Ep. 585 CPT Code Updates for the OBL with Dr. Goke Akinwande

Enjoy the podcast, but one more. Download our new BackTool app. You'll get early access to episodes, case discussions, and courses all in one place. Just search BackTool in the App Store or Google Play on your phone. This week on the BackTool podcast, I think the payers are going to have just as much of a challenge with implementation that everyone else is. Even the telehealth phone CPT code set that was implemented this year through a lot of people for a loop and is taking a long time to really update and be implemented. Because the payers take a long time to get these things loaded in their systems as well. So I think that'll be something to be really vigilant about following the payer policies and make sure they're ready to build the new codes when they come online. Well, I'm really excited to do this episode tonight with Gokai at Can One Day from St. Louis, who's an OBL owner, and Laurie Buzarellis, who is a revenue cycle management consultant, and somebody has helped me a lot over the last couple of years. And we're contemplating started a new branch of BackTool called the, it's like a business branch. And we're playing around with names. My current favorite is look at what you made me do in parentheses DR, closed parentheses. So that may be coming up more. But we started, we're doing this tonight because as people may or may or may not know, there's been some surprise code movements with the CPT codes in the OBL setting. And you know, when these things come out, they take some time to absorb, but they have real life implications for people like Gokai myself because he and I are both always offensive whether or not we should go ahead with an ASC. And ASC investments are very expensive, multiple millions of dollars that individual OBL owners take on that debt on their own. And we finance our, you know, we are personal, we have to have personal guarantees to get loans and whatnot to get the money to build these things. So Gokai and I have talked back and forth quite a bit about this over the last two years because we're in the same boat as the OBL reimbursements have gone down. Are we going to be squeezed out of the OBL and having to go finance a prescient if you get loan to do the exact work that we're already doing? So this was quite a surprise for us that we got some good news. And so what we're going to talk about is that and then Lori's here because as with everything else CPT codes were just the beginning of the story. And what do you do once you have these new codes and how does that incorporate into your practice? We're going to try to give really accurate information. I think there's still some unknowns about where this is going to go, but Gokai is done a really deep dive because that's the kind of brainiac he is. So I guess we like to just start going with you and all your thoughts on these new codes. So I'm Gokai, Kawande. I own a OBL out in St. Louis. I have a practice that is actually predominantly PAD. I'm a do-do embellizations and I love embellizations, but you know, I just I just have a very busy PAD practice and it dwarfs everything else I do. So but every year since I started in 2019, I've always worried about these codes because they've went down every year, except for like maybe one year when it went up like 2% and then it just kept going down. And then I'm the same breath. ASC rates keep going up. So that's a that's a bad trend to be. It's very scary because you invest a lot in building an OBL or whatnot and it's always something where we're always waiting for the the proposed codes that I call Mary. Like do you get it? Do you get it? Where is it? Where is it? And and sometimes it's slow to kind of get through this and then you know, you wait for people to send you information and problems finding information. So one day while I was just hanging out having my martini and my cigar, I decided to go through and find out where these codes came from. And I went to the Medicare website and I was like, wait, hold on a second. What's going on here? Mary had sent me some stuff about some blurb about how the code's my change, but I wanted to find out by myself. I was anxious. And so I did maybe about seven days of looking into everything and pulling out articles, meeting records and all this stuff. Well, these paper, you know, these these things and then I kind of found out some good information that I would love to share today. What are the changes that have been made? Okay, so the biggest one is that now there are more distinct vascular territories. Okay, so so now we have the niliac territory. Sorry, we have a femoral popetial territory. We have a tibial perineal territory, which hasn't changed. But then we have an infromalliola territory. And what that is telling me is that they're listening to some of our voices here. They are rewarding CLI specialists, people that actually do work below the knee because before it used to be that you would just code your infromalliola disease, your perelobe disease as tibial perineal. But now they've created another territory. And this has a lot of implications because you can code another territory. A lot of times you're doing, you know, it's some of my patients, they have wounds and I'm doing an antiquated approach. You're opening up the tibial. You open up a whole tibial and the peel loop. That's now two separate codes. And because you're two separate codes, you do get reimbursed more. Of course, the second code you do is is subject to multiple procedure discounting, which is like 50% but still that is very encouraging. So it also also tells you that even if you had a normal AT and you were just going there to fix the perelobe, you will get reimbursed separately for the perelobe. On the flip side of things, it looks like they really want more information from us. Like what are we really doing? Right? Now if a patient goes in, if a patient comes into your office and has a wound and you go in, you do a perelobe disease, they want to know this practitioner is doing this perelobe. This practitioner is doing a tibial. This practitioner is doing a thermop. This practitioner is doing the iliac. They want to make a clear designation between all those. And the implications of that means that they understand what's going on in your lab. What kind of provider you are. And we can talk more about this but is designed to reward people that are actually doing the hard work. Because we all know people that do PAD work, we know that all PAD work is not the same. I can go into the case and it's like 30 minutes and go to a case is three, four hours. So this structure actually rewards those people. What do you say to the people? I think the obvious criticism of this is going to be, well, there are going to people who now just push a wire and maybe the same balloon down into all three levels. Beautiful. So actually there's something, something for them. The fly-by-nights PAD specialists, I think, are going to be targeted in this. I think what I saw was that they have split everything and we need to get back to these vascular territories. So I'm actually not done, but let me answer your question. So all the codes are divided into complex and simple codes. Okay. Simple and complex. There are now 46 codes as opposed to I can't remember what the count was before maybe like half that. Right. There are now 46 meeting more vascular territories have been added. But also, they're decedinating simple versus complex. Now, try to figure out like what does complex mean? And the last time I talked to you, I was like, well, maybe it's like lesion length, classification blah blah. And I didn't find anything like that. But what I did find, there was a document, Medicare document, where they said their interest is to distinguish between a simple PAD procedure where your wire goes through and occlusion. So your occlusion, so like for instance, like if you do an SFA occlusions, your SFA occlusions, if you actually open it up, you actually make more than 2025 rates. Okay. So you get reimbursed more than 2025 rates. However, if your wireages go straight through and is classified as a simple lesion, your average reimbursement is actually lower than 2020, 2025 rates. So again, this is designed to reward hard work and the people that are doing high end CLI work, those people might see a boost in reimbursement. However, for people that, you know, and they're I'm sure you all know several people that just pick and choose which PAD cases to do, those cases are actually lower than 25 rates marginally lower, but I have a feeling that it will continue to get beeped down as we move forward. So as complexity a CTO and simple is a non-CTO? As far as I know, complexity is CTO versus non-CTO. So if your wire is just going straight through, you're simple. And if you're simple, then compared to 2025 rates, you're about even or actually decreased. And I think that those rates, my suspicion is that those rates would be more at risk in the future for future decreased reimbursement. I think the complex, they really want to distinguish between complex and simple because whoever was in that room, you know, basically let them know that, Hey, the complex stuff, we have to reward these people because 'cause these people are actually doing the hard work, the hard labor, and the fly by night, you know, wire in, wire out, kind of folks and reimbursement. Those ones are gonna be the ones that gonna be targeted. - I'm laughing 'cause I can just think of a slogan, complex for you, simple for me, but that wouldn't go well from I, what would you call it? I'm like complex, if it's not as CTO, is there even a case? I mean, I'm like, you know what you're like, who, that's why it's so confusing, and I feel like everybody we do is like these complicated messes, you know, but Laurie, do you have anything to say or add with this? I think there were previously 16 codes. So if you have anything to add here, or, or I don't know, what do you have to add to? - I think just, I'm so happy to hear that you've been studying and reading about it, because I think that's one of the gaps that often happens. There are actually a lot of resources out there that, and many practices just commonly don't take advantage of them. Having a current CPT book, having a specialty CPT book, having a few of those in your office, and I think there will be a lot of clarity on these codes and how to use these codes in the CPT manual that comes out October 1st, and there's specialty resources that write their own coding books, and I think there will be a lot of support for providers to learn how to use these codes correctly. So I was trying to prepare for this, and I was reading about the CPT, because we'll work on the SIR. Tim Swan is the IR representative on the CPT panel. So do you know the AMA? The AMA controls CPT codes, and they make a lot of money off of them. It's basically a for-profit thing. I mean, chat GPT, how do you make a CPT code, and you're gonna, it's so scandalous, I think. And so there's 12 members, these 21 members, 12 of them are appointed by societies. So that's why like every three to four years when SIR says, "Hey, we really want you to be a member of the AMA." It's because you only get a seat if you have a percentage of your society membership as members of the AMA. And then you get a seat at that table. You basically buy your way into one of those, you know, 12, like by membership. So all IRs need to be members of SIR and members of OIS, 'cause it's all about membership numbers, and that's how you get a seat at these table. So one thing I did learn today, here are the other seats, one seat for Blue Cross and Blue Shield Association, one seat for America's Health Insurance Plans, one seat for the American Hospital Association, one seat for an at-large organizational member, and one seat for an umbrella organization that represents private health insurance. So at this CPT editorial board, there are five seats that are specifically named for health insurance personnel. So there's a lot of suits behind these things, and just the fact that somebody listen to the work that we're actually doing is shocking, and I got it, I mean, I don't even know who was behind this, but I'm sure Tim Swan had a lot to do with it, and I'm sure OIS had a lot to do with an SIR, and I don't know if it's VS, but I think that this is my play to be, you know, to think about SIR and OIS, and I don't think these organizations do everything well, but one thing they do well is they make sure somebody's speaking for us against these organizations. - Absolutely. - Go ahead, goki, what else did you learn? - So actually, I'm really excited because I have a lot to say, okay, so let's just get to it, okay, let's mix it up a little bit. So the other thing I noticed was, I was like, we hold on a second, why is there a femoral code and an add-on femoral code? So we hold on a second, why would you have an add-on femoral code? Remember, we used to have add-on tibial codes because if you did one tibial and you did another tibial, then you get an add-on code, right? But we didn't have an add-on code. The femoral-popartil region is seen as one vessel, okay? It's still seen as one vessel. However, there is now an add-on code, and after a lot of research, what I found is that add-on code is for a popartil disease or a vice versa. So if you did, let's say you did a simple SFA, 'cause we're gonna classify these as simple complex. So you can do a simple SFA, authorctomy, and your popartil disease, you have also a popartil disease, there was non-contiguous. So you can't have bridge and lesions, it has to be, you know, SFA pop. The suggestion, and again, I'm not an expert, but I did a lot of research. So it may come down to the final codes, say no. But right now there is an add-on code, and the only explanation from all the readings I've done is that, and I've seen the comment on it, that the popartil region would now be looked at, kind of sort of like its own separate compartment or department. So meaning that if you do a simple femoral, and you have another simple lesion in the popartil, SFA was the main vessel, you do SFA, then you do the add-on code with the popartil. - But wasn't there previously a distinct lesion code, distinct lesion? - Nope. It was 37224, do some 25, three, seven, two, six, three, seven, two, seven, two, seven, it just fempop, fempop, that's it. - Laurie, do you have no add-on? - Are you sure, Laurie, are you sure about that? - Tibules, yes. - No, but there was a distinct lesion. I swear that I would get comments back from my coders and saying, was this a distinct lesion or contiguous lesion, like a modifier even? - But if you look at the coding now, so if you look at the prior coding, three is 37220 to 37235. There's no add-on, there's as far as I know. - But I think you might have been able to do two units. I'm not positive about this, because if you, if it's, I mean, anyway, the majority of the time, I've never understood with a distinct lesion one. - I read this stuff extensively when I started. The femoral puppeteal region is defined as one vessel. - Yes, agree with that. - If you were doing two units and whatnot, you're probably not getting paid for the second unit. - No, but there definitely was something that was a distinct lesion. - Okay, look at that. - Modifier. Well, that's what I have Laurie for. I just email Laurie. - Yeah. - I email Laurie and I say, Laurie, what do I do here? The bottom line is right now is Clare's day. So whatever you thought you were doing before is different, is Clare's day right now. Right? Because if you think about it, right? The code sequence tells you which area of the leg you are, right? So if there was the femoral code, remember, 37224 is angioplasty, 37225 is Threctomy, 37226 is stent alone, 37227 is stent with Threctomy. 37228, you jump to Tibial. So if there was a popetial code or an additional popetial code, it would have seen that in that sequence. Right now, if you look at the new codes, you see it right there in that sequence. You see simple femoral popetial then add on. Then you see complex femoral popetial, then you see add on. Okay? So the bottom line is right now you are allowed to code and add on for popetial disease. Okay, that wasn't there before. I am so that you something on this. I am like, I am getting that you the biggest bet in the entire world. Mary, Mary, you are not getting paid for it, okay? I'm gonna bet you, I'm gonna bet you an ASC. (laughing) I mean, I got one of the first outfits. Or what are your outfits? You're an ASC or what are your outfits? Your outfits would even become close to fitting me. They would fit over like my right thigh probably. But I was gonna tell you, I came straight from work to do this. Okay, so I respect, you know, you know, respectfully, I'm not my best. I didn't have my haircut, you know, I didn't change. But you know what I was gonna say is that SIR knows what time, they know what time it is. SIR knows what time it is. They know what time it is. I follow you around just so I could find your outgifts. I'm gonna put a little GoPro on your head or something, somebody else's head so they could go pro you. - After my viral cowboy outfit from Nashville. - That's right, did you guys see that one? I was like in a knee deep of like a, that was when cowboy Carter and Taylor Swift had some cowboy stuff. Did you go okay with this cowboy outfit? Oh my god, it was like pornographic. And I was like, I have to take a picture of this. And I had to Twitter it. It was just one of these like knee jerk Twitter that I just had to do. And I mean, it was just unreal that we have such a stylish person in our field. I mean, it's really like if Vogue was smart, they would come to these meetings and they would find the use. And they would, you know, forget the fireman calendar. They'd have like go kay and it was like cowboy outfit. And yeah, I think it did go a little viral. I mean, you know what, good on you. You know, he swims every morning. He's out there swimming up five in the morning, not me, not me. All right, well, let's go back to what next. Okay, so take my word for it. Okay, we'll just, look, just go with this. I'm going with it. If anybody, don't take my silence as a agreement, but I'm going with it. Let the chat, yeah, let the chat, let the chat, no chat. Let me see your comments chat. Okay, so that's what the young and say chat, chat, yeah, chat. Okay, chat. Okay, so anyway, bottom line is, because you have, because you have those add-on codes, right? That's critical because that now closes the gap to ASCs. Meaning that in the ASCs, when we talk about that later, or maybe in a different episode, but ASCs don't have those add-on codes, femoral simple, femoral complex, and then add-on. The add-ons are, you have to report them into ASC, but the ASCs don't pay for them. And that's true, the typical add-on codes too. Exactly. Well, you can get, you get paid for it as the prophy, but not the facility. Okay, so now. Nobody cares about profes. No one does, but so now, because of that, doing the mathematics of this, if you had to ask me, is it worth it to do it ASC? Now, talking from a guy who just got an ASC, okay? Don't do it. It's not worth it. Oh my God, this is a mic drop moment on Backtaval. Does everybody understand what a mic drop moment this is? I feel like, okay, we will. We're gonna listen to that moment over and over again. Like you are just like Taylor Swift just announced her 12th album. You just mic drop this. It will be, it's the 12th album. Tell everybody where you are. 2026, hate story, hate story, not love story. Oh yeah, I know. We'll tell everybody where you are with like the ASC purchase and how, what your thought process was on that. So the ASC, and by the way, we're not done with this APL. And you know, if you stock interrupted me, I can actually get through this. I can't help it. There's a lot to content, but that's fine. They'll edit it out. We have a very now we like two hours, but you know, that's okay. Edit. Cut. So the, as far as the ASC, obviously, I have a lot of patients. I probably have about, and counting about 8,500 patients. And I saw what happened to dialysis. One day, they woke up and they cuts reimbursement by 25%. And I said, look, if they cut this thing this drastically, that would be the death of my practice. And so, you know, every year I would look at the codes and it would just keep going down. About two years ago was the first time that ASC reimbursement actually beat or became neutral with OBS. My thinking was, I have to put myself in a place where I don't have to worry about that. And I fully understand that this is not the case for everybody. If you're just starting out, it'd be very hard to do. But as a mature practices mind, I felt it would help me sleep better at night to do the ASC. But I will tell you this, you know, at the time when I got these codes, I had a conversation with Mary. I already had my earnest money down. And if I walked away, it was a big, it's a big project, big earnest money because of the size of the project. I would have lost it all and I just went through with it. The good thing with it is that I don't have to do it right, right then and there. I can get everything ready and if everything changes, there are significant differences in the ASC versus the OBL. So for instance, now like the only time the OBL really beats the ASC is if you stent in the SFA, if you stent in the SFA, complex a simple, with an additional vessel and add on, you're going to beat the ASC. But every other scenario, the ASC wins. For instance, simple versus complex. In the ASC, you reimburse the same. Simple and complex disease is higher in the ASC and it's reimburse the same. Infermalliola disease is reimbursed twice as much in the ASC. So because I'm already there, I'm moving forward with it, but I will tell you if I saw these codes and I wasn't already in the process, I probably wouldn't have done it. And I think you should probably wait. I don't think it's a time, it's a time yet. And this also is encouraging the fact that you're adding new codes and the fact that you're recognizing true CLI practitioners, if you're a real CLI practitioner, you will be rewarded. I really do feel that some voice in the room, advocating for CLI practitioners, at the expense of fly-by-night PAD practitioners, one of whose told a patient to come off my table because you don't need anything and everything is normal. And then today, I walked in and literally, she had no vessels going down to the foot because you can't do it, doesn't mean another practitioner can't do it because your wire doesn't go freely down, the occluded AT and the PT, doesn't mean another practitioner can't do it. So I think they are rewarding true CLI practitioners and those people would see increases in reimbursement. But let's get to it, let's talk more. So IVL, how about IVL? Do you want to talk about IVL? I was literally just about to ask you about that. I've been waiting for, I've been waiting for lithotrip C in the cath lab for, I mean, in the OBL for years. You and me both. So IVL now has an add-on code. And the add-on code is quite significant. The add-on code ignores whether or not you have done an authorctomy. So let's say a particular case needs an authorctomy down below and you need IVL for it, it's classified CFA, you can use both and you get reimbursed for both. This, ladies and gentlemen, means that IVL, if you use IVL is actually more advantageous in the OBL than the ASC, because the ASC does not have that such code. It's bundled. Does it cover the cost of the equipment? It does, it's about 4,000, something like that. I don't even know what the device is cost. Well, I'm going to find out very soon. Yeah, you'll call my vendor like, "Hey, can I get 100?" How much would it cost if I get 100? We'll just come have some door, you know, the people still steal packages off front doors. What are those people called? Porch pirates? I'm going to porch pirate your lab. But you know what even makes them more exciting? Okay, so another thing too is complex Iliacs. Okay, so you can do complex Iliacs now in the OBL near reimbursed, I see quite substantially. Simple Iliacs, complex Iliacs, simple Iliacs, centine, complex Iliacs, centine, but also IBL in the Iliacs is also reimbursed. And because you reimbursed, you have an add-on code in the Iliacs. And because you have that add-on code, you are doing better than the ASC. So every time you see an add-on code, you know, the new CPT codes, and sometimes you see an add-on, it usually only affects the OBL, not so much the ASC. And so because of that, OBL starts to close the gap on the ASC. So the two things that make ASCs at OBLs close the gap on ASCs is A-stenting, because you don't get additional, you get very, very, very minimal bump when you stand in the ASC with the OBL, you can bridge the gap. Number two is add-on codes, any add-on codes in an IBL. And then also the puppeteal add-on that I was just talked about. - Can I ask you a question? - Sure. - Are you picking up something that you're gonna give to me for winning a bet? - Well, no, no, but I was trying to verify it. I think that the informalial codes is just angeoplasty. I think there's no authorlectomy. - It is, and you know, I kind of personally don't hate that. - I agree. - You know, I don't know. You know, I don't generally like it when people say, oh, I don't know because they just don't do it. You know, but like I'm sure people say that about tibule, atherrectomy. But, Petyl, I've never gotten it, I stuck in a Petyl loop, but I am, those little vessels are fragile little suckers. So, I don't know how I feel, but maybe it's because I use PAT, you know? And so, I just think we have PAT. - Yeah, they're very fragile. Even angeoplasty, you can't, you know, it's like an up and down type of angeoplasty. I typically don't even angeoplasty for long. It's just up, down, up, down. You just, you know, they're very fragile. They spas down. The last time I can't even get a one millimeter balloon through there, even though the two's got a lower profile. So, anyway, yeah, I think it's angeoplasty alone on the, in the tibule loop. But, I am likewise thrilled that people are even talking about the tibule, the petal loop, even tibules, you know, at least, I feel like this is a big jump ahead. I mean, the femoral arteries are so boring. I can't even, I like, can't even think about, they're not even arteries in my mind. Like, real arteries are the tibules in the petal. Unless they are clueded, unless they are clueded, which is quite fun. Yeah, I mean, you do, I'm not saying you don't do them. Like, we, you've got to spend some time in the femoral paratory. But the part that's dicey and the part that sort of makes you want to alternatively, like, jump up and down with glee and throw up with despair is, are the tibules in the petal. Like, the femoral is like, how you can't even, I feel like you can't even hurt somebody that much with the femoral. Because even if it's occluded, it's the tibules in the petal that you can, I feel like you can really secure somebody at. Lori, do you want to comment on how, what, what does one do? Like, what should I be doing? When do I look for code? I, what do I do from right now? I just got all this information from GoKay. Now what do I do? I think, well, it's so exciting everyone's paying attention and they're actually looking at it. And it becomes a great opportunity to take a look at your charge master. So like, what you're charging in your practice for everything you do. And oftentimes those charge masters roll. over a year over a year and they don't get a lot of attention. So if your reimbursement has been set just kind of randomly as a person of hair or something not related to your contracts, you could have prices that are too high, that aren't related at all to what you charge or to what you're reimbursed or you could have actually a chargemaster that's too low. Most people do not know what a chargemaster is. The chargemaster is what's in your software, your billing software that says 99214, everyone's billing a 99214 and maybe you bill 300 bucks for that, 300 dollars. So your chargemaster is your list of CPT codes, your list, you may also have G codes and H codes that you're required to use HICPIC codes specifically for Medicare and some supplies and drugs that you use in the office would be under that HICPICS. So you should have, I would highly recommend people take this opportunity to think about adding in the new codes, deleting the old codes, taking the time to like go through a line by line and clean up that chargemaster. So that's what I call it, what you charge for what you do and bring it into kind of the modern day. Use this as a chance to clean it up, get the right codes on there, delete any codes that are now obsolete and you don't wipe them out completely. You need to do this very, very closely with your software vendor because the old codes stay in there because you need them for processing old claims. They just become in active as it be certain things. So they don't go away. They just become inactive. So this is you, so you go to your EMR. So let's say I have Eclinical works. I go into and I don't know anything about this. You're endorsing. You're endorsing. No, I've never endorsed anything. It just stuff comes out of my mouth. I don't ever, I never like, but I have Eclinical works and I got to deal with this. Actually, what I would do is I'd ask Lori to deal with it. But so you go into your, okay, let's say you go into your Athena, Athena slash streamline slash Eclinical work slash whatever's. Yeah, grants them me whatever, whatever you're using. There's some chargemaster there. Like you find something that says chargemaster and that has all the code by all of the payers. So right now on your chargemaster is what you charge. It's what you charge. We're looking at what you charge by CPT code. So who would have set that up in the beginning of the practice? Everybody's different. Some people have set it up thoughtfully, some people would have had a billing company do it. Some people, right, copied someone else's maybe. So this is, this is what I think a really important point that for people to understand is that everybody has one of these. You just don't necessarily know where it came from or what it says. Really true. And so I think this is a super opportunity for every single business owner to take a look at the chargemaster and use this time, use this opportunity of adding these codes, omitting your, your old codes to clean this up and reevaluate your pricing and be sure it's current, it's accurate, it's relevant to your managed care contracts. It's in compliance. Great opportunity. And now, and that would look, those charges are set. So explain, let's say I brand new and I get Eclanical Work/Streamline/Athena/Whatever. And I am building my chargemaster sheet. What do I put those prices and how does one put numbers in that? People have all sorts of different ways to approach setting their charges. The way I work with clients and help them set their charges is we look at what their contracted allowables are. So we look at every, the fee schedule for every payer contract. And we make sure that we're pricing higher than the highest contracted allowable. And then depending on how high a practice's contracts are, we set that rate technically about 30% above the highest contracted allowable to make sure there's room for a paycheck. So what I get Lori several years ago, we spent two years building this right, Lori, because I didn't have any of the information I needed. And so we built this master charge sheet that's a billion Excel pages long. And it has every CPT code, every off of every fee schedule and every payer that I'm contracted with. And that's we don't use that through my EMR because my billers don't sink with my EMR. So we made a off grid system, which is much more difficult. But I have liked it that way because I really trust my billers. And I find that sometimes when the EMR and the billing company are one and the same, they can be problematic. I think to each alone, I think that the most important thing is, you know, whatever your strategy is, I mean, some people just go take Medicare, multiply by 2, 2.5. And then hopefully, I hope everything comes underneath that. The only thing is that you're going to have basically a bunch of write offs. There's a big delta between what you charge out and what you get. Then the day, longer if you are higher than the highest rates, I think for my practice, I think that that works for us. But what Lori was saying was basically like, you're not going to, you don't eliminate any codes. You're going to add on codes. And your codes are going to be, I mean, we don't even have the true codes right now. They put X's on them. But we anticipate is going to be like, you know, three seven, it's going to be like three seven seven series. It's going to be a three seven. It's like three seven X series. But I think it's going to be three seven seven and whatever. But we don't know. But whatever those are on January 1st, we're going to get the proposal, the final rule later this year. And then we're going to see what it looks like. And then by January 1st, we're going to be billing differently. The world is going to change in the world of IR PAD. So taking advantage for yourselves and for your staff of every coding conference, opportunity, webinar, ordering the books, like whatever resources you have that order legitimate books this year. It's a great year to invest in some of those coding books and make using those to make sure that your charge master is up to date. Where do you get that? Is there one coding book I know SIR has the coding sheets that I always use? Do people need to do more? There's coding books through SIR. But the AMA publishes the official CPT book and they're like 700 bucks, right? No, they're like $250, $300. Not that bad. Yes, they're not that expensive. You can also do it. Dr. there's a guy called Dr. Z. He has like these coding books just specific to each specialty. And so some people, if you feel like the AMA coding books are overwhelming, you can just get the Dr. Z version. But let's mix it up a little bit though. Because we're kind of kind of getting to the end of the podcast. Now we want to mix it up a little bit. Okay, cool. Let's mix it up. Okay. So before we do, we're going to talk a little bit about embellizations and stuff like that. But I just wanted to make another comment to be talked about OBL. So to summarize what I said, OBL 2026 versus OBL 2025. If you're a CLI guy, you're probably going to experience increased reimbursement. If you're a flyby night, you know, just wire in, wire out to kind of guy, you might get a decrease in reimbursement. Add on codes, do add value and closes the gap to with ASCs, ASCs benefit from the fact that it doesn't designates between complex and simple. You will still have to code it as complex versus simple. Because they still want that data, that piece of data. But because it's device intensive, a J a code is a device intensive code, they do not take a deduction when you build an ASC for simple versus complex codes. Okay. So so meaning if you have multi territory CLI, we're using multiple levels of J 8 codes, ASC wins and ASC wins pretty much most of the time unless you have SFA Stent plus Papa to add on and you have multi vessel I VL, which OBL wins because of the add on reimbursement. If you are a high acuity multi territory CLI guy like myself and Mary or now I'm not a guy. I know a lot of people think I'm a guy. Hey everyone, our new backtabled app is now live. Go get early access to episodes, case discussions, courses and an overall better learning experience, all free to download and use. Search back table in the app store and join us there. Then the 2026 codes we reward you and was with regards to OBL versus versus ASC. Remember the ASC's from an authority standpoint does not designate simple versus complex. So no matter what you get a higher reimbursement. Okay. Now the other thing I want to talk about is why I feel like because I've been really cynical about OBLs for a while. And this is the real the real reason why I said I don't really think I think OBLs are here to stay because if OBLs were not here to stay, why is it that OBL reimbursement has gone up in pretty much every sector? Embellization, Dallas's access, in Vast for ultrasounds, Veritas veins, nerve ablation, venus interventions, and fissure creation. So what that is telling you is somebody is in Capitol Hill, I don't know where they are, Capitol Hill White House, wherever you are. Okay. The bottom line is that OBLs look like it's here to stay, and literally across the board it's about a five percent increase in all these codes. Now I don't know if this sustains because you remember it's all about utilization and the more we utilize, the more they're going to cut. It just happens that way. You have, you know, some people, some bad eggs out there, but remember guys, if we want to keep it this way, we have to do the right thing by the patients. Don't be there for the money, be mission driven, and take care of patients because doing that funky stuff, that DOJ stuff is gonna wipe us all out. But the bottom line is, sorry, I couldn't help myself. However, if you're a true practitioner, they would reward you. And especially if you're a CLI guy, but even if you're doing embellizations clearly, Dallas is has gone up even in the OBL setting all these procedures. So it's very encouraging from a global standpoint because you can say, well, maybe maybe everything is going up because they're we have several new codes, but no, they're also increasing it. Embellizations, dialysis and whatnot. So that just tells us that they're they are, they're not trying to wipe out OBL owners like they did in 20. G-A-E, UAE, PAE. Okay, I can we can talk about that. Yeah, so PAE and U-Fees, it's up by about 200 bucks for H-A-E. It's up about $130. What's the other AE? You were talking about? G-A-E, G-A-E, G-A-E, G-A-E is, you know, about 100 bucks. Well, I guess the good news is it's not down. No, yeah, nothing is down. Laurie, do you want to comment on how important it is to know the Medicare year when you're looking at percent of Medicare? Because I think that's a common misconception of 2025 Medicare rates versus in my practice, the best year was 2020 and we know this from this extensive chargemaster. So we're negotiating our contracts and they keep trying to put me on 2025 rates and even though these percentages may go up, I will get paid less if I have a new contract put me on 2025 Medicare rates versus 2020 for my practice. Yes. Do you want to explain that, Laurie? No, that is correct because they have changed the RV use so much. It would take, so for example, on a 2020 contract, maybe we would have you at, I'll make something up like at 150% of 2020. It would take almost 180 to 190% of 2025 to be the same. So we get a lot of offers where the payers like, oh, this is an increase. We're so happy to offer you this increase and yet when we run the numbers against your CPT frequency and every practice is different. So everyone needs to look at this themselves. Their answer might be different. It would take the most important CPT codes to you and actually decrease them. And so we have to be very, very mindful of what year of Medicare and really negotiate heavily to get a big bump if they require movement to a more recent year. I just for the record want to say that I have by far the lowest rates, right, Laurie, of like anybody, but we're getting those, I get paid, we're getting those fixed. But yeah, you were, we're working on fixing them, but I inherited. So, so people always walk around and they're like, oh, I have a 190% of Medicare and you should say, well, of what year? I'd rather have 150% of 2020 than 180% of 2025. So it is funny. People talk about that Medicare expense. It's really just the tip of the iceberg. We start to look at for each practice what year they're talking about. And I would also say that with collection. So we were talking about setting your charge schedule. It's all funny money. It's like, okay, how do you set in your EMR, the amount you want to bill? All right. Well, if I just set it in certain ways, then I can say, oh, it's August and I've billed $10 million so far, right? And people like to talk about how much they bill. And billions are well with it. Billing doesn't pay the utility bill, man. Like, so just be careful of anybody who talks about how much they bill and be careful of anybody who talks about what percentage of Medicare they get. Because like, great, to me, it's like you're wearing like the shoes with like the coach label. Like, great, great. You've got a nice label there, you know, it's so what? And anyway, it doesn't speak to the quality of it doesn't speak to the collections and it doesn't speak to what their rates actually are. Now you have the ability to look at your competitors rates. That's new. I do want to say anything that I have learned about revenue cycle management. I've learned from Lori. So I'm trying to dumb it down for the listener because that's how I have to think about it because Lori's field is incredibly complicated. And I've had many frustrating phone calls over years trying to get a hold of this. But she's, thank God, stuck by me. My MPI number, it grossed all the centers that I've worked in in Oregon. Like, I got paid a lot more to do this when I was younger and working in different facilities. And so what we negotiated were like, look, me, the same person 15 years ago got paid twice as much to do this somewhere else. And they're like, oh, yeah, that's great. But we don't really think you're the same. I mean, who knows? They have a really weird responses. And so you just have to be really persistent. But I'd be careful of that these like one liners, people try to say about their collections because or at least they're billing. And I think all these changes to the charge master too, like adding these codes. It just gives you a chance to say, hey, are we doing the right thing? Let's take a look at it. Let's make sure we have everything correct. If you're going to work on getting that charge master updated, go ahead and load all those contracted fee schedules. So that your billers know if they're posting the correct amount to the CPT level. And every single software vendor that you listed has that capability where you can load your contracted rates into the billing software and make sure that your billers are collecting that the payers are paying you accurately. What should people expect from their billers? When I hear these kinds of bill or encoding folks, like when I hear these kinds of changes being made, I expect the person who does my billing and coding to be all over this, all ahead of this. And right, you're shaking your head now because and this I think is what people need to understand is that just because someone says that they're doing your billing and coding, they may screw this up for two years. One of the biggest complaints in doctors that go out in private practice is billing is literally one that they're literally two things you have to solve when you go out as a doctor to do this is getting your phones to ring, getting patients, being able to collect what you bill out. And those two things are the most important the hardest. And I know I'm going to let you finish, but you know, I want to stress it out. Like we talk about all these numbers. But remember, we're not receiving Mary and I and I are receiving these numbers. If I said like an authorically reimbursive $10,000, we're not getting $10,000. If you actually do an average, it's actually maybe, you know, 70% we're not getting everything because of billing billing. So I was just, you know, just for the viewers because you know, because a lot of people when they see me in NSIR, they look at my shoes and they think like, you know, everything is all glitzy and glamour. But this is a hard thing to do. No BL is a hard thing to manage. It's hard to keep staff is hard to maintain margins. You have to be very, very good at it. You have to almost have a mission and drive to do it. You have to enjoy it because if you don't, you would not win at this. There's a lot more OBLs that close and open. So I just want to let you guys know. Yeah. And I mean, the fancy shoes can come from anywhere. Your wife is like, exactly. I mean, she's like a badass dentist with her own practices. I mean, behind every man like goke is her hard work in woman. Aaron cut it, cut this part, cut this part. Don't listen to cut, cut Aaron. No, but, but no, but to kind of like finish a statement is, is you bill, let's say you bill out $100. It's to remember, it takes about 5% your billing fees. And a lot of times, they don't even get all the money. Then they write things off when they try hard and they can't get it. You know, you have insurance companies that don't want to get, don't want to give you a pre-approval. Right. Then you get the pre-approval. Then they say, you know what? After you do the case, well, we don't want to pay. Then you got the ones that do pay. Then they come around a year later and they do what you call a take back. Okay. So we're not getting all this money. Now, it's encouraging that we're getting higher reimbursement, but I'm also saying, like, you know, we're mentioning these numbers. I mean, Mary just talked about someone billion, 10,000, 10 million dollars. We're not getting 10 million dollars. - No. - Not even close. - That's not how I was working. And I just want to make sure, because, you know, the guy do these talks to this I R and my line, you know, every time I talk about him, "OBL is a long line after." And it's just like, it's exciting. But I want to make sure you guys know what you're be very, very mission focused. I survived COVID because I was mission focused because I enjoyed doing this. I love doing this. So be mission focused. Don't do it for the money, please. - The insurance companies now, I think, united in particular. There's a large push to drop united because of what they're doing. And what they're doing is they're denying things, pre-authorization and they're just not paying. And so what happens is how do you actually collect your money? And this is where you have a really good revenue cycle management team if you're not looking at yourself, where, or, you know, like I have these billers that I use because I trust that they're gonna let me know. They're gonna fight for every bit of it. And then they're gonna let me know if they see any patterns. And they're gonna let me know sooner rather than later. When I first went into this, I had somebody who sort of softly let me know way later. And by then, I was, what was I, Lori? Lori helped me on wine some of this. And I got none of it back despite going to lawyers in this group in Texas that was supposed to go, you know, fight these claims. It was over a million dollars, right, Lori? It's over a million from United. And it was just sitting out there. And this was all work. I was busy. And it was a million dollars, which is translated into, in which we're three and four and a thousand dollars that I just lost out of my own, I mean, your own pocket, your own worth, your own everything. So that's how significant, not understanding the entire revenue cycle management. It's not just $10,000. You're talking over a million dollars of billables. And in those cases, I still pay for all the equipment. So I don't only not collect the money, I still have to pay to do all the equipment and all the staff and everything else. But Lori helped me look at that. And so the question is, well, why didn't you know that was happening? Well, yeah, exactly. I didn't know what was happening, 'cause I didn't know that I had to follow this because I had people that were supposed to be doing it. Yeah. I think that's where it's really important to know enough about the business side of your business that you know if people aren't doing their job. And it takes time. It's hard. That's not easy to do. And the insurance companies are making it harder and harder. They're operating with just complete free reign right now. It is unreal and super frustrating. So once we get those codes loaded into our EMR, Lori, so this is coming in January, what's the next step? So everybody who has a practice, and I would say whether or not you're in the hospital everywhere, I mean, we talk about the value of IR, I've always maintained it. And after the crawl, I think was the first person who pointed this out way back. I mean, at least to me, that when the diagnostic groups get so agitated about the IR groups not making any money, my first question, because I learned to ask it, was, well, how are they coding your work? And so I think this is pertinent. I mean, a lot of what we talk about for OBL, but really it's anybody who really needs to show anybody the value of your work, 'cause I refuse to believe that IR does not make somebody a lot of money. Oh yeah. And it's not an OBL owner, it's gotta be a hospital folks. I mean, there's no way that people doing bigger cases are not making the hospital a lot of money. I mean, if they say you're not, I think they must have their coding wrong. So even if you're in a hospital, I think understanding how the hospital is gonna deal with these new codes is important. So let's say you're coding book and then what? The problem with displaying your value in the hospital is because you are rewarded. The hospital recognizes if you do a lot of PAD in the hospital or in the hospital, they recognize that because they feel that income, the problem is your group doesn't, because your group is so device intensive and so tech intensive that about 95% of what is recovered from a PAD procedure is all technical fees. Yeah, professional fees in my mind don't even count, like I said before. I don't even, they're not even really fee, I mean, they're exactly, I don't know. I mean, there are some groups that do fine with professional fees, they make it work. I don't know, I think there's probably more the story on those groups, but I'm gonna say you, I think the groups what groups need to do is, if you have an IR that's very motivated to do PAD procedures in the hospital, they have to go to the hospital admin and get some kind of reimbursement, physician services agreement that gives them more money and reaberses them for those procedures, 'cause they do reimburse really well, especially in the outpatient hospital setting, but the pro fee would be about 500 bucks, the group would not appreciate you until you get those fees from the hospital. Okay, so let's say you're in your OBL and you've got this book and now you've loaded all these new charges into your EMR. So you're actually loading them probably into your practice management software, which is sort of the billing side of your electronic health record. So the EMR is your side sort of and the practice management software is the side I work in where you take that written record, those codes get assigned based on your documentation and then they go to create a claim in your billing software. For most physicians, their software is the same. Your electronic health record, E-clinical works is functioning in both of those roles. Some people have one EHR and a different actually billing platform. And you kind of do too, because you use a third party billing company that uses different software. So you don't have your actual billing transactions in your own software. So making sure that all those things are aligned, that the information's accurate across those systems and then thinking about also your communication plan with your staff. So if your staff are used to, if they have cheat sheets set up in the office for prior author, they have cheat sheets. Sometimes there is a lot of informal information in medical offices that people use. And so as you're thinking about the implementation going forward, it's not just the formal systems like in your software, but it's also making sure people's cheat sheets, their reference documents, the books they're using, all those kinds of things are up to date and accurate. So anything you can do to kind of tap down the informal and provide formal resources, provide the CBT book, provide references that are accurate and up to date is another really important thing that can happen. So I just had a thought, do you think that this, we think this is a good thing, but ultimately what they did with all these different codes is now you have to pre-auth 46 different codes. Already you have to pre-auth, we pre-auth, femoral tibial, and now there was 16 codes, and now we're at 46. And so everything has to be pre-authed. So I listened to my pre-auth all day long, go automated, pre-approved, and they have to, they literally have to say out the codes three, three, four, two, two, two, three, like all day long, they yell into the phone to somebody. So I wonder if, you know, there's the war strategy of confuse the enemy. I wonder if maybe there's some unintended consequences of this that we're now all gonna be not pre-authoring 46 codes. - I had insurance company, okay. They pre-auth, I pre-auth three, seven, two, two, seven. This is like very early, three, seven, two, two, seven, which is stents and not the rectum of the SFA. At one end, I just did an ortho-rectum. I submitted for three, seven, two, two, five. They came back and told me, hey, you did not get three, seven, two, two, seven approved. - Yeah. - I said, what do you mean? I said, I use a lesser code. I don't get it. They were like, no, you didn't get that approved. Recently, I submitted all my codes to another insurance company, and DM me, you know, chats, ask me on the chat, and I'll tell you what it is. - You can say it aloud. - 'Cause you know, I talk my stuff. I talk my stuff. - We're all, we're all, this one was-- - This one was all-- - We're all friends here, okay? - Okay. The first one was United. - Yeah. - The second one was, this new one is, I can't remember. I didn't know, it's one of those, whatever. So I submitted all my codes. They only approved three, seven, two, three, one. I wanted to do a tibial, so a patient that had like, low extremity wounds, bad, big bad wounds. I went in there, didn't have to place a stent. They only approved three, seven, two, one. They said, three, seven, two, two, eight, nine, you know, three, seven, two, nine, they're all denied. All these tibial codes denied. I want you to do ortho-brechtomy and a stent. I didn't have to place a stent, so I didn't place a stent. - Yeah. - I'm fighting them right now to tell them, hey guys, like I asked for the lesser codes, you didn't give it to me. You gave me the largest code. I assumed that you just meant like, anything below that, I'm fine. - Yeah. - And now I have to fight you. It's crazy. - I think this is also important understand that it's not like, it's not like we're sitting here trying to get the highest codes on everything. I mean, I look at my app for Actemy charges and they're not even 10% of my devices. Yet there's all of this hate towards OBLs and after Actemuses is like utterly insane, where we're trying to avoid some of this stuff when we can't even. Like you said, we had down code. It doesn't mean we're going to do more, but it hits in all different ways. Yeah, so I don't know. We'll see this pre-authorization. I'm not really a fan of AI in any way, but I plan on using AI to figure out how to pre-auth these codes somehow. Okay, so Lori, let's say we have all of the wall charts are updated. All of the, you know, chargemasters are updated. January 2nd. January 1st, we're recovering. January 2nd, we do our first case. Then what? We put in the new codes. We'll see, because I think the payers are going to have just as much of a challenge with implementation that everyone else is. Yeah. Even the telehealth phone CPT code set that was implemented this year through a lot of people for a loop and is taking a long time to really update and be implemented, because the payers take a long time to get these things loaded in their systems as well. So I think that'll be something to be really vigilant about and make sure following the payer policies and make sure they're ready to build the new codes when they come online. What about contracts? We have contracts with these payers, but they don't have these codes in there. How does that work? Most of your payer contracts are going to be reimbursing you either on a proprietary fee schedule or a percent of Medicare. And if you're on an older year of Medicare that doesn't have these codes, there's going to be a paragraph in your contract that talks about it. The term is, I want to say it's like a gap fill is the term and they'll pull it from a different year. So they'll look to another source to fill those coding. So you could be vulnerable. People could, people's reimbursing could definitely be vulnerable. And it will need to be watched like a hawk and probably renegotiated for most of you. And this may be another way they're going to getcha is that these like in your contracts, it could say, well, these are these gap codes. And so, oh, okay, we're going to use them for Medicare 2025 when our best rates are Medicare 2020. And so I think watching the first 10 cases to see how it's going to have to be 10 cases, but different insurance payers, you know, to see how everybody deals with it. But you're talking about private insurance, right? Yeah. Yeah. Or Medicare advantage. You're not talking about Medicare. Medicare. Medicare advantage. Okay. But you're not talking about Medicare advantage either, right? Yeah, I am. Medicare advantage. I hate Medicare advantage. Medicare distance advantage. Your Medicare advantage will be on a current year of Medicare, even if it's a proprietary version. The majority of PAD of Medicare or Medicare advantage. So, so you're going to get 100% of Medicare for those cases. Well, I can tell you that we're supposed to get that, but we don't always get that and United is the worst. No, I'm saying like, is except I'm wrong, I don't really think you can get more in a Medicare advantage plan. Right. Getting Medicare reimbursement rates. Right. So only the minor, it is only maybe about, you know, 5% to 10% of pity patients start just straight private. Now, you fees and your other things, your hemorrhoids or whatever, okay, that's different. Yeah. Actually, I think you're right. I think your major issues with the Medicare advantage plans or the pre-authorizations more than the they just don't cover what they're supposed to cover. They're supposed to cover everything that Medicare plans cover. And Lori, I mean, Lori might have something to say about that. We were thinking there might be a nice class action lawsuit against Medicare advantage. We got one already against Medicare advantage. Didn't get one for like some other issues. I told you about that one. That was why do you have to call? Why do you have to, why do you have to call people out? Why do you have to, you know, I don't talk. I don't talk. Yeah, well, you know what? Someone's got to take the hits for everybody, you know. And since I'm older, I'm aged, I'll take them. Lori, what about, okay, so that's it. We just implement these things, make sure oh, everybody's sticky notes are accurate. Watch the first six months and see how it goes. And we're going to have to do another episode to say whether or not this was a bad thing or a good thing. We think it's a good thing, but we'll see. I mean, implementing such major changes, I don't know that this, I mean, in my time hasn't been, I mean, I know when they bundled UFI, that was a big one, but this is a big change. It's a big change. This is a big, this is a big change. I think this will be one of the biggest changes that most of us see one of the most sweeping changes. The only other time I think we saw so much movement was when the large set of codes went from hospital only codes to outpatient codes, right? Yeah. Three hundred codes that like went from hospital only codes. That was a big movement. So reading Dr. Crowell's article, which I've read several times, there's no add-on code for Papa II disease. I don't want, I don't want to add on it. It's a distinct lesion. Do not, do not edit in Mary's comment. Please guys, please. Don't do, don't do, don't do this. Don't do this. So please, distinct lesion and the new codes. Oh, Lurias. Maybe we can bring Dr. Crowell. Crowe next time. We could just go live. We just go live near you, Dr. Crowe, we just go live straight up and down. To January 1st, we go live on New Years, we do a New Year special episode. No, like I refuse to accept any piece of evidence that says I'm wrong because I feel like I'm really right about this. I will tie on this sword or a hill or whatever I'm supposed to die on. Okay, well, you know, we're thinking about doing, Lurian, I are going to do a podcast, I think we'll be interested in we were talking about reading through a contract, top to bottom through these contracts, because these contracts tell you so much of how you have to behave in all these scenarios. Like, you know, I wouldn't be surprised if there's things in there, like if there are new codes, they can choose to adopt them or not. You know, I mean, who knows? Contracts are very one-sided. I've signed so many of them without reading them. I was a mistake. You used to. I used to. Yeah. Oh my god, I haven't done that forever, but I used to. That's for sure. Automated signature. All right. Well, go, okay. I appreciate you make me feel so much better. It's like the biggest Christmas gift ever, because now I don't have to go build an ASC. I mean, I think that this was a real thing. It's kind of like, I feel like it's like, you get married and you're excited, you're going to have kids or not, but you're not just going to have one kid. The moment you decide to have kids, you're going to have 10 kids. That's how big of this. You can't just be like, well, let's have one and then maybe we'll have another. Going from an OBL to an ASC is like, you're going from no kids. You're 40 years old. You've got a great life. You can retire and move on and do whatever you want to do. Or you can have 10 kids and have to work another 50 years. That's the difference between an OBL going to an ASC. Yeah, the ASC is a big ordeal. It's a big deal. It's a big deal. It's not just, it's not just the walls. It's the fact that you know, the walls cost you about $600 per square foot in today's dollars. And you have to have infrastructure. You have to have nursing support. You have to have leadership support. You have to have all these things. You have to have a nurse dedicated for quality control and compliance. There are certain things you could do in an OBL. You can't do an ASC because it's very strict. So you're going to spend more money. So I would say with these codes, it's not worth it to build an ASC at this point. I think just write it out longer. And you know, maybe the day will come, but for right now, I would say OBL is still fine. For the KPX and the couple of investment that you do, I think OBL is just fine. Well, you found yourself with 10 babies and I'm an empty nester. I'll come though if we're wrong about all this. You'll still have a job and I won't. We won't. Well, it's so great to see you guys. It's always fun. I just, it's very hard to keep up on all this stuff and I think everyone's lucky to have go, okay, you've done so much work on it. And if anything else is just a reminder to like hit the books and grab your martini and start reading or call Lori. You left out the other part. The pajamas. No, that's the cigar. Oh, this is a car. The pajama. Just your wife let you smoke those inside the house. No, no, no, I can't smoke in the front of my, I don't speak of my kids or whatever. It is only like once in a while. So you don't fake a only one is see it's your CPG cigar. I mean, if we're gonna have to do this, we might as well make it all right. Any last comments? I, uh, God, this is just so like the distressing part of this life, but I think we'll be okay. And this was actually good news. I think it will be good. I guess that's the thing we didn't talk about. This was really good news. I actually think it will be good news for everybody. It's gonna level out and be a positive thing. We've had a lot of negative news in the last few years about, you know, for IR especially. And I think this will be a good one. But it'll take some work to get it rolled out. Absolutely. But good times are coming. I always have a good time with you. I love it. Thank you guys so much for tuning in. If you haven't already, please be sure to subscribe, follow, and rate the show. Let us know how we're doing and what we can do to improve it. We work really hard at making this valuable resource for you, and we want to continue to do that. So give us your feedback. Lastly, tell a colleague about the show. We think they'll like it. If you have any questions or comments, direct messages at underscore backtable on Instagram, linked in X, TikTok, and Blue Sky. Backtables hosted and produced by myself, Chris Beck and co-hosts. Ali Beheadie. Michael Boraza. Sabine Dond. In Aaron Fritz. Our production team is led by Kieran Yannen, Aaron Bolz. Gabe Legretzio. Josh Spencer. And Jaden White. Design and digital marketing led by Brian Schmitz. Social media and PR by Danara Cabuto. An administrative support provided by Judy Delecruz. Thanks again and see you next time. 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