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-25 Modifier Usage Among Pediatricians

How often to pediatricians perform a separate and identifiable E&M service during a well visit?  I have some interesting information for those who are interested.  The topic of the use of -25 modifiers, however,  frustrates me considerably.  I'm frustrated for two reasons.  

First, the payors have been using the -25 modifer as a method for denying payment to pediatricians for years.  My reasoning?  Tell me, what is the difference from a clinical or narrative or service perspective between these two visits:

99393 (well visit)
90460 (imms admin)
90651 (HPV vaccine)


99393-25 (well visit...now with a -25 modifier)
90460 (imms admin)
90651 (HPV)

There is no difference.  None.  Zero.  The same thing happened in both visits.  Oh, wait, there is a difference - a bunch of payors, especially the usual suspect national ones, require that -25 modifier in order to be paid because...why?  Given that the -25 modifier there adds no additional information (it makes the data worse, actually, as I point out below), given that there's no clinical benefit, given that there is no analytical benefit, I'm left to conclude that the only reason the payors inconsistently require a -25 modifier is to occasionally deny payment.  Please, someone explain to me how I'm wrong.

The second reason I'm frustrated is that, as a result of this bogus coding requirement, many pediatric practices tend to slap -25 modifiers on everything under the sun.  Well visits, sick visits, imms admin codes, screening tools, you name it.  As a result, it's impossible to actually to any analysis of a practice's work using just CPT codes.  You can't simply count up all the sick visits looking for -25s and determine the number visits that rose to both levels of service. It creates really messy gross data.

I've been meaning to do this for a while, but with the help of the PedSol team here at PCC, we looked through a few million appointments over the last 18m.  Here's what the distribution looks like:


How to read this graph?  About 55% of our clients billed about 5% of their well visits with an additional sick visit.  You'll notice the long tail - that's right.  There are practices who are billing as many as 45% or 55% or even more than 70% of their well visits with an additional sick code.  But they are not common.

The bottom line is that our clients code a sick visit during a well visit 5.7% of the time.

What I also found interesting is the cycle of volume that exists.  We shouldn't be surprised to learn, I think, to see that sick visits are much more common in the winter time, when kids are often sickest.  But there it is.


Comments, insight welcomed.

Tags: -25 modifier, pediatric benchmark, 99212-25, 99213-25, 99214-25, 99215-25, Benchmarks

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