E&M Distribution of -25 Modified Codes

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:

  • mod-25-distribution

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.