00:24:17.279 --> 00:24:22.000 So depending on the initial surgery, you bill your caesarean code, primary or repeat. 00:24:22.240 --> 00:24:33.119 Then you also report the uterine tamponade code, 59623, because you did perform the tamponade, and then the hysterectomy after cesarean code, which is 59504. 00:24:34.240 --> 00:24:48.079 I could actually envision a scenario where that's maybe more common, where the delivery, uterine tamponade, and then hysterectomy might be reported together more frequently, and that's after a vaginal delivery. 00:24:48.240 --> 00:25:05.279 So, in that scenario, say the person has a vaginal delivery, there's uterine acne, it's unsuccessfully managed with medications, you perform a

uterine tamponade, um, and then the device also doesn't manage the hemorrhage and the bleeding continues, and the patient needs a hysterectomy. 00:25:05.440 --> 00:25:08.480 Um, so in that case, you again would report three codes. 00:25:08.640 --> 00:25:19.519 You would report the vaginal delivery code, the 59431 if it's a vaginal delivery like a routine one, and five nine four three two if it's a VBAC. 00:25:20.079 --> 00:25:22.880 You would report your uterine tamponade code again. 00:25:22.960 --> 00:25:24.960 So that's five nine six two three. 00:25:25.119 --> 00:25:30.880 And then because she had a vaginal delivery, you would not report hysterectomy after cesarean. 00:25:31.039 --> 00:25:37.200 You would instead report the appropriate hysterectomy code depending on the surgery you did. 00:25:37.440 --> 00:25:41.279 In my practice, this is most often the abdominal hysterectomy code, right? 00:25:41.359 --> 00:25:47.599 We're not doing very many minimum invasive hists for profound postpartum hemorrhage. 00:25:48.079 --> 00:25:58.400 So using one of the vaginal, the abdominal hysterectomy codes, I'm sorry, um, depending on the surgery that's performed, is what I would report in that case too. 00:25:58.559 --> 00:26:04.319 So you would again report all three: your delivery, your tamponade, and your hysterectomy. 00:26:05.599 --> 00:26:06.240 Great. 00:26:06.559 --> 00:26:06.960 Dr. 00:26:07.119 --> 00:26:12.240 Zertucci, what if the patient insists on being discharged the day of delivery? 00:26:12.480 --> 00:26:15.680 Can I bill for an inpatient visit and discharge? 00:26:17.440 --> 00:26:18.079 Excuse me. 00:26:18.160 --> 00:26:22.720 Um, in that, I would say relatively uncommon scenario, unfortunately, the answer is no. 00:26:23.039 --> 00:26:36.559 So remember that the work done to provide immediate postpartum care, that is, that occurring on the same calendar date as the delivery, is included in the standard vaginal and cesarean delivery codes. 00:26:36.720 --> 00:26:43.759 Postpartum care is really only separately reportable and thus billable starting the calendar date after delivery. 00:26:43.920 --> 00:26:50.000 Um, as such, you cannot separately bill for inpatient or discharged service services on the day of delivery. 00:26:53.200 --> 00:26:53.519 Dr. 00:26:53.599 --> 00:26:59.519 Hoffler, how do we code for a postpartum patient who ends up in the ICU for a period of time? 00:27:01.359 --> 00:27:01.839 Thanks. 00:27:02.000 --> 00:27:04.319 You know, this is a scenario that happens. 00:27:04.559 --> 00:27:10.319 It's scary, and we've all experienced it where our postpartum patient goes to the ICU. 00:27:10.720 --> 00:27:16.880 Uh so you can report critical care codes for a postpartum patient who requires critical care. 00:27:17.200 --> 00:27:19.599 Um and the, as Dr. 00:27:19.759 --> 00:27:27.440 Zertucci just said, the CPT maternity instructions state on the same calendar date as delivery care. 00:27:27.519 --> 00:27:35.920 You don't report subsequent hospital inpatient, you don't report hospital observation codes, and you don't report discharge care codes. 00:27:36.079 --> 00:27:41.759 But the instructions don't preclude reporting critical care services on the same date as delivery. 00:27:42.000 --> 00:27:57.839 And as this group is well aware, usually it's the date of delivery that the person needs the critical care services most frequently and often, you know, right around the time of birth is when the risk and the intensity is the highest. 00:27:58.000 --> 00:28:07.519 And so critical care services may be reported on the date of delivery and may be reported on subsequent days if the patient still requires critical care services. 00:28:08.319 --> 00:28:21.599 In many institutions, it's going to be a different critical care physician who's reporting all the critical care services, but it could be the case that the delivering obstetrician is also the one who's providing critical care services postpartum. 00:28:21.839 --> 00:28:27.119 And in those cases, the delivering obstetrician may report the critical care codes and should. 00:28:28.880 --> 00:28:29.279 Great. 00:28:29.440 --> 00:28:29.920 Thank you. 00:28:30.160 --> 00:28:30.480 Dr. 00:28:30.640 --> 00:28:36.319 Zersushi, do we need to bill every day postpartum while the patient is in the hospital? 00:28:37.680 --> 00:28:51.519 Yes, I would say it is best practice to round on, document services for, and thus to bill accordingly on each postpartum day that your patient remains in the hospital, again, beginning the day after delivery. 00:28:52.400 --> 00:29:01.519 As Helena mentioned before, you can choose from any of the 99231, two, or three codes, which are those for subsequent inpatient or observation care. 00:29:01.680 --> 00:29:14.480 And you can make those selections based on your medical decision making being low, moderate, or high, or based on total time spent on the encounters being 25, 35, or 50 minutes, respectively. 00:29:15.359 --> 00:29:21.119 But remember, however, that billing on the day of the discharge is treated slightly differently. 00:29:21.279 --> 00:29:35.759 On that day, you should select either that 99238 or 99239 based on if less or more than 30 minutes is spent on all of the care provided that day, which can really include a smattering of things, right? 00:29:35.920 --> 00:29:49.759 A review of the hospital stay with the patient, your final physical exam, the extensive counseling we provide on instructions and expectations, preparing, preparing their prescriptions and writing their referrals, and even drafting their discharge summaries. 00:29:52.559 --> 00:29:52.880 Dr. 00:29:53.039 --> 00:29:56.799 Hoffler, how do the new codes impact IPP LARK? 00:29:58.720 --> 00:30:02.799 Helena, how did you know that I also love immediate postpartum LARC? 00:30:03.200 --> 00:30:10.319 Um, this this is an exciting, I think, development in the codes, just that we can report everything that we do. 00:30:10.400

--> 00:30:12.880 And so it becomes a little bit more natural. 00:30:13.200 --> 00:30:28.319 And actually, these new maternity codes should not significantly impact immediate postpartum LARC because we've always had to report uh placing an IUD, placing an implant separate from the maternity bundle. 00:30:28.480 --> 00:30:38.799 And so that those codes are the same codes that we use for an office procedure, 58300 for the IUD, 11981 for the implants. 00:30:38.960 --> 00:30:48.640 Um and so continue to use those same codes for reporting the work of placing the device, um, the IUD or the implant immediately postpartum. 00:30:49.119 --> 00:31:02.160 I think the piece of this that's exciting for me is some payers have said that they cover immediate postpartum LARC through the OB Global being higher than it otherwise would have been, perhaps. 00:31:02.319 --> 00:31:08.240 Um, but they pay the same whether or not you provide immediate postpartum LARC. 00:31:08.480 --> 00:31:12.240 And so the new codes that we have kind of make that argument impossible. 00:31:12.319 --> 00:31:16.559 And it's much more clear what care is covered. 00:31:16.799 --> 00:31:27.039 And if a payer doesn't, like the patient can see that more readily, the clinician can see that more readily, and you know, advocate for change if not covered. 00:31:27.200 --> 00:31:35.680 Um, and because there is no global maternity package anymore, it's very clear what's done and when and what time. 00:31:36.000 --> 00:31:43.039 Um, so for all of that, I would expect immediate postpartum LARC to continue to be reported the same way it has been. 00:31:43.279 --> 00:31:55.039 Keep reporting your placement code and your J code for the device, um, using your your IUD or your implant insertion code and your your Hicks picks for the device. 00:31:55.359 --> 00:32:08.319 And um I hope that this impacts immediate postpartum LARC in kind of a more policy way, where it becomes more clear what's covered and and where the advocacy lies if there's not coverage. 00:32:10.160 --> 00:32:10.400 Great. 00:32:10.480 --> 00:32:11.599 Thank you for that response. 00:32:12.079 --> 00:32:13.200 Uh now back to you, Dr. 00:32:13.359 --> 00:32:14.160 Susucci. 00:32:14.720 --> 00:32:17.359 This is a two-part question, so bear with me. 00:32:17.759 --> 00:32:20.400 Um, will the postpartum period still be six weeks? 00:32:21.200 --> 00:32:30.319 If patients come in for a true problem visit, for for example, vaginal discharge are not regularly scheduled postpartum visit, should it be billed differently? 00:32:30.880 --> 00:32:37.200 And a follow-up to that question is will EBDS continue to be reimbursed as a separate charge? 00:32:38.720 --> 00:32:39.519 Thanks, Selena. 00:32:39.599 --> 00:32:40.799 Those are great questions. 00:32:41.039 --> 00:32:49.200 Um, you know, this six-week postpartum period is really a vestige of when insurance coverage for maternity care stopped at six weeks. 00:32:49.440 --> 00:32:53.920 So we all did

a visit right before women lost access to further postpartum care. 00:32:54.319 --> 00:33:14.079 Um, but currently, and really for the foreseeable future, even as we transition to these new codes, we think of the postpartum period more as an ongoing fourth trimester without really a set end date and lasting truly as long as a woman is recovering from or needs any ongoing services related to childbirth. 00:33:14.319 --> 00:33:30.799 In fact, um ACOG's committee opinion on optimizing postpartum care says that in order to optimize the health of women and infants, postpartum care should be an ongoing process rather than a single encounter with services and support tailored to each woman's individual needs. 00:33:31.119 --> 00:33:40.559 This ACOG document also, more specifically and usefully, says all women should ideally have contact with a maternal care provider within the first three weeks postpartum. 00:33:40.720 --> 00:33:48.880 This initial assessment should be followed up with ongoing care as needed, concluding with a comprehensive postpartum visit no later than 12 weeks after birth. 00:33:49.119 --> 00:34:04.160 So to circle back, Helena, to your questions, um unrelated problem visits, for instance, about vaginal discharge and pregnancy or postpartum related visits specifically, can actually both be billed in the exact same way, right? 00:34:04.400 --> 00:34:07.599 Using these usual EM outpatient codes. 00:34:07.839 --> 00:34:22.000 And really, it will simply be at the discretion of the clinician and maybe the payer regarding whether or not we're using that TH modifier, which signals whether the care is specifically related to pregnancy or the postpartum state. 00:34:22.239 --> 00:34:39.920 And it seems, at least for now, although again, stay tuned, public exams, mental health screening, for instance, the EPDS, the Edinburgh Postpartum Depression Screen that you were referencing, may still be separately reported and billed, as these remain integral components of postpartum and GYN care. 00:34:41.280 --> 00:34:41.920 Thank you. 00:34:42.239 --> 00:34:42.639 Dr. 00:34:42.800 --> 00:34:53.280 Hoffler, how are postpartum visits now defined and builds, especially with emphasis on early follow-up, for example, one to two weeks for hypertension? 00:34:53.440 --> 00:35:03.679 Um, can postpartum complications like infection, anema, anemia, mental health conditions, can all of these be built separately from routine postpartum care? 00:35:06.320 --> 00:35:07.199 Thanks, Helena. 00:35:07.280 --> 00:35:08.639 This is a great question. 00:35:08.880 --> 00:35:18.880 And I think reflects how we used to think about the postpartum period when there was this kind of like bundle we had and the routine postpartum visit falls within it. 00:35:18.960 --> 00:35:28.719 And then if the patient has a complication, we should report that separately and be very explicit that this is not routine postpartum and requires a separate ENM. 00:35:29.280 --> 00:35:35.679 And people trying to follow the ACOG guidance on optimizing postpartum care. 00:35:35.840 --> 00:35:41.599 We're trying to find ways to describe and report the work of this ongoing fourth trimester. 00:35:42.400 --> 00:35:52.000 The postpartum period is really critically important for maternal well-being and for families, and the global maternity codes just made this really challenging. 00:35:52.239 --> 00:35:54.639 So now it's much more straightforward. 00:35:54.880 --> 00:35:59.119 All the postpartum care that you do is reported with EM codes. 00:35:59.440 --> 00:36:25.840 So if it's something that you would might have considered a routine postpartum visit versus a postpartum visit related to their pregnancy complication, like hypertension, versus a postpartum visit for something completely different, like a like a vaginitis at, you know, five weeks and six days postpartum or whatever you might have sort of separated these out in your mind. 00:36:26.000 --> 00:36:29.599 Now everything's an EM, so it becomes much more straightforward. 00:36:29.760 --> 00:36:36.480 And so it doesn't matter how soon the patient is seen or for what follow-up reason. 00:36:36.639 --> 00:36:40.239 Every postpartum visit is reported with an EM code. 00:36:40.639 --> 00:36:54.639 For most of these visits, these are going to be your uh your 99213, 99214, because it'll be an established patient that you have and sort of a problem-based visit. 00:36:54.719 --> 00:37:02.960 Um, but as you heard, the recommendation is within 12 weeks postpartum that there's sort of a comprehensive postpartum visit. 00:37:03.039 --> 00:37:09.119 And that you might consider as you know, your preventive visit using one of those preventive care codes. 00:37:09.280 --> 00:37:15.920 Um, so either way, those are all both EM codes, that's what should be reported for postpartum care. 00:37:16.239 --> 00:37:22.800 Um, just like with prenatal care, though, you would report one EM code per visit. 00:37:23.039 --> 00:37:38.880 So if the patient has routine postpartum follow-up care scheduled for, say, a one-week or a two-week check and they have a new problem or anemia or something, you wouldn't report two ENMs on the same day. 00:37:39.199 --> 00:37:52.079 You would instead, if that visit is more complex, if the patient has multiple unstable conditions, if you're doing a lot of medication management, then it's a higher level of EM code. 00:37:52.239 --> 00:38:04.480 So you would report one EM code, and then if multiple issues addressed, multiple data points, multiple levels of risk, right, that might change your level of visit for that postpartum visit. 00:38:05.039 --> 00:38:09.280 There's also care that can be reported separately from your ENMs. 00:38:09.519 --> 00:38:35.039 So this would be something like an iron infusion if the patient needs iron infusion for their anemia, or as you heard, the depression screening, or a pelvic exam, which still is separately reported from an EM visit, that add-on 99459

that we were so excited about a couple of years ago, to have have have sort of gotten a little bit closer to equity for the work that we're providing. 00:38:35.119 --> 00:38:42.079 Um, and so you might be able to report your EM plus one of or more of these additional codes if done. 00:38:42.239 --> 00:38:48.639 And then the last thing that I would say about this is remember to use the TH modifier for postpartum care too. 00:38:48.880 --> 00:38:59.119 So I think we might be used to thinking about all the antepartum period being pregnancy related and then postpartum as as being a little bit different. 00:38:59.199 --> 00:39:05.199 You know, this is one woman now who's not pregnant who I'm just carrying for as my longitudinal patients. 00:39:05.360 --> 00:39:08.960 Um, but remember, TH modifier is also used for postpartum care. 00:39:10.239 --> 00:39:10.559 Great. 00:39:10.960 --> 00:39:12.159 Thank you for clarifying. 00:39:12.320 --> 00:39:12.880 Uh Dr. 00:39:13.039 --> 00:39:13.840 Sartucci. 00:39:14.639 --> 00:39:20.880 Um for outpatient visits, how do we bill a postpartum appointment with placement of IED or next pollen? 00:39:21.199 --> 00:39:29.599 Or a well-woman visit with procedure or postpartum exam with extended time for problem or multiple problems. 00:39:29.840 --> 00:39:30.880 It's a lengthy one. 00:39:31.119 --> 00:39:32.079 All right, Helena. 00:39:32.159 --> 00:39:33.119 Thank you for that. 00:39:33.280 --> 00:39:40.960 Um, first I'll answer each of those special uh questions specifically and then kind of provide some general comments. 00:39:41.119 --> 00:39:45.679 Um, so the first one was about billing a postpartum appointment with a procedure. 00:39:45.920 --> 00:39:50.719 So for this, I mean again, we are using EM codes now for our postpartum appointments. 00:39:50.800 --> 00:40:00.400 So first you would bill, assuming it's an established patient, somewhere between a 99212 and a 99215, depending on all of the things we've discussed earlier. 00:40:00.639 --> 00:40:06.559 You would also add the TH modifier, which signals that the visit is related to maternity or postpartum care. 00:40:06.960 --> 00:40:09.679 You would add the appropriate procedure code. 00:40:10.000 --> 00:40:24.880 You could consider the 99459 if you are doing more of a contraceptive implant placement and not an IUD placement, because then the 99459 would be incorporated, the work of that would be incorporated into the IUD placement. 00:40:25.119 --> 00:40:31.440 And then finally, you would include the 25 modifier, which signals that multiple services were provided on the same day. 00:40:31.760 --> 00:40:46.960 Um, in the second scenario, to bill a well-woman exam with a procedure in the immediate postpartum period, you would code first for the appropriate preventive visit code based on age and whether they're new or established, the appropriate procedure code. 00:40:47.119 --> 00:40:49.519 Again, maybe consider that 99459. 00:40:49.760 --> 00:40:56.639 Um, if a

pelvic exam is performed, for instance, to collect a pat smear, but the procedure is not an IUD placement. 00:40:56.800 --> 00:40:58.800 And then again, that 25 modifier. 00:40:58.960 --> 00:41:10.880 But in this scenario, you might consider dropping the TH modifier because you're transitioning more from postpartum care to well woman or or longitudinal GYN care. 00:41:11.360 --> 00:41:34.400 And then the final scenario to bill a postpartum appointment with extended time or multiple problems, you would code, I would bet, a level four or a level five EM according to the level of medical decision making or the total time spent, as well as again that TH modifier signaling that at least a portion of the visit was related to the patient's postpartum state. 00:41:34.639 --> 00:41:40.000 Now, in case you didn't follow all of the rambling off of codes, again, let's step back and kind of echo what Dr. 00:41:40.079 --> 00:41:42.000 Hoffler was saying previously. 00:41:42.159 --> 00:41:52.880 Remember, billing for outpatient postpartum care and some of these associated items is now really simplified and generally should feel overall more familiar to all of us. 00:41:53.119 --> 00:42:06.079 Just like for your GYN patients and now also for your pregnant patients in the setting of these new maternity code changes, you can use the same ENM codes in accordance with new versus established and selected by medical decision making or time. 00:42:06.480 --> 00:42:25.199 And then just as you've heard us say a million times tonight, you can add the TH modifier if the care is related to the patient's postpartum state, in addition to any additional services or modifiers that you would need at the time of any other ENM visit, like the 99459 for pelvic exam or the 25 for multiple services. 00:42:26.960 --> 00:42:27.679 Thank you. 00:42:28.000 --> 00:42:28.320 Dr. 00:42:28.480 --> 00:42:38.559 Hoffler, how should coding reflects care transitions between inpatient and outpatient postpartum settings, especially with multiple providers involved? 00:42:40.559 --> 00:42:46.639 One of the nice things about this new reporting structure is that all the work can be reported. 00:42:47.199 --> 00:42:52.239 So every inpatient postpartum day is now reported with an EM. 00:42:52.480 --> 00:42:56.559 Every outpatient postpartum visit is also reported with an EM. 00:42:56.719 --> 00:43:02.079 And so all the multiple care providers involved can now report the work that they do. 00:43:02.639 --> 00:43:18.559 And understanding the number of days inpatient, the number of postpartum visits outpatient that people need or receive, the fact that we're able to code each of those and report is really great. 00:43:18.800 --> 00:43:24.320 So the clinician who reported the care on that date of service is the one who would report that care. 00:43:24.480 --> 00:43:35.519 So if uh you know, if I discharged a patient on today, I would report one of those discharge management codes, you know, greater than 30

minutes, less than 30 minutes. 00:43:35.679 --> 00:43:36.079 If Dr. 00:43:36.239 --> 00:43:43.199 Zertucci then saw her three weeks later for a postpartum visit, she would report the EM for that postpartum visit. 00:43:43.280 --> 00:43:47.280 So the person that provided the care on that date is the one that would report the care. 00:43:48.480 --> 00:43:58.239 There are transitional care management codes that exist, and in most cases, would not apply to standard postpartum care. 00:43:58.400 --> 00:44:01.440 Um, those are a little bit of an Different scenario. 00:44:02.159 --> 00:44:24.000 And there might be a very medically complicated patient who requires interaction with other physicians or qualified healthcare professionals, who might need referrals, who might need a lot of community resources that might be able to report the transitional care management codes, which have to do with moving from the inpatient setting to the outpatient setting. 00:44:24.480 --> 00:44:39.519 I would recommend, if you're considering this, to review the CPT coding manual for more information about the required elements of transitional care management services, because it also requires communication within two business days of discharge. 00:44:39.760 --> 00:44:44.880 It requires a moderate or high level of medical decision making during that period. 00:44:45.119 --> 00:44:52.400 It requires a face-to-face visit within either seven or 14 days, calendar days after the discharge. 00:44:52.559 --> 00:44:58.159 And so most postpartum people are not quite in that kind of situation. 00:44:58.719 --> 00:45:04.400 And so if you're thinking you might need to use transitional care management codes, look a little bit more into them. 00:45:04.559 --> 00:45:11.440 For most postpartum patients, though, it's going to be one EM code on every single date that you provide service. 00:45:11.519 --> 00:45:15.519 And the person that provides the care on that date is the person that reports it. 00:45:16.480 --> 00:45:16.880 Great. 00:45:17.039 --> 00:45:18.400 Thanks for clarifying that. 00:45:18.719 --> 00:45:19.039 Dr. 00:45:19.199 --> 00:45:28.400 Sartuchi, are there updated coding considerations for telehealth or remote monitoring and postpartum care? 00:45:28.559 --> 00:45:31.519 For example, for BP monitoring programs? 00:45:32.480 --> 00:45:33.599 Great question. 00:45:34.079 --> 00:45:36.559 And thankfully, there's a pretty simple answer to this. 00:45:36.719 --> 00:45:46.079 So postpartum telemedicine codes, like all other outpatient telemedicine codes, are simply selected based on the same criteria as all other ENM services. 00:45:46.159 --> 00:45:49.519 That is, again, by this medical decision making or by time. 00:45:50.000 --> 00:45:54.639 And remember, they cannot be reported on the same day as another in-person ENM service. 00:45:54.880 --> 00:46:06.480 So really the only difference with a postpartum telehealth coding or the only difference with postpartum telehealth coding

and billing versus other telehealth coding and billing is the use of that TH modifier. 00:46:06.880 --> 00:46:30.480 So to just briefly give you some specifics, if we were to use an established patient as an example, if you were to do an audio visual visual interaction, telehealth interaction with that patient, the code would be somewhere between 98004 and 98007, or audio only would be 98012 all the way up to 98015. 00:46:30.960 --> 00:46:38.079 And those will indicate straightforward low, moderate, or high medical decision making, or 10, 20, 30, 40 minutes spent. 00:46:38.239 --> 00:46:41.519 But again, just be sure to include that TH modifier. 00:46:42.880 --> 00:46:43.360 Great. 00:46:44.000 --> 00:46:44.400 Dr. 00:46:44.559 --> 00:46:50.400 Hoffler, how do these coding updates support improved capture of severe? 00:46:51.440 --> 00:46:53.519 Sorry, let me ask that again. 00:46:53.760 --> 00:47:00.239 How do these coding updates support improved capture of severe maternal morbidity and quality reporting? 00:47:00.480 --> 00:47:05.599 Are these opportunities to align new coding practices with QI initiatives? 00:47:05.920 --> 00:47:11.920 Example, hypertension bundles, and for both documentation and reimbursements. 00:47:13.840 --> 00:47:14.400 Thanks. 00:47:15.519 --> 00:47:25.920 So as you are all likely well aware, the global maternity code set has also prevented detailed understanding of obstetric care delivery. 00:47:26.159 --> 00:47:32.719 And as a scientist, this was really challenging for me and for many others. 00:47:33.280 --> 00:47:45.519 And as a pragmatist who was working with the AMA to create new codes, we were not really able to answer the question writ large, how long is labor? 00:47:45.760 --> 00:47:48.800 How many prenatal visits do people actually get? 00:47:49.119 --> 00:47:49.440 Right? 00:47:49.599 --> 00:48:03.360 We've had lots of shifts in the way that care is managed based on ACOG changing guidance on the way that pregnancy epidemiology has changed as patients might become sicker. 00:48:03.519 --> 00:48:07.519 And we really have not been able to answer these questions before now. 00:48:07.760 --> 00:48:28.800 So it's really great that now we're going to be able to have a more high-level understanding of maternal morbidity, of quality outcomes, because claims research has really been limited in obstetrics, just because we've had one global that we've reported and there's not much detail there. 00:48:29.440 --> 00:48:43.920 So excitingly, the new codes can provide data that we can then use to understand the relationships between care and maternal outcomes and uh acuity and maternal outcomes. 00:48:44.079 --> 00:48:48.960 For example, now we have straightforward labor management and complex labor management. 00:48:49.039 --> 00:48:52.800 And so the research implications are going to be substantial. 00:48:53.039 --> 00:48:57.519 Even on the surface of it, I think there's a lot of interesting questions that can be asked. 00:48:57.599 --> 00:49:04.400 And certainly as we dig closer, I think we're going to find associations that will help us provide better care for patients. 00:49:05.039 --> 00:49:23.840 There's going to be large aggregate data sets now that we can study, you know, the relationships between visit number and type and labor management and postpartum care and all of these different things that might impact patient outcomes that we haven't been able to understand previously. 00:49:24.480 --> 00:49:34.719 So I think if, especially if implemented thoughtfully, the codes should also provide a foundation for meaningful quality metrics. 00:49:34.880 --> 00:49:48.800 And I think a challenge with the quality metrics is we have so many questions at baseline, it's going to be really important to understand where we are before we start to say what should be. 00:49:49.360 --> 00:50:14.079 And so that is the piece I want to just say, implemented thoughtfully, we might be able to have improved risk adjustment, for example, on the insurance side, or much better research that describes modern obstetric practice, um, you know, distinguishing straightforward from complex labor management by measuring what does it really mean for postpartum care to be an ongoing process? 00:50:14.320 --> 00:50:26.159 And so outcomes like cesarean delivery or severe maternal morbidity or postpartum readmissions or hemorrhage care, mental health follow-up, all these possibilities exist. 00:50:26.400 --> 00:50:30.639 And so I think there's lots of opportunities to understand this. 00:50:30.800 --> 00:50:41.039 And what I really would encourage us to do is be excited and not too excited at the beginning because we don't know the basics. 00:50:41.199 --> 00:50:46.400 So really understanding the basics of where we are and then working on improvements. 00:50:48.400 --> 00:50:48.880 Great. 00:50:49.039 --> 00:50:50.159 Thank you for that. 00:50:50.480 --> 00:50:52.800 And finally, the last question goes to you, Dr. 00:50:52.960 --> 00:50:53.760 Sertucci. 00:50:54.159 --> 00:50:59.920 Are there any recommendations for outpatient postpartum documentation or modifier use? 00:51:01.360 --> 00:51:04.639 What a what excuse me, what a question to end on. 00:51:05.840 --> 00:51:29.599 So I would say, again, circling back to some of the guidance from ACOG, there are recommendations that the comprehensive postpartum visit should include the discussion of very particular things, you know, such as mood and emotional well-being, infant care and feeding, sexual sexuality and contraception, sleep and fatigue, physical recovery from birth, chronic disease management, et cetera. 00:51:29.840 --> 00:51:44.880 And additionally, um, it's recommended at these visits that women with pregnancies that are complicating pre-term delivery, gestational diabetes, hypertensive disorders should be counseled that these are associated with a higher lifetime risk of cardiometabolic disease. 00:51:45.119 --> 00:51:54.719 And

women who come into pregnancy with chronic medical conditions or are diagnosed with them during pregnancy should be counseled about the importance of timely follow-up and ongoing coordination of care. 00:51:54.960 --> 00:52:03.280 Now, all of that said, ACOG does not endorse any specific recommendations regarding documentation of all of these discussions, right? 00:52:03.360 --> 00:52:19.679 So, as been echoed throughout tonight, each clinician really should simply document the work that is being done, the conversations, those important conversations that you're having with your patients, and the medical decision making or time taken on the day of the encounter so that you can justify the code that you're billing. 00:52:19.920 --> 00:52:26.880 And for fear of sounding like a broken record, be sure to add that TH modifier if the visit is related to the patient's postpartum state. 00:52:27.760 --> 00:52:28.639 Amazing. 00:52:29.039 --> 00:52:31.519 Thank you both for taking time to answer these questions. 00:52:31.679 --> 00:52:32.960 We really appreciate it. 00:52:33.199 --> 00:52:36.400 That concludes the QA portion of this town hall. 00:52:36.880 --> 00:52:43.199 And next I will be going over some resources that will be available for anyone that is looking for it. 00:52:46.559 --> 00:52:50.239 So we can go to the next slide. 00:52:53.119 --> 00:53:03.360 Um ACOD provides sever several resources to assist you in this transition, including our coding courses and podcast podcast episodes listed on this slide. 00:53:03.760 --> 00:53:07.519 So be sure to check out any of any of these resources for more information. 00:53:13.760 --> 00:53:24.719 And we also encourage you to scan the QR code on the top corner to learn more about ACOG's resources, um, to stay ahead of the changes to 2027 Observ codes. 00:53:25.199 --> 00:53:34.320 And please join us in our in New Orleans on November 7th for more details on the new OB codes and other coding and billing policies of the year. 00:53:35.119 --> 00:53:37.679 You do not have to be an ACOG member to register. 00:53:37.840 --> 00:53:41.760 Just scan the QR code on the bottom for more information on that. 00:53:44.559 --> 00:53:48.559 ACOG does recommend everyone switch over by September 21st. 00:53:49.119 --> 00:53:53.760 This transition is tied to the timing of the first 10-week prenatal visits. 00:53:54.719 --> 00:54:04.559 Again, please scan this QR code to view our provider toolkit that goes into further detail about the transition to new maternity codes and what that means for our members. 00:54:06.800 --> 00:54:17.440 And recordings of this town hall series will be available in a few days on ACOG's Payment and Practice Podcast, which is available on both Spotify and Apple Music. 00:54:19.440 --> 00:54:31.119 And finally, if you if your questions were not addressed, please submit it through our portal available at this QR code or go to ACOG coding.freshdesk.com. 00:54:32.559 --> 00:54:35.280 And with that concludes our town hall series. 00:54:35.440 --> 00:54:40.639 Thank you all again for taking time uh to join us this evening and have a wonderful rest of your night.