Employers May Contract Directly With Physicians Health care premiums are projected to increase sharply in 1999, according to a recent study. Although the tight job market should prevent employers from balking at those increases, analysts predict that they will start to scrutinize the value and the quality of the health plans they offer. In addition, if steep premium increases continue beyond the coming year, more employers may explore the option of contracting directly with physicians and hospitals. HMO premiums are projected to increase 5 to 7 percent; point-of-service plans, 7 to 9 percent, the Watson Wyatt Worldwide study found. Those estimates came from 445 benefits managers at companies in 12 markets across the country, including Atlanta, Boston, Chicago, Washington, DC, and Northern and Southern California. Maturation of the managed care market is driving the price increases, analysts say. Health plans underpriced their plans the last few years to gain market share, but now they have to recoup their losses. Public Disclosure of Complaints Filed Against HMOs In less than a month s time, Texas went from banning public review of complaints against HMOs to becoming the first state to put those complaints on the Internet. In May, the Texas attorney general s office reversed a decision it made last year barring public disclosure of complaints filed against HMOs. In June, the Texas Department of Insurance launched a website that lists complaints and disciplinary actions taken against all insurers. Consumer groups say expanded access to such data could help enrollees make better decisions about the 30 HMOs in Texas, which covered 2.9 million people in 1997, according to InterStudy. While insurance companies in other states have released information on complaints over the telephone, in newsletters, and in press releases, Texas action will improve public access beyond that, according to a spokesman for the National Association of Insurance Commissioners. The Texas site, which opened in early June, had 300 hits in the first few days of operation, 200 of which downloaded complaints while the rest sought other information on HMOs. New members James R. Bresch, MD Cameron N. Carmody, MD Brain J. Cole, MD John Dwyer, MD Michael J. Gibbons, MD Gale E. Hopkins, MD Samarjit S. Jaglan, MD Jerry Pavlatos, MD Frank M. Phillips, MD Anthony Romero, MD James V. Sciappa, MD Drake B. White, MD CPT Codes Richard L. Wixson, MD AAHKS Representative AAOS Committee on CPT and ICD9 Coding AAOS Representative, AMA CPT Advisory Panel Traditionally, the major reasons for familiarity with coding systems have revolved around the needs for reimbursement. CPT-4, Common Procedure Terminology, maintained and published by the American Medical Association and ICD-9, International Common Diagnoses, maintained by a government agency, the National Center for Health Statistics, are the two main coding systems used by orthopedists to report their procedures for reimbursement. With the growth of managed care, increasing auditing by various groups and agencies, fraud and abuse issues, and the emergence of outcome analysis, the coding systems are now increasingly used for documentation purposes. In the next century both of these systems will be replaced probably by CPT-5 from the AMA and ICD-10 which will be adapted for the World Health Organization. With the increasing importance of accurate coding, familiarity and knowledge of the systems is a major benefit to the individual orthopedist. Physicians who are able to do their own coding have traditionally been found to receive increased reimbursement. In the future, knowledge of correct coding will also help with the auditing, outcome and documentation issues. The goal of this column, which will appear with each quarterly issue of this newsletter, will be to help the Illinois orthopaedic surgeons keep abreast of changes and relevant issues in the use of the CPT codes. It will also serve as a forum for answering any specific questions about coding that members of the society may have. In this issue, I will try to address a number of issues involving the use of modifiers. Although it may not be apparent, modifiers were originally introduced as part of a policy from HCFA with Medicare as part of the implementation of a national payment policy and to help reduce the documentation burden for physicians. Much of the current attention and problems with modifiers seen with orthopaedic practices stems from HCFA's current interpretation of the use of modifier-25. According to a review on the use of this modifier, published in the September 1998 issue of the AMA CPT Assistant, the use of this modifier is now on the agenda for review by the Office of the Inspector General as part of the Medicare Fraud and Abuse Initiative. -25 Modifier Most Orthopaedic surgeons became aware of this issue when they were told by their office staff that they were being denied payments for injections/aspirations being done at the same time as an office visit. In order to be compensated for both office visit and a procedure performed on the same day, the evaluation and management (E/M) code needs to have the -25 modifier attached. This follows the modifier description in the AMA CPT book. Modifier-25, Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of a Procedure or Other Service. It is important to note that the modifier is attached to the E/M service (e.g., Established patient visit, 99213-25) and not the procedure (e.g., Aspiration/Injection of major joint 20610). Since, we as orthopaedists, normally consider the aspiration/injection as the secondary procedure, this is somewhat counterintutive. By following this approach, HCFA policy is to pay for both the E/M and the procedure as long as there is adequate documentation to justify the E/M visit. (E/M guidelines will be the subject of another article once HCFA and the AMA have worked out the final plan). It is also important too only to charge for the aspiration/injection procedure if there were no E/M services provided. While we are still not clear on the guidelines, all E/M visits must have documentation on the key elements including the chief complaint, history of the present illness, etc. An example is the treatment of early osteoarthritis of the knee with Synvisc or Hyalgen where multiple injections are given at weekly intervals. In this situation, for the first visit, most surgeons would evaluate the patient and meet the E/M requirements as part of the decision making process to treat the patient with the injections. The E/M code, with a -25 modifier, the injection code and a supply code can be submitted. However, on the later visits, where there is often no E/M service provided, it is more appropriate to charge only for the procedure and the supplies. -57 Decision for Surgery The need for this modifier arises from the global period definition of coverage for surgical procedures. The surgical payment, based on the work performed, is supposed to cover all care the day before surgery, the day of surgery including the surgical procedure and any pre or post-op care, and all care up to ninety days for most procedures. From a payment perspective the work is broken down into percents. Day before surgery: 10% Intra-operative work: 69% Immediate post-operative work and care over the next ninety days: 21% This is appropriate for routine, elective surgery where the patients are evaluated well in advance of their admission. Frequently, however, in an emergency or urgent surgery, an extensive evaluation of the patient is needed to decide about the need for the operation. An example is an elderly patient with multiple medical problems who is admitted with a hip fracture. The orthopaedic surgeon would generally see and evaluate the patient and perhaps operate the following day. Since there is additional work in evaluating the patient, this modifier is appropriately used with and E/M code such as 99222-57 ( Initial hospital care) or 99254-57 (Initial inpatient consultation). The breakdown of the percent work covered in the global service period is also reflected the group of modifiers for each part: -54 -- Surgical care only -55 -- Postoperative management only -56 -- Preoperative management only The guiding principle here is that HCFA only wants a pay for the surgical procedure once. If these modifiers are used, the surgeons involved must agree to do only submit their component of the total. Frequently, orthopaedic surgeons see patients for follow-up care who have been operated on elsewhere by another surgeon. Often this occurs while patients are on vacation or away from home. The operating surgeon usually submits an unmodified procedure code for the surgery, while the home surgeon sees the patient for the follow-up care. Since the operating surgeon will receive 100% of the allowed charges, the home surgeon would not use the procedure code with the -55 modifier. In this circumstance, the home surgeon should submit the appropriate E/M code to describe the services rendered. -50 Bilateral Procedures Another situation where there may be some confusion on payments covering the Global Service Period is where bilateral procedures are performed. Since the intra-operative work is twice as much (e.g., Bilateral total knee procedures), it would be nice to be paid the same for both knees. However, since the pre-operative work (10%) and post-operative work (21%) is the same for one knee or two knees, there is less total work for the second knee. Consequently, it makes sense the payment is reduced. Unfortunately, we cannot change getting paid !50% for the two procedures instead of the 169% the work breakdown would suggest. Full descriptions of the modifiers are in the front of the AMA CPT books, which are printed every year. Of these modifiers changes are expected in the next several years of -20, Microsurgery, and -62, two surgeons. The -20 modifiers will probably be replaced by specific procedure codes that reflect the complexity of surgery done with the many different types of magnifications. The -62 modifier and all the variations of two surgeons working on the same patient. Particularly with, where different surgeons perform the approach and the definitive procedure, the current payment system seems inadequate and does not address the variation in work over the entire portion of the global service period. With the use of the CPT modifiers, surgeons should be able too more accurately describe what they do. This should translate into more correct coding, fewer denials from the insurances carriers and, hopefully fair reimbursement for out services. Return to the IOS Newsletter Archive Educational Meetings and Program | Board of Directors | Residency | Find a Surgeon | Membership | Allied Association Links | Newsletter | Governmental Affairs | IAOS Main Page All material Copyright from the Illinois Association of Orthopaedic Surgeons, all rights reserved.