Vijay Agarwal: 00:00 
 We have associated for Brian's login is apps +surgeon at the rate makes you Neurosurgery.

Vijay Agarwal: 00:08 
 Yes, I'll do right away.

Vijay Agarwal: 00:10 
 Yeah.

Vijay Agarwal: 00:10 
 So the way we have set this.

Vijay Agarwal: 00:12 
 Up Brian and Emily is we have created alias emails on our MCQ neurosurgery domain which are apps searcher, apps practice administration, apps biller and apps supervisor.  What happens is our single mail which is apps at the rate mechu Neurosurgery can now receive four types of emails means it receives for practice admin, biller, supervisor and surgeon.  And for the testing, we have mapped surgeon to Brian's Gmail ID and everything else to your Gmail id.  Okay.  Technically the icloud issue should not impact us.

Vijay Agarwal: 01:01 
 We just have to re verify that.

Vijay Agarwal: 01:04 
 We have mapped the NPI code given to Brian with Apps plus Surgeon, which I believe we have.  That's how Pratik is able to give all those OTPs to you because they show up in this mailbox right here.  Okay.  And when I do Apps plus Surgeon.

Emily Clifford: 01:25 
 So Vijay, you're saying it goes to both, right?  It goes to the AppSent McQ Neurosurgery and then it also goes to our personal.  It's forwarded then to our personal.

Vijay Agarwal: 01:32 
 Exactly.  And even if mine's not getting it.

Emily Clifford: 01:35 
 To the right personnel, I can log into absent MCQ and tell him the code.

Vijay Agarwal: 01:40 
 Yes.

Vijay Agarwal: 01:41 
 Or we could simplify.  We could even change the filter settings.

Vijay Agarwal: 01:46 
 Okay.

Vijay Agarwal: 01:46 
 And we can just route everything to you.

Vijay Agarwal: 01:48 
 We have right now done two separations.  One goes to Emily and other goes to Brian.  Okay.

Emily Clifford: 01:54 
 I mean I think we want to keep it separate so Brian can do has flexibility to do this.  But can we add his other email address?  Can we forward it to all of his email addresses so we just have a better rate of success for him getting it?

Vijay Agarwal: 02:08 
 Yeah, so we can set that up right now what we will do is we will add another forwarding address.

Emily Clifford: 02:15 
 Great.

Vijay Agarwal: 02:16 
 Okay.

Vijay Agarwal: 02:16 
 And Brian, if you can spell that for me, I'll add it right here.

Emily Clifford: 02:20 
 Your iCloud1 Brian,.

Brian McHugh: 02:25 
 Similar handle bmcq78justcloud.com.

Vijay Agarwal: 02:45 
 Yeah, I think this requires us to have a specific mobile app active.

Vijay Agarwal: 02:50 
 Lynn, can you re attach your mobile.

Vijay Agarwal: 02:52 
 To this email ID so I can forwarding.

Vijay Agarwal: 02:57 
 So Emily, there is one more setting.

Vijay Agarwal: 02:59 
 In MCQ neurosurgery domain for the email.

Vijay Agarwal: 03:03 
 That that you don't have a two.

Vijay Agarwal: 03:05 
 Factor authentication enabled and for the email ID forwarding, Google requires two factor to be mandatory.  So for what we have been doing is adding our office Device as the second factor.  So it allows us to enable forwarding.  We will send you the steps on how you can enable on the entire domain.

Emily Clifford: 03:30 
 Okay.

Vijay Agarwal: 03:30 
 And as such, this is a temporary test phase.

Vijay Agarwal: 03:33 
 After a month, once we are live, you don't need any of this forwarding.

Emily Clifford: 03:39 
 Great.

Vijay Agarwal: 03:40 
 Okay.  So.

Vijay Agarwal: 03:47 
 What we are going to try now.

Vijay Agarwal: 03:48 
 Is let me save the changes.  Strange.  Okay.

Vijay Agarwal: 04:09 
 So now Brian, if you try to.

Vijay Agarwal: 04:10 
 Log in with that NPI ID and password, let's see if your Gmail account receives it.  And I already assumed that you have tested your spam box.

Brian McHugh: 04:26 
 That's a good question.  No, I don't think I did.  I'll double check that.  Oh.

Brian McHugh: 04:33 
 Yeah, I did not test my spam box.

Brian McHugh: 04:35 
 It would be coming from that email with the.

Emily Clifford: 04:40 
 It'll look like this, right?  I am Billy verification code.

Vijay Agarwal: 04:44 
 Yeah.

Brian McHugh: 04:44 
 Okay.  All right.  I'll double check.  So.

Brian McHugh: 04:47 
 So Vijay, you want me to drop.

Brian McHugh: 04:48 
 Off this call and.

Vijay Agarwal: 04:50 
 No, not right now.  If you can just check.  I can check my email?  Yeah.

Brian McHugh: 05:23 
 Yes.

Vijay Agarwal: 05:25 
 Is it in your spam?

Brian McHugh: 05:29 
 Yeah, looks like it goes to spam.

Vijay Agarwal: 05:32 
 Okay.  Sorry Vijay, that's one step sorted.  Okay, great.  So if you can you.  If you can just report not spam the next time it will show up in your inbox.  Cool.

Vijay Agarwal: 05:49 
 So then this part is sorted.  We don't have to worry about the.

Vijay Agarwal: 05:51 
 Icloud and all the other setup.

Emily Clifford: 05:53 
 Okay, great.

Vijay Agarwal: 05:55 
 Great.  So yes.  Now if you are able to type in your NPI ID password, get the otp, get into the app.

Brian McHugh: 06:04 
 Okay.

Vijay Agarwal: 06:05 
 Then you will have to drop off Google Meet.

Brian McHugh: 06:08 
 You want me to do that now?

Vijay Agarwal: 06:10 
 Yeah, you should drop off and do the whole login and see if dictation now pops up.

Emily Clifford: 06:17 
 And then you'll stay online and text if you have any issues.

Brian McHugh: 06:21 
 Okay.

Brian McHugh: 06:21 
 And you want me to try and.

Brian McHugh: 06:22 
 Do a brief trial dictation?

Vijay Agarwal: 06:26 
 That's okay.

Vijay Agarwal: 06:27 
 If it, if it shows up, then we know the entire flow works.  But we just want to make sure.

Vijay Agarwal: 06:31 
 It's working on your device and then we'll show you what things we have tried.  Okay.

Brian McHugh: 06:35 
 All right.  I'll drop off and then I'll do.

Brian McHugh: 06:37 
 That and come back up.

Emily Clifford: 06:38 
 Okay.

Vijay Agarwal: 06:38 
 Okay.  Well, finally that got sorted, so.

Emily Clifford: 06:44 
 Sorry.  We should have thought of that.

Vijay Agarwal: 06:46 
 I know it's not very natural.

Emily Clifford: 06:49 
 Yeah, I don't know why it's not natural.  You'd think it would be by now, but it's not.

Vijay Agarwal: 06:54 
 I mean, you assumed it's coming from.

Vijay Agarwal: 06:55 
 A trusted email id, right?

Emily Clifford: 06:57 
 Yes.  Yeah.  I never check spam for anything.  Are you like read like you.  You're Automated, wired to check.

Vijay Agarwal: 07:08 
 Yeah.  So I'll tell you an incident what happened three years ago.  We were getting emails from hackers that they have got access to some instances that we run, and they send that.

Vijay Agarwal: 07:24 
 Email to 10 people in the organization.

Vijay Agarwal: 07:26 
 And everything landed in spam.  And after five days, they actually got into the system.  So they kept on sending us notifications to before hacking and they could potentially negotiate a deal.

Vijay Agarwal: 07:42 
 So after that, I made it mandatory.

Vijay Agarwal: 07:44 
 That everyone checks spam.  We don't want to miss out anything.

Emily Clifford: 07:48 
 Yeah.  Oh, man, that's very scary.

Vijay Agarwal: 07:50 
 Yeah.  Wow.

Emily Clifford: 07:56 
 Lesson of the day, check spam.

Vijay Agarwal: 07:58 
 Yeah.  I mean, keep everything empty, you know, zero inbox, so zero spam box.  Yep.

Emily Clifford: 08:04 
 You know, it's.  You know what I think why it's people forget to do it is because now that everybody uses mobile so much for email, it's not in your face.  You're not seeing it.  You know, like if you don't have that, if you're not looking at it, you're just not even.

Vijay Agarwal: 08:19 
 Yeah, I see that happening with my personal mailbox.  I'm not able to clean that spam.

Emily Clifford: 08:24 
 Yeah.

Vijay Agarwal: 08:25 
 But the official one is always clean.

Emily Clifford: 08:28 
 Got it.  All right, let's hope it works this time.

Vijay Agarwal: 08:36 
 It should.  I mean, so.  Yeah, because we know what was the root cause.  The root cause was the iOS 26.1 version and above.  Okay.  Done the testing till 26, but the library for dictation was not compatible.  So we know that.  We fixed it.  We have tested it on multiple devices.

Emily Clifford: 08:58 
 Yeah.

Vijay Agarwal: 08:58 
 So we know that it should work.  It's just that we now want to see if the user experience matches with what.  Hi, Brian.

Brian McHugh: 09:10 
 Hey, guys.  It worked.

Emily Clifford: 09:12 
 Great.  Great.

Vijay Agarwal: 09:12 
 Okay, great.  So now that it works.

Vijay Agarwal: 09:16 
 Brian, what we are trying to figure.

Vijay Agarwal: 09:19 
 Out right, in the next few weeks.

Vijay Agarwal: 09:21 
 Is we started with the hypothesis of.

Vijay Agarwal: 09:23 
 How someone is going to dictate.  Okay.  And we created a flowchart for that we all brainstormed in the month of March and April.  Okay.  But few things changed after that.  That is, we do not have direct connection with epic, so we don't have pre patient records in the system.  Okay.  And we cater for patients to be added on the.  On the live, you know, and we.

Vijay Agarwal: 09:47 
 Don't know if patient will be added before the dictation or after the dictation.

Vijay Agarwal: 09:52 
 So we had to cater that situation.  Okay.  And plus, when went through the case files, we also saw that our.

Vijay Agarwal: 10:02 
 Interpretation of templates is not the same.

Vijay Agarwal: 10:05 
 As the case files, because case files.

Vijay Agarwal: 10:07 
 Are showing us we could have five.

Vijay Agarwal: 10:09 
 Templates at the go.

Vijay Agarwal: 10:10 
 At.

Emily Clifford: 10:11 
 In.

Vijay Agarwal: 10:11 
 In one case.  So it's not as simple as ACDF one.

Vijay Agarwal: 10:14 
 Right.

Vijay Agarwal: 10:15 
 It's a combination of five templates.  It can have 10, 12 CPT codes.

Brian McHugh: 10:21 
 Say that again, Vijay.  I'm not sure I followed the last piece like the.

Brian McHugh: 10:25 
 The template piece.

Vijay Agarwal: 10:27 
 Yeah.  So when we designed the template, we took the templates from the cheat sheet that we had.  And cheat sheet typically had one procedure name and five or six codes.  But went through the case files when were training the AI model, we saw some of the case files have 15 to 20 codes in one procedure in one patient record.  Okay.  So which means each claim can have.

Vijay Agarwal: 10:55 
 Combination or more than one template.

Vijay Agarwal: 10:57 
 Which means you can have three templates.

Vijay Agarwal: 10:59 
 Applied to a single claim.

Vijay Agarwal: 11:02 
 Because you did X, Y and Z.

Vijay Agarwal: 11:04 
 Right?

Emily Clifford: 11:04 
 Right.

Vijay Agarwal: 11:05 
 So this we did not anticipate.

Vijay Agarwal: 11:08 
 This is a flow for templates.  Right.  So.  So, but we made some changes in that.  Okay.

Brian McHugh: 11:14 
 I just want to make sure.

Brian McHugh: 11:15 
 I just want to make sure.  I understand that.  Because.  Because if it is a, you know, acdf, a one level acdf, like those should be the same CPT codes each time.  If it's a two level acdf, same.

Brian McHugh: 11:27 
 CPT codes each time.

Brian McHugh: 11:28 
 There are, you know, if you want.

Brian McHugh: 11:31 
 To call it off, label cases where there's a nuanced piece to the case, you'll add in codes to that.

Emily Clifford: 11:39 
 Okay.

Brian McHugh: 11:40 
 We're on the same page.

Vijay Agarwal: 11:40 
 Okay.

Emily Clifford: 11:40 
 Yeah.

Vijay Agarwal: 11:42 
 So essentially what we did.  I'll show you on the screen.

Vijay Agarwal: 11:48 
 We picked up the cheat sheet.

Vijay Agarwal: 11:51 
 Okay.

Vijay Agarwal: 11:53 
 And we said,.

Vijay Agarwal: 11:58 
 Say this, okay, this is one type of surgery and template which has six codes.  Okay.  And then so on each one of the cheat sheet had different naming conventions, right?  XLIF1 level, and it has five.

Vijay Agarwal: 12:14 
 But then when we got into the.

Vijay Agarwal: 12:16 
 Actual case files, okay, that we got.  And in these case files went through, you know, all the records of the actual claim document.  Okay.  I don't know which one has the entire document, but then we saw that claim had 15 to 20 CPT codes.  Okay.

Vijay Agarwal: 12:40 
 Which does not correlate to a single template.

Vijay Agarwal: 12:45 
 This one.  Right.  It has like these many codes here which is not part of a single template.

Brian McHugh: 12:50 
 Got it.  I see the same.

Vijay Agarwal: 12:53 
 That could change.  Right?  So which means when in the original journey, when we thought template, we thought, okay, it's easy.

Vijay Agarwal: 13:01 
 You can just select the template you.

Vijay Agarwal: 13:02 
 Want and you can do additional dictation and you can move on.

Vijay Agarwal: 13:07 
 Now, if you already know that you did three or four types of procedures.

Vijay Agarwal: 13:11 
 Which are part of the template, you will want to select the four templates okay.  So we had to change that in the user journey so that you could select four templates.  Okay.

Vijay Agarwal: 13:26 
 So what we are still trying to figure out, right, is the user experience.

Vijay Agarwal: 13:30 
 That the surgeon should have from opening imbele to completing the entire dictation.  Okay.

Vijay Agarwal: 13:38 
 And when we say entire dictation, it is not just the audio part, but it is also the selection of patient,.

Vijay Agarwal: 13:44 
 Selection of template, looking at the transcript,.

Vijay Agarwal: 13:48 
 Because that has changed since we do.

Vijay Agarwal: 13:50 
 Not have live integrations available at the moment.

Vijay Agarwal: 13:53 
 So there are lots of scenarios that we are getting coming across.  So some, as we are learning, we are incorporating some of those that we.

Vijay Agarwal: 14:02 
 Feel are low hanging fruits.

Vijay Agarwal: 14:04 
 So what we want you to do.

Vijay Agarwal: 14:06 
 Mainly right now in the next, you know, couple of days is look at your user experience.

Vijay Agarwal: 14:12 
 Do you think as a surgeon you.

Vijay Agarwal: 14:14 
 Are able to do this patient MRN entry, the audio note, the template selection seamlessly, or you do you think it's messy, cucumbersome, complex.  We have to simplify something.  Right.  And that's the first feedback we want from you, the user experience.  Okay.

Brian McHugh: 14:35 
 Yep.

Vijay Agarwal: 14:37 
 The next phase of the feedback is the actual audio note that you generate.

Vijay Agarwal: 14:45 
 That audio note will create a transcription.

Vijay Agarwal: 14:49 
 Okay.

Vijay Agarwal: 14:50 
 And we want you to check if.

Vijay Agarwal: 14:51 
 You are satisfied with the quality of transcription.

Brian McHugh: 14:55 
 Okay.

Vijay Agarwal: 14:56 
 Yep.

Vijay Agarwal: 14:56 
 Any dictation that you are not satisfied, we have it on the back end.  You can just tell us with the.

Vijay Agarwal: 15:02 
 Screenshot that, hey, this is a dictation that you did in the mobile app.  You will have a list.  You just flag it off and send it to us.  We will check why the transcription was not good.

Emily Clifford: 15:14 
 And you're saying that DJ because based on what you've done, you had mentioned this in a few calls ago, he'll say a word and the AI won't pull the correct word.  That's what you mean, right?  To scrub through and ensure that all the terminology actually corresponds to what he's saying.

Vijay Agarwal: 15:30 
 Yes.

Vijay Agarwal: 15:31 
 When we, when we showed the STT.

Vijay Agarwal: 15:33 
 Demo a few, you know, four to five weeks ago.  Right?

Emily Clifford: 15:36 
 Yeah.

Vijay Agarwal: 15:36 
 That time were showing you various cases that happen.  Yeah.

Vijay Agarwal: 15:39 
 So we want to make sure that.

Vijay Agarwal: 15:41 
 First the user experience of the app,.

Vijay Agarwal: 15:44 
 Second, the dictation quality, and then finally we land into the actual billing codes.

Vijay Agarwal: 15:50 
 Mapping.  Yeah.

Vijay Agarwal: 15:52 
 So for the billing codes, we are.

Vijay Agarwal: 15:54 
 Running our own tests on the claim documents that you gave us.  Okay.  And we have, in some cases we.

Vijay Agarwal: 16:03 
 Are able to get 100 mapping.

Vijay Agarwal: 16:05 
 In some cases we are getting 85, 88% mapping.

Vijay Agarwal: 16:09 
 And in the others we are also flagging off what is not making sense at all.

Vijay Agarwal: 16:13 
 I Mean, the description is completely different from the codes.

Vijay Agarwal: 16:19 
 We probably got the wrong files.

Vijay Agarwal: 16:22 
 Possible.  Right.

Vijay Agarwal: 16:24 
 The problem was that we don't know what happened with these claims.

Vijay Agarwal: 16:27 
 Were they accepted as is was their iteration.  Okay.  So what we need now for validation is potentially the claim journey from the billing team.

Vijay Agarwal: 16:39 
 Just a few where they can say, okay, these were the rejected claims.

Vijay Agarwal: 16:43 
 Okay.  When they were submitted as is.

Vijay Agarwal: 16:46 
 And then they got converted as approved when the claim was modified.

Vijay Agarwal: 16:49 
 We don't have that journey and history right now.  Lindsay, you want to add anything?

Vijay Agarwal: 16:57 
 No, just One thing that Dr. Brian has just created a cla.  Not created a claim, he has just dictated, but he has to associate the patient from the association queue.

Vijay Agarwal: 17:10 
 Yeah.

Vijay Agarwal: 17:10 
 We will show it to him on the screen.

Vijay Agarwal: 17:11 
 I think we will have to show it to him exactly how to do it.

Emily Clifford: 17:15 
 Okay.

Vijay Agarwal: 17:16 
 Okay.

Brian McHugh: 17:19 
 You're bringing up interesting points, Vijay, because.

Brian McHugh: 17:21 
 One of the things we wanted to.

Brian McHugh: 17:23 
 Build toward, and maybe it's something that comes up earlier, is, you know, call them Surgeon X.  Surgeon X dictates their procedure using their own language.

Brian McHugh: 17:38 
 That language is not appropriate to support.

Brian McHugh: 17:42 
 The CPT code they're trying to get a reimbursed for.

Brian McHugh: 17:47 
 And it.

Brian McHugh: 17:48 
 Ideally, the app would kind of lead the surgeon.  Right.  If you say, I did an app.  I removed an appendix.

Brian McHugh: 17:55 
 Right.  That.

Brian McHugh: 17:56 
 It starts with that.

Brian McHugh: 17:58 
 The app says, okay, so then you.  You likely want to bill these CPT.

Brian McHugh: 18:02 
 Codes and your patient has a diagnosis supported by these ICD10 codes.  The surgeon's like, yeah, that's what I'm trying to do.  And then it kind of populates everything with the appropriate language.  And then the surgeons, if they insist on dictating or want an active role, can simply adjust the file to reflect that specific patient.  Everybody's on that page.  Yeah.

Vijay Agarwal: 18:27 
 Okay.

Emily Clifford: 18:28 
 Wouldn't that be where the template comes in?  Vijay, Isn't that when they would select the.  So they dictate and then they select the appropriate templates.

Vijay Agarwal: 18:37 
 Yes.  Yeah.

Vijay Agarwal: 18:41 
 So that's what we realized, that it's going to be a combination of templates, not one template.

Vijay Agarwal: 18:46 
 Yeah.  So what we did was at this point, the surgeon dictates, they map it to a patient, they select a template,.

Vijay Agarwal: 18:58 
 Or they can select more than one template.

Vijay Agarwal: 19:00 
 Okay.

Vijay Agarwal: 19:01 
 Now, the intelligence is not yet applied.

Vijay Agarwal: 19:03 
 On the mobile app where we can.

Vijay Agarwal: 19:05 
 Tell them, hey, based on your dictation,.

Vijay Agarwal: 19:07 
 You may want to choose these templates.  Okay.  So this is part A of the.

Vijay Agarwal: 19:12 
 Intelligence, but the part B also is that their dictation does not support the.

Vijay Agarwal: 19:19 
 ICD and CPD codes for which they.

Vijay Agarwal: 19:21 
 Are trying to Get a claim.  So we don't know yet if we.

Vijay Agarwal: 19:25 
 Should re ask them to redictate if they insist.  Right.  This is, this is where what Brian.

Vijay Agarwal: 19:33 
 Has been telling us from the last.

Vijay Agarwal: 19:35 
 Review as well, that for the doctors.

Vijay Agarwal: 19:37 
 Who don't dictate as per the payers accepted terminology, how do we guide them to either dictate for that terminology or how do we show them that hey, these are the codes.

Vijay Agarwal: 19:49 
 Did you mean these codes?

Vijay Agarwal: 19:50 
 Just select the codes and we will manage the terminology at our end.  And if you still insist that you want to dictate, then go ahead and dictate this language.

Vijay Agarwal: 20:00 
 Okay.

Vijay Agarwal: 20:00 
 So that's what that is the user experience part.

Vijay Agarwal: 20:03 
 Okay.  And this is a flow.

Vijay Agarwal: 20:05 
 For a surgeon who is not dictating.

Vijay Agarwal: 20:07 
 As we expect them to dictate.  So we have to create a flow and a sequence.  Right.

Vijay Agarwal: 20:12 
 But first we wanted to check what a pro surgeon like Brian does.

Emily Clifford: 20:17 
 Yeah.

Vijay Agarwal: 20:17 
 Who everything, you know, in his brain and he's able to do a perfect dictation.  Right.  And then we go to the step.

Vijay Agarwal: 20:23 
 Two because we are trying to fix.

Vijay Agarwal: 20:25 
 Brian's flow first and then the other surgeons flow.  But Brian, you are right there.  I mean that's the intelligence.  We want to bring two levels to the surgeon.  And, and the language for the builder and the.

Brian McHugh: 20:39 
 I mentioned something.

Brian McHugh: 20:40 
 I just want to raise two issues.

Brian McHugh: 20:42 
 One on the.  And I think you guys have figured this out already.  Vijay.  But you had pulled up that cheat.

Brian McHugh: 20:48 
 Sheet where you said, look, here's a surgery that some of these codes showed up in a more, you know, templated surgery.

Brian McHugh: 20:57 
 So maybe I didn't communicate appropriately about this list.

Brian McHugh: 21:02 
 Some of those categories are fully packaged surgeries.  So for example, what do we have here?  Like one of them that's labeled ACDF1 level or XLIF1 level or ACDF2?  Yeah, XLIF1 level.  So that procedure, if you just.

Brian McHugh: 21:26 
 Did an xlif, those are all the codes you'd expect to bill.

Brian McHugh: 21:29 
 Then there are other columns on the cheat sheet that one of them I know is labeled osteotomies, for example.  They don't reflect whole surgeries.  They're kind of add on codes.

Brian McHugh: 21:49 
 And the whole cheat sheet collectively was.

Brian McHugh: 21:53 
 Given out to surgeons to say, you know, what surgery are you doing?

Brian McHugh: 21:57 
 You're doing an xlif.  Okay.

Brian McHugh: 21:59 
 This is what you should bill here.

Brian McHugh: 22:01 
 We also included in the cheat sheet.

Brian McHugh: 22:04 
 Some common codes that get added into those procedures.

Brian McHugh: 22:08 
 So you've done an xlif and you also did an osteotomy.

Brian McHugh: 22:12 
 That's a frequent association.

Brian McHugh: 22:14 
 Okay.  In the cheat sheet here, you know,.

Brian McHugh: 22:17 
 A list of the common osteotomy codes.  So if you're holding the cheat sheet,.

Brian McHugh: 22:20 
 You say, did my xliff?  Well, what about the osteotomy code?

Brian McHugh: 22:23 
 Yeah, that's on there too.

Brian McHugh: 22:24 
 But I just wanted to mention that to you because, and like I said, I think you guys figured this out already.  If you're looking at that cheat sheet.

Brian McHugh: 22:32 
 And saying this surgery called osteotomy, you.

Brian McHugh: 22:36 
 Know, that's a little confusing.  It's like, oh, right, that's not.

Brian McHugh: 22:40 
 Actually a complete procedure.  That's a bucket of codes for a.

Brian McHugh: 22:45 
 Specific type of technical maneuver called an.

Brian McHugh: 22:49 
 Osteotomy that you might sprinkle into other procedures.

Brian McHugh: 22:54 
 The other thing that I don't think.

Brian McHugh: 22:57 
 Adds complexity, but just so you know, on your end, I'll stick with this.

Brian McHugh: 23:02 
 Example of an XLIF physically.

Brian McHugh: 23:06 
 In reality, what we'll usually do is a full X lift surgery.  We stitch up that incision during the same operative period.  The patient is rotated around and will then do a posterior fusion or arthrodesis, a lumbar arthrodesis that for many surgeons that will generate two independent operative reports.

Brian McHugh: 23:35 
 So it would be two, you know,.

Brian McHugh: 23:38 
 Complete surgical packets, if you will.  On this cheat sheet.  For certain surgeons, depending on your network status with the insurer, you may combine those two surgeries into one operative report.

Brian McHugh: 23:58 
 So sometimes you guys will see that.

Brian McHugh: 24:01 
 It would actually be a complete XLIF procedure followed by a complete lumbar arthrodesis procedure all in one operative report.

Brian McHugh: 24:13 
 And that would do what you would, I think you guys would expect it to do.  It would take all the CPT codes.

Brian McHugh: 24:21 
 For XLIF and all the CPT codes for lumbar arthrodesis and just those would be listed out in order to.  So it's a little bit modular in that way where sometimes these can be combined for bigger procedures.  And that's kind of option A.

Brian McHugh: 24:42 
 Option B is you may do a.

Brian McHugh: 24:46 
 Whole procedure like a lumbar orthodesis, but there are some frequent add in codes like osteotomy that you may tack on because that was part of that particular surgery.

Brian McHugh: 25:03 
 And, and so we wanted it to be able to say, you know, it's,.

Brian McHugh: 25:08 
 I'm the surgeon, this is the patient.  I did a lumbar arthrodesis at these levels.  I also did, you know, two levels of osteotomy.

Brian McHugh: 25:19 
 And the intelligence of the app says,.

Brian McHugh: 25:21 
 Okay, so you did a lumbar arthrodesis.  So you're trying to build these codes.

Brian McHugh: 25:26 
 And you're telling me you did two osteotomies.

Brian McHugh: 25:29 
 So you're trying to build these codes.  So your operative report, the narrative needs to contain this language.  And like we already went over, based on that procedure, we're assuming your patient has the appropriate ICD10 diagnostic codes that would substantiate that procedure.  And, and all of that could kind.

Brian McHugh: 25:54 
 Of build the record.

Brian McHugh: 25:58 
 For the surgeon.

Brian McHugh: 26:00 
 So I just wanted to say that.

Brian McHugh: 26:01 
 Was the first thing I wanted to kind of tell you guys.

Brian McHugh: 26:03 
 The second thing I had communicated to.

Brian McHugh: 26:05 
 Emily, but I wanted to make sure I communicated here.  And it was the format of the OPERA report, at least mine, which I think is something that should be modeled.  I didn't invent it.  I took it from mentors and whatnot.

Brian McHugh: 26:19 
 But if you look at our operative.

Brian McHugh: 26:21 
 Reports, it's the surge, it's demographic information, it's the surgeon's name, the CO surgeon's name, the date of the surgery.

Brian McHugh: 26:27 
 But then it's the pre.  And this is a standard template across.

Brian McHugh: 26:31 
 All of Western medicine.

Brian McHugh: 26:33 
 It's a preoperative diagnosis.  And then they typically list out the diagnoses.

Brian McHugh: 26:40 
 1, 2, 3, 4, 5.  Those are meant.  Not all surgeons recognize this, but each of those is meant to correlate to.

Brian McHugh: 26:49 
 A specific ICD10 code.

Brian McHugh: 26:54 
 So you kind of start the operative report with.  To the insurer who's going to be reimbursed the claim.  The operative report starts with preoperative diagnosis.

Brian McHugh: 27:05 
 These are the ICD10 codes.

Brian McHugh: 27:07 
 And then further down is a description of the procedure.  That's how we label it, description of procedure.  And we list out the parts of the procedure.  A lot of surgeons don't realize this either.

Brian McHugh: 27:22 
 That's meant to be.

Brian McHugh: 27:25 
 Each one of those items is meant.

Brian McHugh: 27:27 
 To correlate to a specific CPT code.  Then when you move down to the.

Brian McHugh: 27:34 
 Narrative elements in the text, it'll say it usually says something like operative description or something like that.  The first paragraph of that is what we call a history of present illness or an hpi, which is a narrative paragraph that introduces the patient.  So it says Emily Clifford is a 35 year old female who came in with.

Brian McHugh: 27:58 
 And you list their diagnoses.

Brian McHugh: 28:00 
 So it's a re.  It's a narrative version of the ICD10 codes.  As such, we discussed surgery with her and proceeded with the below procedure.  The next paragraph is the start of the actual narration of the procedure, which should go paragraph by paragraph, the narrative elements supporting the CPT code.  Ideally there would be parallel construction from those.  The list of ICD10 codes would map to the narrative history of present illness.  So that the narrative component, Emily, is a 35 year old female with lumbar radiculopathy, lumbago, et cetera.

Brian McHugh: 28:48 
 That is in the sequence that is.

Brian McHugh: 28:50 
 Listed higher up on the report, line by line under preoperative diagnosis.  And then the paragraph by paragraph description of each CPT code narrative description of each CPT code would parallel the header higher up in the report where the.

Brian McHugh: 29:17 
 Individual CPT codes were listed out.  If does that make sense to people?  I'll give you an example.

Vijay Agarwal: 29:24 
 And we have that on the screen.

Brian McHugh: 29:26 
 You have that.  Okay.  Okay.

Vijay Agarwal: 29:30 
 Emily had sent this to us.

Brian McHugh: 29:33 
 Okay.

Vijay Agarwal: 29:35 
 And I would have a follow up question on this.  Okay.  Does the sequence really matter from the claims perspective?  Because the objective for the AI engine would be to identify all the ICD and CPD codes from the entire dictation that you gave us and then try.

Vijay Agarwal: 30:03 
 To correlate with the pre operative report or the post operative report that you.

Vijay Agarwal: 30:08 
 Have uploaded on the shared drive.  Initially this was going to come from epic, but now on the shared drive.

Vijay Agarwal: 30:14 
 So for the engine, you send all of this block of data, irrespective of.

Vijay Agarwal: 30:21 
 Their sequence, and then the engine is.

Vijay Agarwal: 30:25 
 Supposed to come out with this final.

Vijay Agarwal: 30:27 
 List of codes and the flags that.

Vijay Agarwal: 30:32 
 It's not able to make sense from.

Vijay Agarwal: 30:33 
 The data that you send it.

Vijay Agarwal: 30:35 
 So the question is the sequence really important for the engine?

Brian McHugh: 30:42 
 The code sequence pj?

Vijay Agarwal: 30:44 
 Yeah, yeah.  In the way you dictate.  So you can dictate in your own sequence, but the engine will process the entire thing as one block of content.

Brian McHugh: 30:56 
 Yeah, I think that's if the question is, do the sequences of codes matter.

Brian McHugh: 31:04 
 Either how they're listed out one by one or how they're narrated.  No, I don't think so.  It's all for simplicity.

Brian McHugh: 31:13 
 And.

Vijay Agarwal: 31:17 
 Yeah, so I mean a very professional,.

Vijay Agarwal: 31:20 
 You know, surgeon who knows everything in their head in a sequence like you would do, you would say, hey, this is the patient and I just came out of, I mean with this ailment and then diagnosed with X.  And then I am recommending this surgery or I did this surgery which had these pre operative conditions.  And then you performed XYZ parts of the surgery.  Right.  You would go in precision sequence.

Brian McHugh: 31:48 
 Yeah.

Vijay Agarwal: 31:48 
 Right.  Someone can be a bit haphazard and they can say I came out of surgery and I performed this surgery for patient X.  Okay.

Vijay Agarwal: 31:59 
 And because I had recommended or found.

Vijay Agarwal: 32:03 
 ABC situations in the preoperative diagnosis.  Okay.  So even if they did all this haphazard.

Brian McHugh: 32:10 
 Yes.

Vijay Agarwal: 32:11 
 The engine would still have to figure out what is the patient, what was.

Vijay Agarwal: 32:16 
 The pre diagnosis and then what was.

Vijay Agarwal: 32:18 
 The actual surgery done?

Vijay Agarwal: 32:20 
 And then try to map it to ICD and cpts.  Right?

Brian McHugh: 32:23 
 Yes.  Yes.

Vijay Agarwal: 32:25 
 Okay.  Yeah.

Vijay Agarwal: 32:26 
 Because the way that engine is working.

Vijay Agarwal: 32:29 
 Is all this block of data that you record and the patient documents, they.

Vijay Agarwal: 32:35 
 Get fed into it.  Then it tries to make sense of what has been dictated versus what is the operative report telling us.

Vijay Agarwal: 32:44 
 And if there are red flags.

Brian McHugh: 32:47 
 Yep.

Vijay Agarwal: 32:49 
 So for the engine right now, sequence doesn't matter.

Vijay Agarwal: 32:51 
 Hence I wanted to check if the sequence really matters.

Vijay Agarwal: 32:55 
 But I think this description that you have given us, this is a very good guide for all the surgeons who.

Vijay Agarwal: 33:02 
 Don't have everything in their head.

Vijay Agarwal: 33:04 
 And then we can tell them now.

Vijay Agarwal: 33:05 
 Is the time to, you know, record the patient name, record the procedure date, record the pre diagnosis, record the operative, the entire surgery, code by code, something like that.  So we can create a guided template.

Brian McHugh: 33:22 
 And to your point too, Vijay, like if we had a magic wand and could just make this product what we want it to be and the user.

Brian McHugh: 33:32 
 Experience what we wanted it to be, you know, people would use it as we wanted.

Brian McHugh: 33:37 
 We would push them to say, look,.

Brian McHugh: 33:39 
 Just put the patient information in, tell us you did an appendectomy, we'll construct the perfect operative report with all the.

Brian McHugh: 33:48 
 Right language, billing codes, etc.

Brian McHugh: 33:52 
 And then you can just, if there's.

Brian McHugh: 33:53 
 Some particular nuance to this case, feel free to add it in.

Brian McHugh: 33:56 
 But otherwise we'd really rather not have you dictating with your own language which doesn't map to the payer language.  That's where the problems align.  That'd be great.  As we all know, in a user experience world, if you're trying to get clients to use it, they may just not want to do that.  And then we have to correct for their current workflows.

Vijay Agarwal: 34:17 
 Yeah, yeah.  So I think eventually, you know, we,.

Vijay Agarwal: 34:21 
 We could get to that state where.

Vijay Agarwal: 34:22 
 It's an end to end autopilot system.

Vijay Agarwal: 34:27 
 At least at the beginning.  We have to make sure that if.

Vijay Agarwal: 34:31 
 Dictations are being made and if operated reports are being fed from a emr,.

Vijay Agarwal: 34:38 
 Then we are able to flag off.

Vijay Agarwal: 34:42 
 The content that is not making sense as per the payer's policy.  That is step number one.

Vijay Agarwal: 34:48 
 Because we would need human in the loop to make the system more.

Vijay Agarwal: 34:53 
 Robust before we start telling them, hey, you just, you know, give the surgery name or just tell us the patient and then we figure out the entire report for you.  Yes, we are right now at step one, but yes, I understand what you are trying to say.

Vijay Agarwal: 35:08 
 So I just want to clarify this again.  Even in today's practice, surgeons do have to dictate after every surgery, right?

Brian McHugh: 35:18 
 There needs to be a operative report.

Brian McHugh: 35:22 
 Created after every surgery.

Brian McHugh: 35:25 
 Some people, many people dictate them.  Many people like myself will use a template.

Brian McHugh: 35:33 
 And you're on the computer type.

Brian McHugh: 35:35 
 I just.

Brian McHugh: 35:35 
 The template comes up and I fill in the variables on the template.  So it's.

Brian McHugh: 35:41 
 There's no dick, there's no dictation.

Brian McHugh: 35:43 
 In my workflow, I have templates that are saved in the emr.  Some surgeons do that.  Many surgeons still dictate.  And dictation takes a couple forms.  Dictation can be.  And this is true of different hospitals as well.  Some of the EMRs have Dictaphones that go straight to the EMR and there's a speech to text.  Some surgeons, private offices, they'll carry around a dictation recorder and it will be transcribed later by a secretary or someone less common, obviously, as technology advances.  And then many hospitals will still have a dictation service attached to the hospital.  So you call the hospital dictation number.

Brian McHugh: 36:35 
 And you dictate into the hospital system.

Brian McHugh: 36:39 
 And then that hospital transcribes that dictation and faxes it to your practice once it's dictated.  That's less and less common as well, as you might expect.  One question came to mind, Vijay, when you were talking about connectivity and getting this documentation in time.

Brian McHugh: 37:04 
 Billy, Is it simple to add the.

Brian McHugh: 37:11 
 Camera function to just take a picture of those documents and it can be translated into text?  And what I'm thinking is most doctors, as they're sitting at the workstation after the surgery's completed and have either a phone in their hand or.  And they're dictating the operative report or are sitting at the computer putting together the operative report.  The additional documents we would have if we had connectivity to the emr, are in front of them on the emr.  And in my old app, which was totally different and much simpler, I would.

Brian McHugh: 37:51 
 Just pull up those documents and take.

Brian McHugh: 37:53 
 A picture of it and include that in the bundle back to my billing department so that they didn't have to go pull it from the emr.  They had a PDF copy that was a picture.

Brian McHugh: 38:07 
 And I know, you know, you can also.

Brian McHugh: 38:10 
 I know now there's technology where it'll take that snapshot and extract the text and make that a document.  Is that very difficult?  Is that too error prone?

Brian McHugh: 38:22 
 I don't know.

Brian McHugh: 38:22 
 It may be a way to short circuit use cases where perhaps we'll never.

Brian McHugh: 38:30 
 Get connectivity in mainstream hospitals who use.

Brian McHugh: 38:34 
 Mainstream products like EPIC or Athena will get connectivity to those systems.  Right.  They're built to have connectivity.  Some that are so old or hostile from a user standpoint that will never allow us to have connectivity.  Is that a workaround there?

Vijay Agarwal: 38:57 
 So I think as we progress, you.

Emily Clifford: 38:59 
 Know,.

Vijay Agarwal: 39:01 
 Scanning or taking pictures from the.

Vijay Agarwal: 39:05 
 Mobile, putting it through a transcription engine that reads all the content, then tries to make sense of it.

Vijay Agarwal: 39:13 
 Of course the technology is available.

Vijay Agarwal: 39:15 
 It is still, I would say between 80 and 85% accurate.  In very few cases it reaches 97 or 95%.  So I think gradually what we can.

Vijay Agarwal: 39:31 
 Do is for those situations we can build this feature where they can potentially.

Vijay Agarwal: 39:36 
 Take pictures, upload it as the docket for the patient and then immediately tries to make sense of it.

Brian McHugh: 39:44 
 Yeah.

Vijay Agarwal: 39:44 
 But begin with we will have to at least get the correlation done between what we are getting from a EMR.

Vijay Agarwal: 39:53 
 Like epic, which is not definitely scanned, but it is more typed information.  So it is you know, actually digital.

Vijay Agarwal: 40:01 
 Information that we are getting.

Vijay Agarwal: 40:03 
 And then we are comparing that against the digital note which you have dictated and trying to make sense for a successful claim.

Vijay Agarwal: 40:12 
 Because our focus right now is to make sure that we create a claim.

Vijay Agarwal: 40:16 
 Which is almost 100 accurate.

Brian McHugh: 40:19 
 Yeah.

Vijay Agarwal: 40:19 
 Although we will not be there, you know, in this phase.  But eventually that's our first goal to address.  And then we can start addressing on the data acquisition like what you're saying.

Vijay Agarwal: 40:30 
 Is the data acquisition layer where how many different ways can we acquire that data into imbele to process a claim?  Yeah, I think but the technology is there.  You are right, it can be done.

Brian McHugh: 40:45 
 Understood.

Vijay Agarwal: 40:46 
 Yeah.

Vijay Agarwal: 40:47 
 So, yes.

Vijay Agarwal: 40:48 
 So this to your question on the sequence.  Okay.

Vijay Agarwal: 40:53 
 And what you had mentioned to Emily.

Vijay Agarwal: 40:55 
 I, I understand that the sequence is.

Vijay Agarwal: 40:57 
 Not important for the engine, but doctors,.

Vijay Agarwal: 41:01 
 They will have a sequence in their mind, the imbly engine right now that you will see and the transcriptions that.

Vijay Agarwal: 41:09 
 You will see will appear like a one big blob.

Vijay Agarwal: 41:12 
 Okay.  It is not segregated by sentences or by paragraphs.  It doesn't understand that.  So it is all one dictation.  So don't be confused.  You know, why is it showing that?

Vijay Agarwal: 41:25 
 But we are just trying to consume.

Vijay Agarwal: 41:27 
 That as one single piece of content.

Brian McHugh: 41:30 
 Do you want me if I do mock dictations, Vijay?

Brian McHugh: 41:33 
 Because I actually, if I'm forced to dictate, there's a few hospitals I work at where I'm forced to dictate and I actually dictate the format into the report.  Just because as you might Imagine there are fewer errors on the billing side if you can produce a document even if it's through dictation, where it's formatted appropriately.  Because the biller who ultimately ends up with it's in an organized fashion, so they're far less likely to make mistakes.  Do you want me to.  If I'm doing mock dictations, should I do that or should I just dictate a block of text like many doctors would?

Vijay Agarwal: 42:12 
 I think you can give us that.

Vijay Agarwal: 42:15 
 Dictation piece where or better is if.

Vijay Agarwal: 42:19 
 You can just send a small note.

Vijay Agarwal: 42:21 
 Saying, Para 1 should be patient info, Para 2 should be pre diagnosis, Para 3 should be whatever you have recommended, Para 4, and so on.  Right.

Vijay Agarwal: 42:33 
 What we will try to do in later versions is we will try to convert this block of data into something.

Vijay Agarwal: 42:40 
 Which fits into your template and automatically structure.

Vijay Agarwal: 42:45 
 Because right now, whatever you dictate as an audio, it will get converted into.

Vijay Agarwal: 42:51 
 One stream of text.  No matter what.

Brian McHugh: 42:54 
 No matter what.

Vijay Agarwal: 42:55 
 Yeah.

Vijay Agarwal: 42:56 
 So what we can do is for presentation to billers, we can figure out if there is a better way to.

Vijay Agarwal: 43:04 
 Templatize, like you're saying, in different paras.

Vijay Agarwal: 43:07 
 And we templatize that for them to.

Vijay Agarwal: 43:09 
 Understand, oh, this is the patient data.  And then second, hey, this is the preoperative diagnosis, and then so on.

Brian McHugh: 43:17 
 And that's all.  That's all kind of available, by the way.  Like if you.

Brian McHugh: 43:20 
 If your team just Googles, okay, operative report format, you know, it's a.

Brian McHugh: 43:26 
 There.

Brian McHugh: 43:26 
 There's subtle variations across the country, whatever, but they're all roughly similar in terms.

Brian McHugh: 43:32 
 Of, like medical schools used to hand.

Brian McHugh: 43:34 
 Out, because these were all paper forms.  They'd say, okay, here's an operative report.  This is how you're supposed to structure it.  Here's a progress note.  Here's a consult note.  Here's a history and physical note.  They're supposed to have almost a nationalized format to them.  Each institution tweaks it slightly so it's not regulated like that.  But if you guys wanted to look at typical formats, I think if you.

Brian McHugh: 44:00 
 Just googled it and you'd see.

Vijay Agarwal: 44:02 
 Yep.

Vijay Agarwal: 44:03 
 Yeah, if it's public knowledge, then we.

Vijay Agarwal: 44:06 
 Will find that out.  We'll take that as a note and see, you know, what is the complexity to convert this block of dictation into that format?  Right.  Because like we discussed, there are multiple entry points into the claim engine.  The real brain is the claim engine.

Vijay Agarwal: 44:23 
 And those entry points are that people can get to it just by selecting.

Vijay Agarwal: 44:27 
 The template and no dictation at all.  Right.  And the second entry point is you.

Vijay Agarwal: 44:32 
 Have a beautiful dictation and you also.

Vijay Agarwal: 44:36 
 Have a few more templates that you want to combine.

Vijay Agarwal: 44:39 
 Right.  So dictations content is just one part.

Vijay Agarwal: 44:44 
 That we are trying to structure here.

Vijay Agarwal: 44:47 
 For the operative report.

Vijay Agarwal: 44:48 
 We don't know, you know, when we.

Vijay Agarwal: 44:50 
 Get to the actual stage of generating operative reports, what would happen if people.

Vijay Agarwal: 44:56 
 Only selected the templates?  We don't have any other information.  So we would pull in from EMR to create the patient para and then the pre diagnosis because there was no dictation.  Right.  Just a template.

Vijay Agarwal: 45:10 
 So then the EMR has most of.

Vijay Agarwal: 45:11 
 The knowledge for us to create that structured paragraph as an operative report.

Vijay Agarwal: 45:17 
 So we are still away in that.

Vijay Agarwal: 45:20 
 Sense to reach a stage where something.

Vijay Agarwal: 45:22 
 Like that can be fully automated.

Brian McHugh: 45:24 
 Say that last part again, Vijay.

Brian McHugh: 45:26 
 I just want to make sure we're clear on that.

Vijay Agarwal: 45:29 
 So the full operative report that we.

Vijay Agarwal: 45:32 
 Are trying to generate in terms of.

Vijay Agarwal: 45:35 
 Structured paragraphs, we are still away in.

Vijay Agarwal: 45:38 
 Terms of creating that.

Vijay Agarwal: 45:39 
 Because we are right now creating the.

Vijay Agarwal: 45:42 
 Claim form with the CPTs and ICDs.

Vijay Agarwal: 45:46 
 Mapped and not the whole operator report for the doctor.

Vijay Agarwal: 45:50 
 Because that is already available in EPIC that we are pulling out.  Right.

Brian McHugh: 45:56 
 Well, what is already available in epic?

Vijay Agarwal: 45:59 
 So we get the EMR patient records.

Vijay Agarwal: 46:02 
 That people will submit within.

Vijay Agarwal: 46:05 
 So whatever they created in epic.

Vijay Agarwal: 46:07 
 Right, which is the diagnostic report, the patient record and the after surgical record or the report that they create.

Brian McHugh: 46:17 
 Yeah.

Vijay Agarwal: 46:18 
 So those documents they will upload in epic.  And since it does not integrate with IMBD at the moment, we will have a copy of that uploaded manually into the shared drive of im.

Vijay Agarwal: 46:30 
 Billy.

Vijay Agarwal: 46:32 
 Now, the surgeon who is operating on.

Vijay Agarwal: 46:36 
 That patient does an additional dictation to.

Vijay Agarwal: 46:39 
 Tell us what surgery was performed in detail.  And then we help them correlate that.

Vijay Agarwal: 46:45 
 To the ICD and CPD codes and.

Vijay Agarwal: 46:47 
 We compare that with the document we got from epic.

Vijay Agarwal: 46:52 
 Okay.

Vijay Agarwal: 46:53 
 So our final output is the claim form for this patient, for this encounter.

Vijay Agarwal: 47:00 
 That you are at, for the surgery that you are at.  Right.

Vijay Agarwal: 47:04 
 So when you say the creation of a structured operative report, at the moment we are not generating a structured operative.

Vijay Agarwal: 47:14 
 Report as an output.  Right.  We are generating the claim form as an output.

Vijay Agarwal: 47:21 
 So.

Vijay Agarwal: 47:22 
 And I guess, yeah, sorry, please, no, keep.

Brian McHugh: 47:27 
 Keep going.  Vision.  Maybe you're.  Keep talking.

Vijay Agarwal: 47:30 
 Yeah.

Vijay Agarwal: 47:30 
 So when you said that there is.

Vijay Agarwal: 47:32 
 A, you know, public knowledge for structuring.

Vijay Agarwal: 47:37 
 This paragraph, do you intend for IMBELE to create the entire reports in that structured format as well, apart from the claim form?

Brian McHugh: 47:46 
 Yeah, I think that would be ideally, yes.  That's what I mean.  When I say, you know, I pick up the app and just say, the patient's Emily Clifford.  I did an acdf.  I Am Billy generates the operative report.

Brian McHugh: 48:01 
 In the standard format and basically asks me if I approve of that.  And then probably from a workflow standpoint.

Brian McHugh: 48:10 
 Says, okay, well that would mean that.

Brian McHugh: 48:12 
 You're going to claim this patient has these diagnostic codes and you're trying to.

Brian McHugh: 48:18 
 Bill for these CPT codes.

Brian McHugh: 48:19 
 I say, yeah, that's what I'm doing.

Brian McHugh: 48:21 
 And then it's.

Brian McHugh: 48:22 
 The operative report is generated and the claim form is generated.  I have the ability to approve both or my billing director does and it's sent out.

Brian McHugh: 48:33 
 And I just want to make one.

Brian McHugh: 48:34 
 Comment, I think, in response to what.

Brian McHugh: 48:38 
 I think you were saying, Vijay, about.

Brian McHugh: 48:42 
 How we're not creating operative reports as an output from I Am Billy yet, because we need information from.

Brian McHugh: 48:53 
 The emr.

Brian McHugh: 48:56 
 And I just want to make sure I'm being clear.  For example, the ideal operative report for any surgery.  And they all should be roughly identical, Right.

Vijay Agarwal: 49:12 
 If you.

Brian McHugh: 49:13 
 An appendectomy is an appendectomy with subtle nuances for that patient.  Right.  That aren't really important for billing.  Right.  Surgeons will go off and say, well, you know, they're.  We got into some bleeding for a period of time.  We stopped that with gauze and whatnot.  From a billing standpoint, nobody cares.

Brian McHugh: 49:31 
 Right?

Brian McHugh: 49:32 
 Like the claim is, you did appendect.  That's what you're trying to get paid for, right?

Brian McHugh: 49:38 
 Just an appendectomy.

Brian McHugh: 49:40 
 If you're saying the bleeding and all the stuff you're describing equates to some additional code, okay.  Then it's important from a claim standpoint.  But none of it is important from a billing standpoint.  The surgeons will involve it or include.

Brian McHugh: 49:57 
 It sometimes because they're just used to that, other times because it is important to be part of the record.

Brian McHugh: 50:04 
 If another surgeon has to go in, they know that there was this problem with bleeding and it's in the record, but from a billing standpoint, it doesn't matter.

Brian McHugh: 50:15 
 So my point is the ideal appendectomy.

Brian McHugh: 50:19 
 Or ACDF operative report is Googleable, right?

Brian McHugh: 50:23 
 You can say, Google me.  What's, you know, give me the format.

Brian McHugh: 50:28 
 On ideal ACDF or operative report.

Brian McHugh: 50:32 
 Available, and then that's all we want an.

Brian McHugh: 50:38 
 Ability to kind of generate pre correlated with the appropriate codes and have that as an option for an output to suggest to the surgeon.

Brian McHugh: 50:50 
 Does that, does that make sense?

Vijay Agarwal: 50:52 
 Yeah.  So.

Brian McHugh: 50:53 
 So I, I just want to be clear because you, it sounded like you.

Brian McHugh: 50:56 
 Had said, we can't Have a clean ACDF operative report be an output from imbilly because we don't have the information connectivity to the emr.  And my point is an ACDF operative report is a generic document that we can put together and we can do that for every surgery.  And the payer language almost defines the document.

Vijay Agarwal: 51:24 
 Understood.

Vijay Agarwal: 51:24 
 So maybe I took part of operative report to contain patient information and the.

Vijay Agarwal: 51:33 
 Pre surgical encounters information that comes as part of the whole operative report.  So those two paragraphs where you describe.

Vijay Agarwal: 51:41 
 The patient and the diagnosis, this will.

Vijay Agarwal: 51:46 
 Not appear if we just select templates from imbl.  If you select a template,.

Brian McHugh: 51:54 
 Good point.  Like if you select, let's say you say, you know, acdf, you could have IM Billy as an output, generate the.

Brian McHugh: 52:07 
 Narrative component of the operative description.  So the description of the actual operation that is largely dictated by what CPT codes you're trying to get reimbursed for.  And the payer language,.

Brian McHugh: 52:25 
 It should be.

Brian McHugh: 52:26 
 Able to automatically generate that because that's available on the Internet.  And then the optional comp or the nuanced component at the beginning, which is patient specific, the surgeon could fill in.

Brian McHugh: 52:38 
 Right.  So you could say, look, I did.

Brian McHugh: 52:40 
 A routine acdf, so go ahead and generate my routine ACDF narrative, but give.

Brian McHugh: 52:48 
 Me the optionality to say the, you know, the patient was vj, we had.

Brian McHugh: 52:51 
 To delay surgery because he had a fever for a couple days.

Brian McHugh: 52:54 
 Like the stuff that's nuanced, you can.

Brian McHugh: 52:56 
 Dictate just that piece perhaps.

Vijay Agarwal: 52:59 
 Understood.

Vijay Agarwal: 53:00 
 So basically what we are currently solving.

Vijay Agarwal: 53:05 
 Is from the dictation we figure out the relevant ict, ICD and CPD codes.

Vijay Agarwal: 53:12 
 And we match it with the payer.

Vijay Agarwal: 53:16 
 Lingo and we bring that into the clip.

Vijay Agarwal: 53:19 
 So what I understand is for the operative report, this is just one component.

Vijay Agarwal: 53:26 
 Where you describe the procedure and which is standard Google.

Vijay Agarwal: 53:31 
 Google can give you the standard lingo.  Okay, but before the operative procedures, there is a part where you describe the.

Vijay Agarwal: 53:39 
 Patient and the diagnosis and the other things which the surgeon can additionally dictate in their entire dictation flow.

Brian McHugh: 53:50 
 Yes, and even that to some degree could be automated.  Vijay, like if I said,.

Brian McHugh: 53:57 
 If you.

Brian McHugh: 53:58 
 Googled, what's a typical hpi?

Brian McHugh: 54:02 
 So that's the history of present illness.  It's a standard paragraph format for a lot of these documents.  What's the typical HPI for someone with appendicitis?  There's standard language that describes the diagnostic ICD10 codes for appendicitis.  The surgeon would probably want to add color to that.

Brian McHugh: 54:29 
 Right.

Brian McHugh: 54:29 
 But 99.9% of patients who are there.

Brian McHugh: 54:34 
 In the hospital with an appendicitis who.

Brian McHugh: 54:37 
 Will then have an appendectomy performed on them should have largely identical documentation from a claim standpoint.

Vijay Agarwal: 54:48 
 Yeah.  Yeah.

Brian McHugh: 54:49 
 The doctor will need to add some elements of color to it just for the documentation purposes.

Vijay Agarwal: 54:58 
 Yeah.

Brian McHugh: 54:59 
 But for the claim purpose, the ICD10 supporting language, the CPT supporting narrative, are boilerplate.

Vijay Agarwal: 55:09 
 Almost always the same for that pair, Correct?  Exactly.

Brian McHugh: 55:14 
 And the one caveat that we've already gone over is in spine specific.

Brian McHugh: 55:21 
 Spine's probably the most complicated surgical coding, just so you guys know, for our procedures, we already discussed it.  Routine back problem patient, routine language for.

Brian McHugh: 55:34 
 Their diagnostics, routine CPT language for their cpt.

Brian McHugh: 55:39 
 The only little tweak is the surgeries are all buckets of CPT codes with subtle modifications, like the lumbar arthrodesis surgery.

Brian McHugh: 55:52 
 But in this one, we did osteotomies.  Okay.  So that adds some CPT codes, maybe one, maybe two.  And that each one of those CPT.

Brian McHugh: 56:01 
 Codes needs a little paragraph to describe what you did.  And really, if you boil it down,.

Brian McHugh: 56:10 
 That's the only thing that makes spine so complex.

Brian McHugh: 56:15 
 In an appendicitis case where you're doing.

Brian McHugh: 56:17 
 An appendectomy, you can only do one procedure.

Brian McHugh: 56:20 
 There's nothing else to do.

Brian McHugh: 56:22 
 Right.

Brian McHugh: 56:22 
 So the language is identical.

Brian McHugh: 56:24 
 Spine is exactly the same, except you.

Brian McHugh: 56:29 
 Can sometimes tailor the procedure slightly more.

Brian McHugh: 56:33 
 In a case by case basis with.

Brian McHugh: 56:36 
 One or two extra codes.

Brian McHugh: 56:38 
 Because you tweaked what you did technically, just a little bit.

Brian McHugh: 56:43 
 But the concept, the principle, is the.

Brian McHugh: 56:45 
 Same, that even the ICD10 and CPT.

Brian McHugh: 56:52 
 Codes for an appendicitis diagnosis and an appendectomy surgery are identical across the board.

Brian McHugh: 57:01 
 The language that describes the ICD10 codes.

Brian McHugh: 57:04 
 And the CPT codes for that episode are largely identical across the board.  The elements of the operative report that are not identical from one patient to the next that are not strictly demographic.  Right.  Obviously, John Smith is not Emily Clifford is not Brian McHugh.  So the elements of the narrative report that aren't just demographic are very small percentages of the report.  They're just color versions, you know, little.  Little pieces of the story that.  That make it VJ's appendicitis as opposed to Brian's.

Brian McHugh: 57:45 
 And they're.

Brian McHugh: 57:46 
 They're pieces of the clinical story that need to be in the report to communicate to other doctors, but they're irrelevant to the claim.

Vijay Agarwal: 57:56 
 So it means very specific minor details which may differ patient to patient.

Vijay Agarwal: 58:03 
 But otherwise, from the claims perspective, each.

Vijay Agarwal: 58:06 
 Code has its own language, which is primarily consistent for both ICD and cpd.  Correct.

Brian McHugh: 58:13 
 And this is where exactly.

Brian McHugh: 58:15 
 And this is where most denials happen because the providers or the physicians get wrapped up in the story of the patient's journey, but don't include the critical language needed for the code.

Brian McHugh: 58:34 
 So it'll be, you know, I'll make it up.  But VJ came in vomiting, he was.

Brian McHugh: 58:38 
 At the park with his kid.

Brian McHugh: 58:39 
 He had abdominal pain.

Brian McHugh: 58:42 
 They tell this whole story about how you got to the operating room or.

Brian McHugh: 58:45 
 What your diagnosis, but they don't use the language specific to support the ICD10 Code of Appendicitis we want to put in.  It's like you're T.R.  This patient had appendicitis.  Right.  Here's what needs to be in that description.

Brian McHugh: 59:03 
 You can add in that they were at the park and they had to get their dog, you know, taken care of before they got picked up by an ambulance.

Brian McHugh: 59:11 
 Like all that may be valuable to.

Brian McHugh: 59:14 
 The next provider who takes over for them or something, but in the eyes of the payer and from the standpoint of the claim, it's meaningless.

Vijay Agarwal: 59:24 
 Yep, understood.  So I think that is the language.

Vijay Agarwal: 59:28 
 Part is what we are working on.

Vijay Agarwal: 59:30 
 For the ICD and CPT codes.  Okay.  But the pre, you know, the pre paragraphs, which is the patient description and the historical description, etc.  Is something we are not currently building in the claim report.

Vijay Agarwal: 59:46 
 Right, But a actual operative report would contain all that historical data and the.

Vijay Agarwal: 59:51 
 Patient data plus the paragraphs which dictate the procedure that we are talking about and the relevant terms for the ICD10 codes and the CPD codes.

Vijay Agarwal: 01:00:04 
 So what I mean is for the entire report to be built, we need that dictation history.

Vijay Agarwal: 01:00:10 
 Okay.

Vijay Agarwal: 01:00:11 
 Or history from EPIC plus we need this, you know, generated content of the codes which.  Which can be either dictated by the surgeon or generated by IM Delhi.

Vijay Agarwal: 01:00:22 
 But I am.

Vijay Agarwal: 01:00:22 
 Billy definitely fixes it in the final leg when it creates the claim form.

Vijay Agarwal: 01:00:27 
 So it creates the claim form with these codes plus the language which will be absorbed by the payers.  Right?  That's the final end objective.

Vijay Agarwal: 01:00:39 
 So it doesn't output a full operative.

Vijay Agarwal: 01:00:41 
 Report in the way you described.  Okay.  But it outputs a claim form which has the codes mapped and the language required for that.  But I get what you are saying.

Vijay Agarwal: 01:00:54 
 Eventually, if someone can just dictate, then you have a full operative report in the template that you mentioned.

Vijay Agarwal: 01:01:04 
 We could borrow from Google, which is.

Vijay Agarwal: 01:01:05 
 Standard, and we could in fact create the whole template with the patient history, with whatever was observed, and then the.

Vijay Agarwal: 01:01:13 
 Relevant ICD language and the CPT language.  Right.  So it is like one form which is used for internal discussions as well as for payer.  Sending it to the payer.

Brian McHugh: 01:01:25 
 Yeah, exactly.  Correct.

Vijay Agarwal: 01:01:26 
 I got what you were saying.  Yes.

Brian McHugh: 01:01:28 
 Okay, I know we're out of time.  I just wanted to say one other thing and I'll say it quickly.  That concept I just discussed with you,.

Brian McHugh: 01:01:37 
 That is also true for the operative description.

Brian McHugh: 01:01:41 
 Right.

Brian McHugh: 01:01:41 
 Surgeon to surgeon, they may go on and on about how they control bleeding.

Brian McHugh: 01:01:46 
 And what product they use if they're.

Brian McHugh: 01:01:49 
 Trying to get reimbursed for a laminectomy.  There is standard laminectomy language.  All the other color commentary irrelevant to a claim.

Vijay Agarwal: 01:02:00 
 You mentioned that in the past as well, so.

Vijay Agarwal: 01:02:02 
 But before we complete today's call, Brian,.

Vijay Agarwal: 01:02:05 
 There is one thing we have to make sure you have got on the app.

Vijay Agarwal: 01:02:09 
 So the dictation that you just made,.

Vijay Agarwal: 01:02:13 
 If you open the app, you will.

Vijay Agarwal: 01:02:16 
 See that on the top right corner.

Vijay Agarwal: 01:02:19 
 There is a folder icon.

Brian McHugh: 01:02:27 
 Oh, it logged me out.  Yeah.

Vijay Agarwal: 01:02:29 
 Yeah.  It's a good test that it should.

Vijay Agarwal: 01:02:33 
 Log you in and you should get.

Vijay Agarwal: 01:02:34 
 The OTP as well.

Brian McHugh: 01:02:36 
 Yeah, good point.  You want me to do that, right?  Right?

Vijay Agarwal: 01:02:41 
 Yes, I want.  Yes.  So.

Vijay Agarwal: 01:02:43 
 And you wouldn't have to log out of Google Meet because you're not doing the dictation.

Vijay Agarwal: 01:02:47 
 So app should still work.

Brian McHugh: 01:02:49 
 Yep.

Brian McHugh: 01:02:50 
 Give me a second.

Brian McHugh: 01:03:27 
 Okay.

Brian McHugh: 01:03:27 
 I'm in the app on the right top corner.

Vijay Agarwal: 01:03:30 
 You will see there is a folder icon.

Brian McHugh: 01:03:33 
 Yep.

Vijay Agarwal: 01:03:35 
 If you click on the folder, it.

Vijay Agarwal: 01:03:38 
 Shows the dictations which are not mapped.

Vijay Agarwal: 01:03:40 
 To a patient yet.

Brian McHugh: 01:03:43 
 I don't think I have any there.  Mine.

Brian McHugh: 01:03:45 
 If I click on the folder, it says action required.  These recordings were captured during high speed workflows and require EMR patient link before review.  But I have no.  And then it says no recordings pending because I didn't do a dictation.  I'm sorry.

Vijay Agarwal: 01:03:56 
 Oh, you did not do a dictation.

Vijay Agarwal: 01:03:58 
 Okay.  Last time I did.

Brian McHugh: 01:03:59 
 Yep.

Vijay Agarwal: 01:04:00 
 So what would happen is when you actually do the dictation test dictations, you.

Vijay Agarwal: 01:04:07 
 Start with entering an MRN and then.

Vijay Agarwal: 01:04:10 
 You do a dictation.  When you finish the dictation, it will.

Vijay Agarwal: 01:04:14 
 Appear on the folder over there on the top.  Then when you click over there, you will see the list of patients.

Vijay Agarwal: 01:04:23 
 Okay.

Vijay Agarwal: 01:04:24 
 That you need to associate this dictation with because we don't have live integration.

Vijay Agarwal: 01:04:30 
 With EPIC yet or any.  Any emr.

Brian McHugh: 01:04:33 
 Right.

Vijay Agarwal: 01:04:33 
 So you need to actually tell us.

Vijay Agarwal: 01:04:34 
 Which patient is this.  Okay.

Brian McHugh: 01:04:36 
 Okay.

Vijay Agarwal: 01:04:37 
 So can you.

Vijay Agarwal: 01:04:38 
 You.

Vijay Agarwal: 01:04:39 
 You need to select the practice, which is make your neurosurgery the Patient.

Vijay Agarwal: 01:04:42 
 Okay.

Vijay Agarwal: 01:04:43 
 And then it will tell you to.

Vijay Agarwal: 01:04:45 
 Select the template for which you had done the dictation.

Brian McHugh: 01:04:48 
 Yeah.

Vijay Agarwal: 01:04:49 
 Okay.

Vijay Agarwal: 01:04:49 
 Then it shows you all the ICD and CPT codes.

Vijay Agarwal: 01:04:52 
 Okay.

Vijay Agarwal: 01:04:53 
 You can choose to add and remove anything.

Vijay Agarwal: 01:04:56 
 Right now it is just a list.

Vijay Agarwal: 01:04:57 
 Derived from the template.

Vijay Agarwal: 01:05:00 
 Then you submit.

Vijay Agarwal: 01:05:02 
 After that, the audio and the patient data and the templates go to the.

Vijay Agarwal: 01:05:09 
 Backend brain of imb.

Vijay Agarwal: 01:05:11 
 Then they start prescribing, they start the.

Vijay Agarwal: 01:05:14 
 Matching process, and then they get into the biller queue.  Okay.

Vijay Agarwal: 01:05:18 
 So which means for you to generate a full dictation that can get into biller's queue, you will dictate, you will do the patient mapping, you will select the templates.

Vijay Agarwal: 01:05:32 
 Okay.  And then you will push it.

Vijay Agarwal: 01:05:35 
 So I really want to see is.

Vijay Agarwal: 01:05:38 
 As a actual surgeon, do you find.

Vijay Agarwal: 01:05:41 
 This whole process intuitive?  This is the first feedback we would want on what we can simplify.

Vijay Agarwal: 01:05:46 
 Okay.

Vijay Agarwal: 01:05:48 
 Then the second feedback would be to see if your audio dictation got converted to appropriate English.

Brian McHugh: 01:05:56 
 Okay.

Vijay Agarwal: 01:05:57 
 These are the only two things we'll.

Vijay Agarwal: 01:05:59 
 Focus now for the next few days with you.  Okay.  While with.  With the billing and, you know, Emily,.

Vijay Agarwal: 01:06:04 
 We are doing a lot of rounds of discussions.  So there we'll focus on the, you.

Vijay Agarwal: 01:06:09 
 Know, actual quality part and the accuracy part.  Yeah.  This is how we want to structure the next few days on the test.

Vijay Agarwal: 01:06:19 
 So apart from this, what we have also done, I want to also show you that.  So the team has also gone through.

Vijay Agarwal: 01:06:28 
 The 21 test cases that we had received.  The.  The sample case files.

Vijay Agarwal: 01:06:34 
 So we ran the imbly brain on those.

Vijay Agarwal: 01:06:38 
 Okay.

Vijay Agarwal: 01:06:39 
 And we have created a results document of this, of which certain cases were able to map 100 accurate.  Certain cases were not.  And some of them we flagged as a false positive.  So we would want the billing team.

Vijay Agarwal: 01:06:58 
 Who gave us these sample cases, if.

Vijay Agarwal: 01:07:01 
 They can just check the particular report.

Vijay Agarwal: 01:07:05 
 Okay.  Which we are flagging as a false positive.

Vijay Agarwal: 01:07:08 
 If they can check and tell us if Imbele is doing correctly or is.

Vijay Agarwal: 01:07:12 
 Something wrong with imbd.

Brian McHugh: 01:07:14 
 Okay.

Vijay Agarwal: 01:07:16 
 As a step number one.

Brian McHugh: 01:07:18 
 And we see that where Vijay.  Like we could show what.  What can we show the billing team?

Vijay Agarwal: 01:07:25 
 So we would basically tell them this.

Vijay Agarwal: 01:07:28 
 Results on all the 21 cases.  We will tell them the case numbers.  Okay.

Vijay Agarwal: 01:07:33 
 And the case numbers that we could not score.

Brian McHugh: 01:07:36 
 Got it.  Okay.

Vijay Agarwal: 01:07:38 
 Okay.  And in the report we have described what.  What we think is not matching.  Okay.

Brian McHugh: 01:07:44 
 Okay.

Vijay Agarwal: 01:07:45 
 So if the billing team can see.

Vijay Agarwal: 01:07:47 
 And tell us, no, your interpretation is wrong.  And you know, this is how I.

Vijay Agarwal: 01:07:50 
 Am really should have operated.

Vijay Agarwal: 01:07:51 
 So we will feed that information back into Imbali.  Okay.  Yeah.  Cool.

Brian McHugh: 01:08:00 
 This document, you'll email us this document,.

Brian McHugh: 01:08:03 
 Vijay, so we can.

Vijay Agarwal: 01:08:05 
 We are emailing a bunch of documents to Emily regularly.  So we have the user manuals.  We are going to email the coding accuracy report on the 21 cases.

Brian McHugh: 01:08:17 
 Okay.

Vijay Agarwal: 01:08:18 
 And we have also emailed her a.

Vijay Agarwal: 01:08:20 
 Few other documents on test cases.  So, yes, we will.

Vijay Agarwal: 01:08:23 
 But we will try to also put some language around it on what document.

Vijay Agarwal: 01:08:27 
 Is meant for what purpose.  Okay.  Yeah, perfect.  Cool.  Cool.

Brian McHugh: 01:08:34 
 Sounds good.

Vijay Agarwal: 01:08:34 
 We took a lot of your time on the road.  Sorry.

Brian McHugh: 01:08:36 
 No, it's okay.  Yeah, I appreciate it.  It was good to talk to you guys.  This was fun.  I'll play around the next couple days and.

Brian McHugh: 01:08:43 
 And provide some feedback.

Vijay Agarwal: 01:08:45 
 Yeah.  Okay.  Thank you.  Bye.

Brian McHugh: 01:08:47 
 Thanks, everybody.

Vijay Agarwal: 01:08:48 
 Thanks.  Bye.  By.

