Posts tagged with -25 modifier

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Oh, first: major drama at PCC's office last night. Let's hope this post is the closest I come to being a war correspondent. I don't like the proximity of the event to yesterday's message about flooding.

Meanwhile...Igor and I were doing some work on our [secret project, still] and were looking at E&M distribution among pediatricians. Here's a trick question - should 9921X codes that result from an initial well visit be counted as part of your distribution? Most people say yes - but I'm not convinced. Sick codes discovered during well visits should, by their nature, have a different distribution. It's not as if, for example, Mom waits until next week for her scheduled physical to talk about that seizure or red, sore throat (ok, some wacky ones do, but you get the point). 99214s and 99215s come to the office as a rule. I believe that -25 modified codes will have a different distribution. I'll post the results later.

What we did look at, though, is how many pediatricians actually use the -25 modifiers in the first place and how often they do. Here it is, data you can't get anywhere else:

What this shows is that 2% of our clients put -25 modifiers on 40% (or more) of their E&M codes. 12% put it on 20% or more. Get it?

What the chart doesn't show is that 22% of PCC's clients never use a -25 modifier.
That's crazy. Especially when you consider the fact that we have good customers. So, how about you? How many of your E&Ms have -25 modifiers?

Last week, Igor and I were looking at the usage of -25 Modified E&M codes as the information about them is a bit of an unspoken subject in our business. I can't find any good, definitive sources so, as usual, we have to create our own.

Two days ago, I posited that the distribution of -25 modified E&M codes should be different from non-modified codes for a simple reason: acute medical issues typically generate their own sick visits and the most common type of modified E&M would be an "Oh, by the way..." Those OBTWs don't often rise to the level of a 99214 or 99215, at least as often as a walk-in would.

That was the thought, anyway. Here are the results, complete with my original estimate of what it would be:

What do we learn? That -25 modified E&M codes actually mimic "normal" E&M codes quite closely. Fewer 99213s, certainly...but more 99214s and 99215s! The opposite of what I predicted. Figures.

So, why were we wrong (I'm trying to spread the blame)? First, we learned that our clients have as many modified E&M codes as non-modified! In other words, even with 22% of our clients not using the codes at all, boatloads of -25 modified codes go out the door of our practices. Why? A faithful reader - who will go unnamed until she asks for credit - offered the following insight:

They are not only when there is an associated well visit
Asthma Checks
When we do spirometry at these visits, we don't get paid unless we put a -25 on the E/M.
Imms visits
When there is a recheck of illness, Imms won't pay unless there is a -25.
Infant Bili-Weight Check Visits
When We do a transcutaneous bili, we need the -25 on E/M.
Sick visits with opth complaints, migraines, injuries
Visual testing won't pay without the modifier.
Sick visits with hearing, tinnitus
Hearing testing requires us to add the -25 on the E/M.
If the modifier -25 is not used , we would get "bundled" payments from quite a few inscos.

Well, that explains that. Perhaps Igor and I will explore looking only at E&Ms at well visits after all! Harumph.

Back on one of the coding lists, a brave soul asked:

I am curious to know what you are being paid for these. To avoid any questions, please don

Back on one of the coding lists, a brave soul asked:

I am curious to know what you are being paid for these. To avoid any questions, please don't tell me the name of the carrier and what they pay......I would greatly appreciate knowing the range of PPO reimbursements for vision and hearing?

I was curious myself and these codes were next on my list to look at, so off I went. I begin with the 99173, "Vision Acuity Screening." In 2008, it clocks in at - get this - .07 RVUs (no typo), or about $2.60-something in taxpayer dollars. I suppose I shouldn't complain, as it only received RVUs in 2007...before that, it was 0.

With a little help from Igor, I computed the average charge and reimbursement for each of the many modifier permutations our clients used from 2005 through 2007. Normally, I might lump them all together, but I noticed some important trends we should consider. Click on the graph below to zoom in on the results.

What do we learn? There is been a slight decrease in overall 99173 reimbursement since 2007, but that $9.04 our clients received in 2007 (very last columns) is worth millions to them across the country. Two other important items:

• -25 modifier usage, once very popular, has always been reimbursed at a lower rate and it's declining rapidly.
• -51, -52, -59 modifier usage makes a big difference. Other than the "vanilla" 99173 itself, the -59 modified version is the most popular (does anyone want a distribution graph showing modifier usage? Just ask...). The implication is that using the -59, appropriately, may lead to an increase in well earned income. Like the 90471 vs. 90465 discrepancy, this might be an opportunity to fix your coding.

It started when Susanne Madden sent me this "nice" message from Horizon to help me warn our clients about games Horizon continues to play.  Bottom line: they expect to stop paying for -25 or -59 modified codes starting May 10, 2010.

Two minutes of email exchange led the helpful Dr. Stoller to send me this announcement from MSNJ.   Good work.

I would love to have been in the room when the folks at Horizon decided to break the rules of their settlement.  "I wonder if any of the docs will react?  Let's try this!"  

More importantly, though: there shouldn't need to be a class action lawsuit to keep these bozos from flouting the CPT rules.  This is bad medicine and it makes the doctors and patients pay the price.  Shame on you, Horizon.