Posts tagged with cpt codes

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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.

In 2008, the CPT definition of the classic "after-hours" codes changed. Gone is all the rigmarole about whether your hours are "posted" or whether your patients know you are open on weekends and all the other commentary that used to convince our clients not to use these important codes. The bottom line: if you see patients in any of the following circumstances, there is an add-on code that you should be using:

• Any patients seen "after normal business hours" (definition below)
• Any patients seen in the evening (8pm and later)
• Any patients seen on a weekend
• Any patients seen on a holiday (definition below)
• Any patient seen between 10pm and 8am if you are open 24 hours
• Any patient who is forced into your appointment schedule (definition below)

"Oh, the insurance companies never pay for these codes," I hear the complainers saying. Baloney. I am going to post some surprising reimbursement data later, but I wanted to start with the 2008 changes. These codes are no longer confusing, they are really simple.

What does "after hours" mean? For me, it's easy - when do the insurance companies stop taking your calls about their bad claims? 4:30? 5:00pm? 5PM IS AFTER NORMAL BUSINESS HOURS. If you regularly see kids after 5pm, every one of them ought to walk out of your office with a 99050 attached to the E&M/Well Visit. Remember, you are saving the inscos tens-of-thousands of dollars a year by providing this service (I'd put it at $300 a visit). Stop being a wimp.

What is a holiday? At the very least, it's the official list of "bankers' holidays" for your state. Here is a list of Federal Holidays - note that it doesn't include things like MLK Day (that's an enlightened state thing) and any of the Jewish holidays. This is the only grey-area in this arena, imo - if the physicians and patients in your area happen to celebrate Yom Kippur, for example, I'd bill an extra code for patients you see during that time. If every one else is working, though, it's a hard sell. Celebrating Election Day or Inauguration Day or Halloween or May Day - not so much.

Finally, patients forced into your schedule. This really is obvious 99% of the time - if the treating the patient in question disrupts your existing schedule then you are on the board. Walk-ins who pop into your sick blocks don't count. The mom who insists on being seen today for an hour in your waiting room doesn't count. These are for the accidents who rush in the door and the asthma attacks who pull you out of the room you are in.

Great, these are easier to use now...give me some real info. I'm going to tease you and hold off on the $$ until next time, but get this:

I realize it's tough to read, so click here or on the picture for more detail.

What do we learn? I'm sorry for the complexity of the graph, but we see that each valid code schedule-based code (99050, 99051, 99053, 99058) is used by more and more PCC clients every year with a fairly steady volume. In my next episode, I'll show you the money!

As promised, I will show you the money.

Click on the picture below (or here) for a better view of the average reimbursement for these scheduling based codes.

What we see are fairly consistent reimbursement for the codes with the variation being explained by the additional payers being added on all the time (look at the data showing the big increase in usage).

So, there ya' have it without a lot of comment...pediatricians are getting paid for these codes, even by the Medicaids.

Hit the poll to your left to show the world whether you are a good coder or not (don't worry, it's anonymous).

First, some amazing news.  I understood that it might happening, but I guess it's official: new admin codes:

The American Academy of Pediatrics (AAP) was successful in obtaining new CPT codes for immunization administration. The new codes will replace the 90465-90468 immunization administration codes starting January 1, 2011 to better reflect the work associated with administering combination vaccines.
 
AAP will present valuation recommendations for the new codes during the October 2009 American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) meeting. Final RUC recommendations will be forwarded to the Centers for Medicare and Medicaid Services (CMS) for consideration in the 2011 Resource-Based Relative Value Scale (RBRVS).

I believe this effort is related to the disparity between the payment for a one-antigen vaccine and a 5-antigen vaccine.  Rather, there is no disparity between those payments and perhaps there should be.  

Meanwhile, the AAP has updated its Vaccine Coding Table.  I've hosted my own flavor here (complete with ICD9 info), perhaps I'll update ours.