-25 Modifier Data

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.

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