If modifier 25 is slashed, ethical implications

[Hotei]

Anecdotally some dermatologists I've talked to would set up a separate "procedure only day." Many PCPs in my area who perform biopsies already schedule separate "procedure visits" for biopsies. This has the following ethical considerations:
1. Patients may need to take extra time off work (2 days instead of 1 day).
2. While most would (probably correctly) argue that delaying a biopsy by <5 days would have negligible risk on progression of a suspected skin cancer, would this result in an increased malpractice risk (invasive melanoma, MCC, etc)?
3. Patient waiting times would increase, as a patient needing a biopsy would effectively take up 1.5-2 patient slots instead of 1.
4. Reimbursement would still decrease overall, as you would be using ~two appointment slots to get the same effective reimbursement as an RV3 + mod 25 for biopsy. Sure, the procedure visit would be quick, but you still have to repeat intake + room turnover.
5. If a separate procedure day were being considered, would the rates of excisional biopsies (e.g. for clinically dysplastic nevi) increase? Would this affect SLNB accuracy if the result came back as melanoma?
6. Probably cryotherapy and Efudex would be a thing of the past for AKs, and everyone would start doing PDT and setting up separate PDT days.

Others say it would be the final straw, and if reimbusement is cut too much they might as well transition to a direct pay/cash only model, outside of the medical insurance reimbursement structure entirely. While their overall revenue would be reduced, it would also come with less overhead and less headaches (theoretically).

If modifier 25 were cut or nerfed, how would you deal with it?

---

Members don't see this ad.

 

[Skindoc83]

Insurance companies only goal is to deny you payment. meanwhile my student loans and overhead Remain the same. i would tell the patient why they have to come back on a separate day for a biopsy and give them their insurance companies phone number so they can complain. This is part of the reason I wont do mohs on two sites on The same day. I’m not going to take the financial hit for an insurance companies **** **** games

 

[reno911]

Insurance companies only goal is to deny you payment. meanwhile my student loans and overhead Remain the same. i would tell the patient why they have to come back on a separate day for a biopsy and give them their insurance companies phone number so they can complain. This is part of the reason I wont do mohs on two sites on The same day. I’m not going to take the financial hit for an insurance companies **** **** games

Well, why stop at not doing 2 sites in a day? Why not just do the Mohs on one day and bring them back on a later day for their reconstruction?

 

[sore eye asses]

I wonder what % of mohs surgeons usually perform only a single case per patient/day.

I wonder how this would compare to the % of mohs surgeons who usually send patients home after clearance and close the following day.

 

[MOHS_01]

Changes in practice patterns in response to changes in policy is a big no-no, the kind that lands one in the news, in the papers, and potentially in the courts.

Nothing good will come of these changes. It wasn't spelled out until recently, but medical prices are intentionally being driven down -- not just to squeeze more services out for less dollars -- but because these serve as input prices in the calculation of CPI, literally creating counter-inflationary inputs, thereby allowing the lie to continue.

It's all egregious BS. All of it.

 

[dermie1985]

I think the AMA, AAD, and other organizations have been pretty effective thus far at making sure the Modifier 25 code doesn't go away for exactly these reasons. There were a few insurance companies that were planning on no longer accepting 25 codes a few years ago, but I was under the impression most of that movement has gone away.

 

[Merely]

Changes in practice patterns in response to changes in policy is a big no-no, the kind that lands one in the news, in the papers, and potentially in the courts.

Nothing good will come of these changes. It wasn't spelled out until recently, but medical prices are intentionally being driven down -- not just to squeeze more services out for less dollars -- but because these serve as input prices in the calculation of CPI, literally creating counter-inflationary inputs, thereby allowing the lie to continue.

It's all egregious BS. All of it.

what does this mean? It would be illegal to have the patient come back as a result of this change in insurance reimbursement?

 

[Slack3r]

I think the AMA, AAD, and other organizations have been pretty effective thus far at making sure the Modifier 25 code doesn't go away for exactly these reasons. There were a few insurance companies that were planning on no longer accepting 25 codes a few years ago, but I was under the impression most of that movement has gone away.

CMS proposed removing modifier 25 last year before backing down after the comment period. Every procedural specialty stands to lose big if they get rid of modifier 25, so there was/will be a ton of push back, not just from dermatology. That said, I highly doubt they’re not going to try again.

 

[bronx43]

CMS proposed removing modifier 25 last year before backing down after the comment period. Every procedural specialty stands to lose big if they get rid of modifier 25, so there was/will be a ton of push back, not just from dermatology. That said, I highly doubt they’re not going to try again.

Every procedural specialty? 25 modifier is for outpatient add-on procedures that are separate from the primary diagnosis.

Most procedural specialties do not have this problem. I don't believe surgeons, Interventional cardiologists, GI docs use these codes often.

 

[MOHS_01]

what does this mean? It would be illegal to have the patient come back as a result of this change in insurance reimbursement?

CMS change, but yes.

 

[MOHS_01]

CMS proposed removing modifier 25 last year before backing down after the comment period. Every procedural specialty stands to lose big if they get rid of modifier 25, so there was/will be a ton of push back, not just from dermatology. That said, I highly doubt they’re not going to try again.

Oh, it never went away. Anthem is doing it again come 2020, others will follow.

 

[Merely]

CMS change, but yes.

there’s no other option tho what else could someone do

 

[bronx43]

25 modifier is tip of the iceberg. Cigna and UHC just got rid of consult codes. Pretty soon, we'll be looking at Medicare as a desirable payer...

 

[MOHS_01]

there’s no other option tho what else could someone do

I don’t think you understand the way .gov works; if I still had a copy of my letter from a Medicare ombudsman from 2006 or 2007, a cc of a letter written to my senator addressing his questions to CMS (questions prompted by a letter I wrote him re: the loss of the multiple procedure reduction for Mohs surgery), I would post it up. The .gov is not the good guy, they are not the protector of the innocent, the impartial executor or the law. They, in fact, are quite the opposite when it comes to issues that benefit them.

 

[MOHS_01]

25 modifier is tip of the iceberg. Cigna and UHC just got rid of consult codes. Pretty soon, we'll be looking at Medicare as a desirable payer...

Consult codes for most payers in my neck of the woods have been a historical remnant for years; even those that recognized them reimbursed at new patient visit amounts.

The latest executive order should scare the living **** out of everyone, for it openly lays out the direction that they’ve been covertly taking for years. It’s the proverbial trial balloon if you’re being generous - and naive.

 

[Merely]

Consult codes for most payers in my neck of the woods have been a historical remnant for years; even those that recognized them reimbursed at new patient visit amounts.

The latest executive order should scare the living **** out of everyone, for it openly lays out the direction that they’ve been covertly taking for years. It’s the proverbial test balloon if you’re being generous - and naive.

so trump is a bitch and he’s working against doctors? I thought republicans were supposed to be on our side

 

[bronx43]

so trump is a bitch and he’s working against doctors? I thought republicans were supposed to be on our side

no one is on our side, don't drink the koolaid

 

[MOHS_01]

no one is on our side, don't drink the koolaid

#truth

 

[reno911]

25 modifier is tip of the iceberg. Cigna and UHC just got rid of consult codes. Pretty soon, we'll be looking at Medicare as a desirable payer...

There are parts of the country where Medicare is already the best payer (i.e. reimburses higher than private insurers in the area for most codes).

 

[doctalaughs]

I wonder what % of mohs surgeons usually perform only a single case per patient/day.

I wonder how this would compare to the % of mohs surgeons who usually send patients home after clearance and close the following day.

I understand the pain but gotta still do what’s best for the patient.

I sure as h*ell wouldn’t send to a mohs person that would only do 1 site, much less do the mohs and repair on separate days.

Same as I wouldn’t expect PCPs to send anyone to me if I did the e/m and the biopsies on separate days....

 

[Slack3r]

Every procedural specialty? 25 modifier is for outpatient add-on procedures that are separate from the primary diagnosis.

Most procedural specialties do not have this problem. I don't believe surgeons, Interventional cardiologists, GI docs use these codes often.

I know what modifier 25 is for. ANY field doing “minor” procedures or infusions in the office will be affected, most notably ENT (“most affected behind dermatology” -https://www.entnet.org/modifier-25-advocacy). But also, ophtho, ortho, urology, and yes GI and cards. you could quibble about how often they’re billing mod-25, but doesn’t change the fact that it affects more than just derm.

 

[bronx43]

I know what modifier 25 is for. ANY field doing “minor” procedures or infusions in the office will be affected, most notably ENT (“most affected behind dermatology” -https://www.entnet.org/modifier-25-advocacy). But also, ophtho, ortho, urology, and yes GI and cards. you could quibble about how often they’re billing mod-25, but doesn’t change the fact that it affects more than just derm.

You said every procedural specialist would lose BIG. I disagree with that, though certainly how you define "big." I know for a fact the cardiologists and the GI docs in my group don't care about the 25 mod.
I do in office infusions... 25 mod won't affect me enough for me to even notice, though joint injections would be a bummer - would lose maybe a few thousand tops per year.