Posts tagged with E&M

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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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.

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Physician's Practice magazine has released, both in print and on-line, the results from their annual Fee Schedule survey. On one hand, I continue to applaud PP's effort. On the other hand, their data continues to diverge from ours considerably. In effect, the fortunes of PCC customers continue to rise while those of PP contributors continue to fall. Is it sample size? Are our clients simply doing that much better than the rest of the world? Does PP measure things different (and somewhat oddly)? I suspect it's a combination of all of the above.

Let's see how the numbers compare. There's so much here that I'll have to split it into a few blog entries, I suspect. Let's start with the big piece, the drop in E&M reimbursement. From the article:

Sorry, but the news is no better today. In fact, it’s disturbingly similar: Another sizeable drop in E&M visit reimbursement.

Here is a quick snapshot of their E&M details:

If you want a closer view, you can find their PDF here.

I took the time and made a similar chart for our clients over the last four years. Check it out. It took me a long time to figure out how to lay this out, so applause is welcome :-)

You'll note that we have a distinctly different pattern of behavior over the last four years. While Physician's Practice magazine reports a distinct negative trend in E&M reimbursement, PCC clients are improving.

In the next day or so, I'm going to zoom in specifically on pediatrics and their results. Anyone here seeing different results?

Gosh, a guy makes a couple statements in a blog and now people actually want him to explain the numbers so that they make sense. There's no satisfying the mercurial reader any more. My word isn't good enough?

Actually, my apologies for some confusing data. Let me explain yesterday's post in more detail and, perhaps, add some information. Igor and Susanne Madden pointed out that I accidentally cut off the Y-axis label/Title (d'oh!), which makes it confusing.

I decided to measure the average E&M reimbursement for PCC clients in a different manner than Physician's Practice for a variety of reasons.

• First, they use absolute dollars and not a specific year as a yardstick. I think this makes it difficult to actually gauge any changes in relative terms without looking closely at the graph (and then guessing what the values really are) and then doing some math in your head.. If you look at their first graph, for example, Middle Atlantic seems to have gone from a $90 to a $70 average E&M payment, more-or-less, from 2004 to 2007. Wouldn't you rather know that this is a 28% decrease? I would, I guess.
• Second, from what I can tell, PP doesn't take the code volume into account. That is:

CPT
Volume
Reimbursement

99213
10000
$100

99215
10
$500

...is the average E&M reimbursement here about $100.39 or is it $300? I say it's $100.39, and I think PP lists it as $300.

Therefore, the numbers from yesterday look at overall "average E&M reimbursement" and use 2004 as a base year for measurement. In our data, the Middle Atlantic group has seen their E&M reimbursement improve 16% since 2004 (vs. an estimated 28% decrease in the PP data).  I also took some care to make sure that the scale of our graph resembled theirs so that, even though we measure things differently, they approximate a similar message with different results.  The bottom line?  PP continues to measure a downward trend in E&M reimbursement and we measure an upward one.  Which is correct?

I've updated the graph so that the explanatory title is back.

More in a bit.

While I'm mentioning samples from my seminar collection, here's something I just received from PCC's coding Igor (ette). She was at a local E&M coding conference and reported this tidbit:

Comprehensive exam is defensible for Medical Necessity simply by virtue of being a peds exam (developmental component not present for other specialties), by exploration of mechanism of injury, systemic/chronic disease involvement.

A much more eloquent (and concise) way of putting something I've been trying to say for years.  When I discuss pediatric E&M distribution, I often find myself fighting the perception among pediatricians that pediatric visits aren't complex - it's easy, kids' stuff.  "Adult medicine, especially with all those chronic conditions and crazy medications...now that's complex."  I don't buy it.  Why?

• Nearly every pediatric visit has a layer of communication complexity simply not found in other specialties.  Many of your patients can't even talk!  Usually, though, you have to translate something a parent says and balance that against what you are seeing...and balance that against what the patient tells you.  That's easy for pediatricians, but not for someone who hasn't been trained and does it every day.
• You have developmental issues.  Every well visit is an acute visit waiting to happen.  Every acute visit is a chronic diagnosis in disguise.  The example I always used to give was a simple sore throat - don't you always check a dozen other developmental issues while you're at it?  I thought the language above made and excellent point.

A note over on an MGMA mailing list reminded me that I haven't done any good benchmarks in a while, so why not quickly publish our latest pediatric E&M distribution results. Here's a comparison of PCC's pediatric E&M distribution, 2007 vs. 2003, when we started pushing our clients on this issue...

 

For those scoring at home, the data:

	2003	2007
99212	9.3%	6.4%
99213	81.0%	77.2%
99214	8.9%	15.1%
99215	0.9%	1.2%

That's a good increase in 214s and even 215s. I'm proud of that!

By request (check the comments), here is the latest Pediatric E&M Distribution data from PCC. You can't get it much fresher than this - a few million E&M CPT codes, from May 2007 to May 2008. I had a good, in-depth, analysis earlier this year.
To understand the chart, let me explain a few things. The first set of codes, in red, represents our "vanilla" E&M distribution - plain ol' 99213s, etc. The second set, by label (and in blue), represents the distribution of -25 modified codes which are about 1/6 the size of the vanilla codes now (i.e., enough to have an effect). The final set, in green, represents the combined E&M distribution using all the codes.
Enjoy. Click here or the pic for a better shot.