Posts tagged with Benchmarks

Sorry for the delays - a busy Users' Conference, some great family camping, and prep for an AAP coding event, and a guy gets distracted!

I have grand plans for a series on pediatric benchmarks. Tim and I have been working feverishly on a series of WWW-based tools for our clients and our hands are dirty with all sorts of tidbits that I hope to share.

If I were smart, which I am not, I would start small and build up a series of benchmarks, culminating in an overflowing abundance of pediatric data that the world has never seen. But, like I said, I'm not smart, so I'll just jump into one thing I found fascinating:

...I'm sneaking in a bunch of benchmarks at once, so read closely.

First, you get the average charged, per visit, by PCC customers (the pediatric ones) in both 2003 and 2006. Then, you get the average revenue/visit for both years. This is gold in the benchmark business.

But we took it a step further and removed the revenue that comes from immunizations. Not the admins, just the vaccines themselves. This allows us to compare practices who purchase everything to those who purchase nothing (like VT pediatricians) and the majority, who are somewhere in between.

What do we learn?

• PCC customer revenue/visit increased 29% from 2003 to 2006. That's crazy!
• However, the real increase is tempered somewhat when you remove immunizations from the equation. Since those items can often lose money, the real increase from 2003 to 2006 is a little over 13%. Still great (when most practices lost ground), but...
• ...it makes us realize that a scary chunk of a pediatric practice cash flow is caught up simply in immunizations! In 2006, it's a solid 15% of the practice revenue ($91 vs $77), increasing almost 3% in that time frame. I bet if we went back to 2000 or 1995, the difference would be staggering.

Another scoop for the blog.  Pediatric benchmarks regarding the use of -25 modifers.

This is part of the quick examination the AAP asked us to do.  Ultimately, they are trying to determine whether improper payment for -25 modified codes should take priority over immunization admin codes or not.  Tough call, though I lean toward the latter.

One of the challenges of this examination is that the proper use of -25 modifiers is so limited.  We wondered how many practices use the -25 modifiers at all (and at what rate) and the results took some work to determine.  Why?  Well, we have some customers who actually put a -25 modifier on every single well visit code.  Yup, every one.  We have others who put it on almost every single sick visit.  And some who do both.  Any many who do neither.

OK, enough chatter, here is some interesting data you won't read anywhere else.  Tell your friends.

• 90% of our customers used at least one -25 modified sick code in 2006.  Yes, that means one out of ten didn't.  And these are cream-of-the-crop practices.
• The ratio of -25 modified sick visits to total well visits was 17%.  In other words, nearly one out of every five well visits were coded with a -25 modified sick visit.  I am stunned by this - I thought the volume would be in the single-digits.
• The ratio of modified sick visits to non-modified sick visits is 7%.  This relates to another important benchmark (Sick-to-Well visit ratio) that I'll talk about soon.

I don't know what the "industry" thinks the proper ratio of "separate and identifiable" services should be, but there's one data point.

This arrived in my mailbox last week:

By the way......Take a look at my SRS coding numbers from 7/23/06-9/14/06 compared to 7/23/07-9/14/07. I listened at the conference.

For the unitiated, "SRS" is the name of our "Smart Support Suite" that our customers use to look at their data. It comes with all kinds of pediatric benchmarking tools built in. In this instance, the doctor is referring to an E&M distribution. So, per request, I called into the practice's system to see the results. Wow!

E&M Rates
Code	2006	2007
99213	87%	74%
99214	10.6%	21%
99215	.7%	4.5%

At the average reimbursement for this practice, this improvement projects to a revenue increase of over $10,000 a year for just this one physician. Just for getting charts right, no extra overhead. Sadly, this pediatrician has 3 other partners (out of 6) who are as bad or worse - putting more than $40,000 a year into the pocket of the MCOs. The way I see it, though, even one doctor is an improvement. Congrats!

I was reading "The 2006 Fee Schedule Survey: POWER to the PAYERS" article from Physicians Practice magazine, as many of us in this business often do, and I realized that a) I never compared their data with ours and b) I don't think it agrees. So, Tim threw some numbers together for me. To begin, let's look at some of the highlights from their piece. It's a fascinating read (and it quotes PCC friend and seminar-leader, Laura Morrow!).

Compensation for E&M visits dropped 10 percent nationally and 27 percent in the Northeast from 2005 to 2006.

I'm pretty sure I would have noticed a 27% decrease from anywhere! We ran our numbers comparing the E&M results for our NE pediatric clients in 2005 and 2006 for 99212-215. Something is definitely different.

Source	99212	99213	99214	99215
Physicians Practice 2006	$36.58	$51.92	$77.82	$95.54
PCC 2005	$43.15	$60.30	$88.41	$124.15
PCC 2006	$44.98	$63.20	$92.99	127.71
Difference PP/PCC	-17.9%	-16%	-13.6%	-29.9%
Difference PCC 2005/PCC 2006	4.2%	4.8%	5.2%	2.9%

First, not only do our pediatric clients in NE get paid a lot better for their E&Ms to start (about 18-20% better), but they actually recognized a 4+% increase in the codes from 2005 to 2006...while Physicians Practice reported a 27% decrease! Some caveats: I only looked at the 9921x codes. PP used about a dozen other codes (though none of the well visit/9939x, unfortunately) to determine their overall results. We obviously have that data, too, and it shows the same results. PP may also be getting a different sample from 2005 to 2006, though we both believe there is a lot of crossover (i.e., the same folks complete the surveys each year). Who knows, maybe their pediatric sample is bad? I'm beginning to think, though, that PCC's sample is getting too biased. When PP says:

Physicians need to get smarter about negotiating and look for other revenue sources.

...I realize that our clients are already doing this. How else do they see their reimbursement go up 4% while it drops precipitously for everyone around them?

By the time any reasonable person reads this, I will be giving or have given a talk at the local AAP VT Fall meeting here in Burlington. I am quite flattered that Dr. Aakre thought me capable of being sandwiched in among the likes of Drs. Barry Heath and Wendy Davis. My talk will be something along the lines of "Preparing for a Pediatric Electronic Health Record." I won't give away all the best lines, but the opening slide reads something like this:

The single biggest and most common mistake practices make when
choosing an EHR is to learn what they need after they purchase
the system.

The second most common mistake...

You'll have to ask me for the rest of that sentence.

Meanwhile, we are working with Dr. Lander and the helpful SOAPM admin folks (shout out to Heather to see if she's reading) to figure out where and what to do next after our kick-butt pediatric coding and practice management event in NYC in August. In addition to a practice management and clinical event our massive UC in late July, we're considering doing two more all-day events (with the same and additional speakers - how can we turn down Lander, Harbaugh, Tuck, and Bradley?!) and perhaps some 1/2 day events.

One of the first considerations in this process is where to do them. Using a cool map that I helped SOAPM put together to show the locations of all their members - Google is the coolest - we have a couple places in mind:

• Washington DC / Baltimore / Alexandria (somewhere in there)
• Cincinnati
• Detroit / Buffalo / Rochester
• San Francisco / Seattle
• Philadelphia

Here's what we're thinking:

The DC-metro area has a lot of pediatricians and, in particular, a lot of SOAPM folks. Plus, it's a family-friendly place. And maybe I'll stop by Volker's place and have the best beer in the world. We're looking there for an April meeting.

Cincinnati is smack in the middle of a lot of small hot spots and part of the country that the AAP and other educational resources often passes over. We have customers it would reach, too, which is always a bonus.

I don't know if Rochester will support a full-day meeting (~60-100 people), but we do have an amazing location and, though I haven't asked her yet, the support of Dr. Francis. I'm definitely interested in doing at least a 1/2 day there.

San Fran seems a little redundant, considering everyone was just out there, but we may get some local support and there are lots of pediatricians. Alternatively, we will shoot for Seattle, another corner of the world that doesn't get requisite AAP attention and has a good crowd. It would be a lot less expensive to simply stick to Philly, but we can't ignore the west coast.

Why do I ramble about this? Besides it being my nature, I'm looking for feedback and comments. You want the best Pediatric Road Show in your town? Let me know.

This month's issue of the Pediatric Coder's Pink Sheet features yours truly in a piece about E&M distribution along with Dr. Lander, Susanne Madden, and Donelle Holle. Such esteemed company! Anyway, we give away our latest E&M benchmarks:

You can see the entire article by subscribing to their newsletter. It's a good one, and you get to see me slip the word "boogey man" into an article. Next month, if Alison will have me back, I am going to work on getting "abominable snowman" in there.

Perhaps, to salute my kids, I'll use "Abbott and Costello" or "Laurel and Hardy" - it would sure work when describing the UHC payment policies.

As promised - or threatened, I suppose - here is a breakdown of the expected impact of the 2008 coding changes based on pediatric utilization.

I logged back in to add the punchline, which I forgot to add in my spreadsheet nerdiness: if it weren't for the expected 10% Medicare cut, pediatricians would see an approximately .83% increase in expect RVU production in 2008. That's lower, obviously, than last years' 2% increase.

At least we can look forward to 50-80 years from now when, at this rate, we'll be about right. OK, back to it.
I took the top ~200 codes, about 1/2 of which have RVU values, performed by our pediatric clients and calculated their average usage by FTE physician (for example: an average PCC doctor performed 1843 unmodified 99213s last year, 85 87081s, etc.). I then compared the pricing of each CPT code for 2007 vs. 2008 and calculated the total effect.
There are many different variables that can/should go into this analysis, some of which I left out. For example, I left out the GCPI calculations. This is all at 100% of Medicare. I looked only at Transitional Medicare rates. Here's what I learned:

	2007	2008	Difference
Expected RVUs Performed	9,063	9,130	+.83%
Expected $$$ Charged Medicare Cuts Upheld	$343,140	$311,059	-$32,080 (-10.3%)

The CPT with the largest total RVU cut: 51701, the bladder catheter insert. It loses about 7% of its value, or about $5 in 2007 terms. However, if you look at true pediatric utilization, the real crime is apparent: the bread and butter of pediatric coding takes the biggest hits! The codes with the largest RVU decrease, based on utilization are, in order: 99392, 99391, 99393, 99394, 90466, 99381, etc. Each of which drops between 2-5%. If you look at the total $$ lost, the 99213 obviously beats the pack, with an approximate $10,500 hit next year.
To restate: without even looking at your (negative) GCPI adjustments, you can expect a $10K hit on just your 99213s in 2008 RVU terms. Your 99214s (-$3.5K), 99392s (-2.9K), etc., don't fare much better.
On the flip side, there are some "winners." That's why it's "only" a 10.8% average decrease and not more. Circumcisions jump by nearly 50% (to $196). The 92587 (Evoked Auditory Test) goes up 5x (from .2 to 1.26) and there's the arrival of the Physician Phone Consultations, which are worth $0 until Jan, when they get a $35 value! (I know most folks won't see it for a while...but imagine!). In fact, an entire stack of procedural items get decent boosts - look closely and you might see some interesting items: 92587, 54150, 94010, 99371, 95004.
Now that I've taken the time to build this gnarly spreadsheet, let me know if there's some other data you'd like me to extract from it.

We've been working on it for a long time (toooo long), but we are just about to officially release our Practice Vitals Dashboard service to PCC customers.

"Dashboard?" you ask. "What's a dashboard?"

You'll know them as soon as you see them. In fact, here's a quick sample of a piece of one:

This is a quick snapshot of just the initial graphical display of one of six benchmarks we hope to display to them at first (Revenue-per-Visit, E&M Distribution, RVU-Per-Visit, Pricing, Sick-to-Well ratio, A/R Days). The example above shows that the E&M distribution for this sample customer is 18.7%, putting them at the lower end of the "Good" scale.

Each of the benchmarks, like the one above, is "clickable" for more detail. Thus, you could log into pcc.com using your special login and would be immediately presented with your most important management measurements, complete with detailed explanations of the benchmarks, comparisons to other pediatricians around the country and in your region, and an historical view. It's really cool to click on a PCC customer and watch their Revenue/Visit rise every year. Actually, here's what it looks like!

Pretty cool, eh?

I mention all this for a couple reasons:

• We are going to make some very simplified versions of these benchmarks public as part of our new pediatric resources WWW site (more about that later). You won't be able to find this information anywhere else.
• P CC customers will have access to more than I am describing here - super cool.
• PCC customers who are also part of our "Practice Advancement Plan" will receive the Advanced Practice Vitals Dashboard, which will include many more benchmarks as well as the ability to drill down like crazy. You want to know your RVU-Per-Visit for Doctor X in 1999? Click it!

Obviously, all of these reports are available in our system and our clients can run them at any time on their. This service exists for the majority of physicians who don't have the time or inclination, however, to do that. We think it will go over pretty well!

Any suggestions for benchmarks welcome!

I've had a request to post some information about the 2008 RVU impact, but I've decided to wait a day or two for the dust to settle about the latest news. Hope you don't mind. In the meantime, let's return to a simpler time...like this year...when the only curve-ball is the Budget Neutrality adjustment. Igor was looking at the soon-to-be-ready benchmarks for 2007 and realized that the average price for PCC customers dropped from 150% of Medicare to 147% of Medicare. Alarm bells! We both agreed that the largest culprit would be the increase in RVU values to E&M codes that outpaced our customers' corresponding price increases. Let's check!

CPT Code	2006 AVG RVU	2007 AVG RVU	2006 AVG FACF	2007 AVG FACF	RVU Diff	$$ Diff
99212	1.04	1.05	151%	155%	+1%	+3%
99213	1.43	1.71	151%	133%	+19%	-12%
99214	2.3	2.61	141%	129%	+13%	-9%
99215	3.31	3.51	141%	140%	+6%	-1%

Because I never have enough time to make tables properly, here's a quick explanation. In 2006, the average RVU value for our customers for a 99214 was 2.3 RVUs. In 2007 it was 2.61 (a 13% increase, as noted in column 6). In 2006, the average PCC customer charged 141% of Medicare for a 99214, but that dropped to 129% in 2007 (a 9% drop, as indicated in column 7). In absolute terms, you can see that the customer price for a 99214 went up 4% (the difference between columns 6 and 7), but that wasn't enough to keep pace with the RVU changes. Interesting. At least to us RVU nerds.

Need proof that this is the best pediatric practice management resource on the planet? Check it out.

 

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?

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