Joint Effort PAs
We're two orthopedic surgery physician assistants discussing PA school, life as a PA, cases and topics related to orthopedics, and much more!
Joint Effort PAs
Same Work, Less Pay
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This week, we’re breaking down the proposed changes surrounding Modifier 25 and what they could mean for PAs, physicians, and practices that routinely provide an E/M service and a procedure on the same day. We talk about what Modifier 25 actually means, why insurers are targeting it, how the proposed reimbursement cuts could affect the way we practice, and the bigger problem with continually asking healthcare providers to do more for less. Because apparently evaluating the problem, making a medical decision, and treating it in the same visit is just getting a little too efficient.
Welcome to Joint Effort PAs, where two orthopedic surgery PAs get real about life in medicine. From tips and tricks to professional growth, work-life balance, and everything in between. We're here to share what we've learned and what we're still figuring out. Let's get into it. Okay. I'm hoping to not make this too boring.
SPEAKER_00But I think I think we're gonna be okay.
SPEAKER_01No, it it won't be boring. Um, but it is necessary. It's this is like very relevant. I fear that this topic could very much affect everybody.
SPEAKER_00Yeah. Uh it also, though, it also though gets down to the core of like what we try to do every single day is be efficient and do the most for each of our patients.
SPEAKER_01And be like good people.
SPEAKER_00And be good people. And then you have governing bodies that tell you that you can't.
SPEAKER_01They make it so impossible to be good people.
SPEAKER_00Yeah.
SPEAKER_01Um, okay. Well, any exciting cases this week? Anything fun?
SPEAKER_00Yeah. Yeah, we had a we had a um we had a good week. I did a lot of training in the OR this week. Um, so my hands didn't like get in as much as I wanted them to. It's okay. It's okay. I get like different satisfaction from teaching. Yeah.
SPEAKER_01Um you were molding different hands.
SPEAKER_00I was molding different hands. I have perfected suturing with a um straight clamp as a needle driver. Oh, and that's hard. Yeah. And a straight clamp as an adsin. I've perfected it. I love that. I will I refuse to have the scrub text um peel pack another pickup or a um needle driver.
SPEAKER_01I have a question to ask you. Has anybody ever referred to you in these moments as Hannah with a hemostat? No.
SPEAKER_00No.
SPEAKER_01I wait, fill me in. Ask around for that? Ask around for that. Um yeah, no, I don't like doing it. I hate suturing with a hemostat, but we also do not open up peel-packed things if you need another set.
SPEAKER_00Because the needle twists. It twists every time. You don't get a good grip on it. And it like everything's weird, but I've done it.
SPEAKER_01I unplug the bow or the bipolar tip, which really doesn't grab anything. No, but that's smart. And I use that as my pickup, and I use a hemostat. Generally, I get some sort of curved hemostat. And then I'm like, oh, everything's yeah.
SPEAKER_00No, I I that's interesting. Hand them with a hemostat. Okay. Yeah, yeah. No, I will use a straight and then a straight. It's really better. Yeah, but then again, the light suboptimal, but that's like the challenging part of the case for me, is when I'm doing that secondarily. Yeah, no, I I do, I like it, but in a very obviously different way. Yeah. So, but it's also hard to teach, like, this is an acceptable way to do things, and then there's my way.
SPEAKER_01Yeah.
SPEAKER_00So they're two different things.
SPEAKER_01As in, as in this is the more efficient way to do it, or and this is the way like the textbook says to do it.
SPEAKER_00For example, when we put on our shoulder dressing, it's usually um again around the curvature of the shoulder, you have A B D pads and then four tagerms. Four tegoderms in four quadrants, like upper right, upper left, lower right, lower left. If you hold the tegoderms lengthwise, it gives you more coverage. Um, the P I used to work with would do like willy-nilly, and I'm like, What do you what are you doing? Then you would go, then you would go diagonal with one, and I'm like, oh my god, stop.
SPEAKER_01No, I do two. But you would you Yeah, I do I do, yeah.
SPEAKER_00I will do four for the coverage. So anyway, so I was like, you know, oh yeah, and then you put the tegoderms on. I was like, oh, you can put them lengthwise, and then she turns it, and I was like, just put them lengthwise.
SPEAKER_02Just do it the way I do it.
SPEAKER_00Yeah, anyway, but uh no, it's interesting. It's just interesting. But um, no, so yeah, surgery was good. We did uh it was a heavy shoulder week. We did one, two, three, four, five, five shoulders out of four, five, six, seven, eight cases. So a couple short days because of clinic and then because of travel. Um, we did another Misha. Misha was done in 37 minutes. Is that a record? Um, I think the implant was in in 37. Uh, skin was starting to close at 40 something, and tourniquet was down by 60.
SPEAKER_01Did you guys talk about this during? Are you like, what's the time right now?
SPEAKER_00Um, no, it felt very smooth. And then I I looked. Yeah. Because we've done like a 45er, but this one was 37, not because it was rushed, but because it was just space. It happened, yeah. Yeah.
SPEAKER_01I mean, all the stars aligned, so to speak.
SPEAKER_00Yeah. Um, but no, it was it was good. So cases were good. Um, again, still kind of in clinic training, and then we had some new um providers shadowing us, and we had some physical therapists shadowing us, so a lot of a lot of that. That feels like summertime when we have a lot of people watching. So I'm a little bit over that. A little bit over that, but um, but it was okay. It was good. Yeah. Some good, I had a bunch of good patient visits this week, too. Yeah. What about you?
SPEAKER_01It was just a blur. We had like our weekly. It was a short week, too. It was a short week because of Labor Day, and then that created some inherent issues of like scheduling, and we just had more constraints. So we had to split up the days half and half, like reschedule a bunch of clinics as we had a bunch of add-on cases that we had to get fit in. Um, and so it was a lot of back and forth. Like, for example, yesterday we started at the hospital, and I thought I gave myself like a very appropriate cushion for our three cases that were supposed to end by like noon at the latest. But you know, turnover times, all that good stuff. Um, we started the case at like, I don't know, probably like 11 30 or something, maybe. And my the clinic that I was supposed to start at one is a 45-minute drive. And we started at 11 30, and it was just a quick, like three fingers were cutting the flexor tendons out to give her back length. So it should be quick and easy. Well, the closure is not quick and easy. Um took a little longer than expected, and before I knew it, I looked at the clock and I was rapping on the splint and it was 1236. And I was like, okay, I gotta be 45 minutes away from here in what is that, 24 minutes? Um, I don't know how that's gonna work. So I didn't change. My scrubs are actually the scrubs I wore to the hospital are still in the locker there. Yeah. Because I grabbed my stuff and I just went ran out the door and left. Um, and I called our uh athletic trainer on the way. I was like, hey, so I'm on my way. By that I mean I just walked out of the hospital.
SPEAKER_00You're gonna be mad at me, but here we go. Yeah.
SPEAKER_01But like it's gonna work out. Do not get them any sooner than like 115 and then make them wait approximately 10 to 15 minutes in the room before getting x-rays, and then text me a picture of the x-rays, and I will come from my car into the room. It's like you're not even late. I was like, yeah, and that like everything is gonna be perfect. And you know what? It worked out great. It was there wasn't a single get, like, people weren't like, oh my god, and you're running in late. I did have one patient that showed up, he had like a 345 or a 315 appointment and showed up at like 115 or something before that appointment. So, like, that's on them that you're waiting that long. Um, I still saw him probably 10 minutes before his scheduled appointment time. But I walk in the room and he's like, There you are. I'm like, Well, yeah, here I am. And he's like, I saw you running in here all disheveled, right getting here late, and I was like, Yeah, I did get here late. But I'm 10 minutes early to this. So look at me. Why'd you get here so early, dude? And like, don't you hate that though? If you have patients that like get there early and they're like, Why did it take you so long to see me? And you're like, I'm still actually seeing you at your appointment time.
SPEAKER_00I had a patient who showed up this week for a 3 30 pre-op that to his credit was communicated to him via email. To my credit, nobody put it on the schedule. So when he got there, they were like, Hey, this guy says he got an email, he has a 3 30 pre-op day. And I recall saying, like, Adam on at 3 30 this day. I was like, Yeah, he's right. They're like, Yeah, but it's not on the schedule. I'm like, You are also right. Uh so I'm, you know, in my head, I'm like, who was it? What's the name? Like so, this guy's surgery is next week. So this is like the only time. He's like, All right, check him in, but just explain to him the situation. Did they explain? No. They said, Oh, yep, she said no problem. So then they come back, so it's like 327. He checks in for 3:30. I'm thinking I can definitely see him before four. So it's like four, four ten. And he says, Hey, how much longer? Because I have to go pick up my kid, bro. Like, yeah, you know what I mean? And I get it. From his point of view, he's probably like, This is my appointment. I was here, but from my point of view, I'm like, oh my God. So anyway, so I like I moved patients around, I knew some patients who wouldn't be mad waiting. And of course, the last five patients of the day after this guy, they're like, You tired? I'm like, You're saying that because I look tired. Like, I feel like I'm I'm thriving right now on all of this chaos. Yeah, but yes, I'm late. I'm a little late. Yeah, but I got this guy's pre-op done, you know. Oh, and then my last patient was like, How many more? Do you get to go home? Do you have to get to have a nice glass of wine? And I was like, I literally have a couple more patients.
SPEAKER_01Like, I literally um, okay, so I thought that it would be great for us to discuss this upcoming potential change. Now, this is not full disclosure, this is not like a thing that is definitely happening. This is something that um CMS, so Center for Medicare Services, is that the appropriate abbreviation, right? Um proposed this change. So right now, how office visits, I'm sure you guys all know, are billed. So you have EM codes for your office visits, um, and then you have separate codes, uh, CPT codes for procedures like injections, casting, things that you do during your office visits. And those are all separate codes that you build during the visit. So, and I actually don't understand it. It's kind of like math. I don't know how this came to be that the way it works is that you use your office visit code and then have to put modifiers on things to tie them to the other things you do rather than these are all the codes I used and just do it that way. But regardless, you have to use these things called modifiers, and they're arbitrary numbers that you enter in a system to get things um covered so that you are able to bill for an office visit. An office visit covers you for literally seeing a patient, evaluating them with your hands, coming up with a diagnosis and a treatment plan.
SPEAKER_00So that is what an EM and again, just to back up, any new provider, you learn jack shit about this in PA school. There's nothing about billing in PA school. I don't know about you. No, zero.
SPEAKER_01I don't even know, like I don't even what does EM stand for?
SPEAKER_00Evaluation management?
SPEAKER_01I don't know.
SPEAKER_00It's it's your decision making. Yeah. Anyway, you are you are supposed to, as the provider, meet a list of criteria that um your ENM code, sorry, evaluation and management, your EM code determines was it a low-level complexity visit, higher level, moderate complexity, and off-the-chart complexity. Yeah. Now, uh when you get audited, your documentation should support the level of ENM, right? Yes. There's AI stuff, there's rubrics, um, sometimes it's, you know, talking about X amount of body parts, sometimes it's the time you spend with patient, decision making, imaging, blah, blah, blah, blah, blah. Part of what goes into that is procedures that you do. Like if you order X-rays or do injections. So, like when you do your visit, every visit has an E and M code, technically. And again, I won't get into the ones that don't, but the modifiers are, like Hannah said, it's your splinting, it's your injections, it's doing something else on that day. The procedure, if you will, that you did. So it's assuming you can do an EM code with zero procedures. Yes.
SPEAKER_01So like an office visit, you know, in a primary care office might be just that you saw somebody for abdominal pain, whatever, and um diagnosed them and maybe ordered a lab test or something on ultrasound to go with it. Um, and that is your EM code. That doesn't count for you doing anything procedurally with your hands, right? Other than palpating the patient or what is this the perc percussion the tap tap. Yeah, tap taps. Um so yeah, in orthopedics and a lot of other subspecialties, it's very heavily procedural-based. Uh, and so we do a lot of things, procedures on the same day as your visit. So, for example, I could see a patient for arthritis in their thumb and tell them, hey, this is what you have. Here are all the things that we can do to treat it, one of them being a steroid injection. Now, what we do typically, and what I assume many other places do is if the person would like to get an injection, we will offer to do that then that same day, like during that office visit. So, in order for me to get paid, not only for the decision making of diagnosing them, coming up with a management plan and the injection, I have to bill the EM code, a 25 modifier, and the code for the CPT code for the injection.
SPEAKER_00So, what CMS is proposing is to basically um Well, so currently, so currently, what a 25 modifier is, is when we say, I'm gonna see the patient, do an injection, it's part of the visit, but it's not the only reason for the visit. We decided to do it on the day of the visit, right?
SPEAKER_01Yes.
SPEAKER_0025 modifier is a significant, separately identifiable evaluation and management, so EM service by the same physician on the same day of the procedure. So it's saying that you did the evaluation, that was the visit, then you also decided to do the procedure.
SPEAKER_01Yes, you decided to do the procedure, and now you're getting paid for the procedure and your office visit. Now, what they're proposing is that the highest valued service, whether that be your office visit versus the injection, gets paid at 100% of the allowable amount, but the thing that the 25 is attached to, the the lower of the two things would only get paid at 50%.
SPEAKER_00Yeah. So CMS is proposing cutting the reimbursement for the lower valued of the same services to 50%. Yes. So it's not garbage.
SPEAKER_01It is garbage. You would they're not saying, oh, you won't get paid for it, but you will get paid significantly less for doing it. So this is the only me and my supervising doc were having this conversation yesterday. This is like the only field of work in the world where we continue to do more, see more, work harder, and get reimbursed less, kicked in the face repeatedly for trying to do the right thing. Because I mean, think about it, like an auto shop or something, rates go, like they're charging more than they were five years ago to do the same things. Um, you can't go in, I assume, and say, like, hey, my, I don't know if this is too soon for you given your current circumstances, but like, hey, my answer is yes, the bumper of my car fell off, but also my tire is flat. Can you charge me 50% less for the tires since you are you're doing my bumper in the same day? Like, no, you're gonna pay for both things. Yeah. CMS is proposing that, like, oh, so their reasoning is that the the um one of those things was easier for you because you did it in the same day.
SPEAKER_00Yeah, that's yeah, exactly. Well, it's like getting your hair cut and colored. Like, you don't get a freaking uh um, oh my god, I can't even think. It's the end of the week. You don't get a discount, you don't get a discount on your hair cut because you're getting it colored. It just costs more. And guess what? It costs more now to get your hair cut than it did 10 years ago or two years ago.
SPEAKER_01Our rates are doing nothing but dropping and going down every year. It's it's quite depressing. Um, again, this is not something they teach you in PA school at all, but like it's reality. And I think that working in private practice, it is much more of like a forward reality than if you're in a hospital system supported by RVUs. But um, yeah, this is the real deal.
SPEAKER_00But we also like I have um patients that come in for gel injections, and it is a series of three. Their first visit is the discussion visit. This is why we're here today. Let me review your x-ray. This is what it looked like a year ago. This is the expectation. Let's discuss how your symptoms have changed. What are we looking to get out of the gel? What's our prediction with how long this is gonna last? That's a visit. That's an EM code. We've made a plan that we're either gonna continue with the current plan, or maybe we'll sprinkle in steroid injections, or maybe we'll start a weight loss thing, or maybe we'll do physical therapy, brace, whatever, whatever. Um, that's the first gel visit. And at that visit, I will also do a gel, right? So I'm gonna bill for both those things. The second visit, they're coming in for their gel. There's no decision making. I'm not doing the now. If they come in and they're like, hey, my knee is swollen, and can you look at my other knee? Now we're doing an EM code plus the injection visit. But there are there are certain things that like I know why you're here, we exchange pleasantries and we do the injection. Like that's not the visit we're talking about. We're talking about your run-of-the-mill visit where you're evaluating new patients, trying to deliver a great experience and still wanting to do that all in one and get paid for it.
SPEAKER_01Yeah, because I mean it ultimately it comes down to being a business. Like, I this toes the line of like, am I the asshole? versus like trying to to be efficient and stay afloat as a provider, private practice, as a business, as a provider, private practice. I mean, you know, medicine is unfortunately just not just as much a business as other things, but like it is still a business. Like you still have to buy supplies and have lights on at the end of the day, you know. So I so dramatic Yeah, well, I took that to another level, but still, um, you know, you have to pay the employees that are here, and people expect raises. I'm getting out of my own. But here's also the issue.
SPEAKER_00Yeah, here's also the issue. There is the perception of patients that come on to see you that think that you're just trying to get more co-pays out of them. Like even with my gel injections, there's three injections. They're like, hey, can I come in one? And then on my second one, you do two and three. No, like that's not how it works. Um, but with this proposed new change that is forcing us potentially to continue doing what we're doing and make 50% less, which is garbage. Yeah. And also to make up for that, what do we do in our field? We see more patients. And so yeah, it's insane. It's insane. Because guess what? That can't continue to climb. You can't continue to see more patients. You have a cap. There's a cap. There's at a there's a point where you're going to Beth has basically like hit the cap.
SPEAKER_01I've most doubt. I'm looking on the cap.
SPEAKER_00Like, I can't, I can't do more. So so now you you're sending the message that I'm gonna give you the slam dunky valuation visit. Can you do the injection? Not today. So here's the deal.
SPEAKER_01I think you make less either way. Whether you chant you decide to handle this as like the uh I'm gonna call it the asshole, but it's not because we're just working to accommodate the changes being forced, and they're not forced upon us yet, but the changes potentially being hypothetical made. Yes. Um, so you can handle this two ways. I suppose one could just decide to say, I am making less money during this visit. That sucks. I mean, you're doing the same exact thing that you were doing, same amount of work. Now all of a sudden you're making significantly less for doing it. Um, or you can decide to now I'm only gonna charge one of these things and do one thing a time. So I see a new patient for CMC arthritis, I tell them, hey, these are the options. They choose injection. I say, come back on Friday and we'll do your injection. Well, that inconveniences everybody.
SPEAKER_00Yeah, but I can't, but like my neighbor drove me and I can't, like, I only had time today. I'll tell you what, we were just talking about this. For me to take time off to go do the mandatory things, can't even find time for that. Yeah. If I have to take time off to go to the dentist and they look at my teeth, they're like, all right, we're gonna do your fluoride treatment next week. I'm gonna be like, you know what? I'm not getting the fluoride treatment. No, because I'm not taking the time off to do it, it's not happening. I won't tell you how long it's been since I've been. I probably should edit that out. Um I won't. But I think I but it's it's requiring the patient to come back, which guess what is also another copay.
SPEAKER_01It is. It's a copay for them. It's an inconvenience for them. And now that is another spot on my schedule that I could have been seeing a new patient. So I'm getting less either way. I'm I'm fucked no matter what.
SPEAKER_00So super passionate over camp.
SPEAKER_01Um, I'm very passionate about this because I I feel like a lot of what I try to do is make things more efficient and like make our clinic run more efficiently. What are things that we can do to make it make sense?
SPEAKER_00But it also is the it's just like you're getting beat, like whack-a-mole. But it's the same thing, and again, this is uh you know, a sense of comparison. It's like when administration today, okay. Today, someone um someone came into urgent care because they called the call center. And again, the call center, they're not providers, they don't make clinical judgments. Are they given forms that says what is in our scope of practice? And not, yeah. Some kid came in. Because his toenail fell off. Okay. There was no injury. There was no question of a fracture. His toenail fell off. Interesting. Okay. So I was walking by and I happened to hear this interaction. The patient came in, the mom was like, Hey, my son checking in for his toenail fell off. And the front desk turned around and they were like, Hey, do you mind? Can I can I ask you, you know, do you think this is appropriate for for check in? Again, it was done in front of the patient, but like it was right there. And so the provider came over and the provider was like, What's the story? He's like, So his toenail fell off. Like, did he did he play sports? Did he like bump it anything? No. Yeah. So they were the provider was like, Oh, well, that's I mean, that's um, that's usually not an emergency, right? That's there's usually no treatment. We're not gonna sew it back on. Yeah, um, we can look at it, make sure it's not infected, but there's not, there's not like treatment for that. The treatment is wait till the next toenail grows. Yeah, I mean, like, you know, right? So I'll save you time. I'm not gonna check you in to like over that. And so the mom was like, so I'm like super frustrated right now because I called and they told me, yeah, come on in. We absolutely will take care of that.
SPEAKER_01What did she expect the take care of it would be?
SPEAKER_00I think she thought we were going to reapply the toenail.
SPEAKER_01Yeah. Which, like, I get this from both, you know, the the call center or any like non-medical person is gonna look at that like, I'm not gonna turn somebody away, right? What if to fall toenails falling off are bad? Like, I don't know if toenails falling off are bad. So you sure go into the urgent care, they can tell you if it's an emergency that your toenail falls off. I know I know where to send you. Yeah. Um, so like I get that, but also like, you know, from the patient's perspective, like that's the answer. I know it's just not the answer you were.
SPEAKER_00But the perception of the patient is I came here, I expected something to be done. And it wasn't where I'm trying to make the comparison is you have people who don't know what you can and can't do making decisions for you. It's CMS deciding that the work that you're doing is not worth um reimbursement. Yes. So it's it's a governing body telling you what you can deciding what is valuable and what is not valuable. It's garbage.
SPEAKER_01It is garbage. Not only is it garbage, but like where does it end? Like when do we get something good? When when do we reimburse more? Yeah, when because like everybody, you know, uh expects raises at some point. Milk is more expensive. I don't know why I just said milk. I don't even buy milk, but everything's our hair is more expensive. Um yeah, so I don't know, like at what point do we say, hey, like, how about med medicine? I feel like still in people's minds, they're like, oh, if you're in medicine, like you make good money or whatever, and you're protected. It's like the opposite. But what's crazy isn't hyper protective.
SPEAKER_00Yeah, I'm stuck on they decide that again, you're gonna see your CMCR arthritic patient, you're gonna take x-rays, you're gonna examine them, you're gonna talk to them about like, I don't know, their work or their video games, whatever they like can't do. Yeah, you're gonna make a plan, you're gonna talk about custom bracing. And then it come time comes time for the shot. And they think that shot is worthy of what to cut, you know what I'm saying? And by 50%. Like you can't, I mean, I think, I think if there was some medical whatever, maybe cut it by 10%. Yeah. I'll reimburse you 90% instead of a hundred.
SPEAKER_01Easier to swallow, I guess, but still like, why are you cutting it at all? Like, why do you feel the need to punish me? Yeah, why am I being punished for doing more for patients? It is personal. Do you want people, everybody to be more inconvenienced? Do you want them to like miss more work and come? I don't know.
SPEAKER_00Again, the question is, what behavior does this incentivize? Does it incentivize providers to become lazy and just do the bare minimum? I think so.
SPEAKER_01It can, yeah. Yeah, because again, you can handle it either way. You can say, Oh, I'm not gonna do an injection on the same day as I evaluate you and I will see you back. Or you make less money overall, which I would argue most hospitals and practices aren't gonna be happy with you doing that. They're gonna want you to do what you know is more profitable and makes more sense. Um, or like it incentivizes people in medicine to go more towards like a self-pay model where you're just not even dealing with insurance companies. Yeah, and then you can charge less for it.
SPEAKER_00Now, but I think though when these changes come into place, some someone on CMS probably thinks that the modifier is being overused. Yes.
SPEAKER_01And that is that is where you can play devil's advocate into their side of the argument. Um, so basically, there's, you know, I from their perspective, we'll have the angel and the devil on the shoulder. Uh, I don't know, which is, I guess they're the devil, right?
SPEAKER_00No, they're definitely the devil.
SPEAKER_01Yeah. Yeah. That's definitely not bad. Can I say that on here? Anyway, so basically, you are not having to, you know, check in the patient more than once. You're only rooming them once for both things, taking vitals, whatever, we don't do that. Um, you're not using two separate rooms. It's not like duplicating staff and other resources. So some of these resources have overlap, so why pay it twice? Like, what resources are they really talking about, though? I still need the resources of the injection and like the supplies I'm using for it and like the you're doing a procedure. Yeah. Like, why am I not getting reimbursed for doing a procedure? Like, if somebody, if I take a picture to Michael to be framed, they get paid for framing the picture. I just I can't make it make sense. So could it be abused in certain scenarios? Yes. I mean, so tell me when you might not use the modifier and only bill one or the other.
SPEAKER_00Oh, I would do my second gel shots. I will not build an EM.
SPEAKER_01When I know the can you even bill an EM with a second gel shot? You can.
SPEAKER_00But technically, if there is no decision making and they're just coming in, this is a mechanical visit, I will do that. And sometimes when I have like, and then not a gel visit, not when it's like they are here for their shot. Um, if I have a patient that comes in and I see them every three months, and the only time I see them is when they want an injection, sometimes I don't bill an EM code. Like I just feel bad about it. I do too, because has anything changed? Nope. Do you have any questions? Just want my shot. I haven't seen you in a year. Yep. Okay. Like, I mean, they don't want anything else. I don't want anything else. Like I would hate. I'm not gonna charge them an EM to see that patient. But at the same time, what I currently do right now is I will, you know, make it like fruitful for them. Like, you know, they'll ask if anything has changed. What are you guys doing now? Maybe my x-rays look worse. Let's take pictures. But I have some patients that are just so much like, do my shot. That's it. So I want, I don't care if my x-rays x-rays look worse.
SPEAKER_01So if that's what makes the most sense, like if somebody comes in and I know I can go in the room with my injection, they're sitting out ready for it, and they're like, Yep, I'm here for my shot today. It helped so much last time. Great. We do it, and I'm like, follow up in you know, three months or whenever it comes back. Yeah, I'm not gonna charge them an office visit code now. If that visit turns into a, well, this injection didn't work as well as the last one, or like, what's the next step after this, or talk to me about the surgery? Yep. I think that my time is worth being compensated for. So yes, I will charge an EM code for that. Yeah. Um yeah. So I suppose if some out there are abusing it, I mean, I can't imagine it's being that overabused, but I don't know.
SPEAKER_00I mean, do you do you use 25 modifier for anything else butter procedure?
SPEAKER_01Uh I guess not. I mean, the only time so I really use it or right for injections, um, I have to use one for so diagnostic stuff, like if I do diagnostic ultrasound. Yeah. But that's like the add-on. Yeah. You know? Yeah. I did something extra. Not only did I do a physical exam and come up with a diagnosis and treatment plan, I then on that same day decided to do a diagnostic procedure and interpret those results.
SPEAKER_00Yeah. So Well, again, all of these, like all of these examples, right? It's gonna be new patient and you do the knee injection. Uh patient, maybe it's not a new patient, it's the same um patient worsening of the same condition and you do an injection. Um, patient presents for a scheduled shoulder injection, but also has neck pain. Yeah. That's a 25 modifier. Um, chronic shoulder pain, but has new acute knee injury, and also I did a shoulder injection. Like it again, it's all of our visits. 100% of our visits.
SPEAKER_01Yeah, this is orthopedics, and I think this would affect us the most. Um, so particularly for private practices, um, you know, I think that from a patient perspective, this can look like, ooh, why are you arguing about this? Like, don't doctors and medical practices, they're already sucking me dry. I pay so much in my insurance, and you know, you guys make enough money, but like that doesn't equate to what they think it equates to.
SPEAKER_00Correct.
SPEAKER_01Um now the AMA is fighting this, and I mean, I think appropriately so, yeah. That it's gonna make it very difficult for office-based providers um to perform procedures and deliver quality care.
SPEAKER_00Yeah, because you're gonna you're gonna think over your head, like you said, you're gonna have the the devil and the angel saying, like, what do we do today? Do I I mean I've normally I make my decision on do I have time? Yeah, yeah. If I have time, I will do it. But I'm not gonna say, ooh, let me get more money and have them come back so that my 100% injection can be actually worth it on another day.
SPEAKER_01Yeah.
SPEAKER_00I don't know.
SPEAKER_01Yeah. So let's say this were to happen in my personal hell, this passes and this becomes reality for us. How would you handle if somebody like say a patient comes in that like drives from the beach? You have a couple patients like this, they come to see you and you evaluate them, do the the EM visit, and then they want an injection that same day. What do you do? Do you just do it?
SPEAKER_00Um you know what I would do, and again, I will put my name on it. I will charge a higher ENM code and do my injection to try to make up the difference.
SPEAKER_01So yeah, and this is uh these are things that would potentially happen too, right? That that, you know, from an insurance perspective or from a yeah, CMS perspective, like people are gonna find ways, they're gonna have to find ways to make up the difference, or they will drown and not be able to exist anymore. So they will have to find ways to compensate. And you're not gonna like those ways either. Like, do you, you know, they're gonna be constantly fighting up charged ENM codes. Um, but yeah, I mean, I guess that's one way, one way to handle it.
SPEAKER_00It's just, it's just so um contradictory because again, in our worlds right now, when you see patients and we were just talking about it earlier, we're trying to work smarter. We're trying to use AI to help us document so we're not doing all this stuff. So, in in one respect, 2026, there's so many things that are available now that weren't available previously, but also now it's we're getting reimbursed less or proposing getting reimbursed less for doing a really good job and trying to be efficient. Yeah, it's just for the patient, too. It's very contradictory.
SPEAKER_01Yeah, we're getting penalized for, and again, we're not getting penalized, but this theoretically would I feel personally victimize.
SPEAKER_00And again, and we and again, this is special attention to us because out of your 30, 30-something patients you see, 10 to 15, you're doing an injection.
SPEAKER_01Yeah. Yeah, at least it's pretty much like all I'm doing that's not post-op visit is injection. So like I become obsolete.
SPEAKER_00But in our world, we're worried about this 25 modifier, but the you know, the other crazy stuff, like for example, total joint replacement from 25 to 26, there is a 7% decrease in surgeon professional reimbursement. It's insane. Okay. For all total joints, right? In all total joints for the codes for total hip and total knee. Oh, yeah, shoulder. No, live to see another day back out there. In 2027, they're proposing a 20% additional reduction in surgeon professional reimbursement. Now, just so everybody who is not in total joint world, guess what? They're not doing 20% less work. The total joint that was put in in 2024, it still requires the same time and the same energy and the same equipment and the same uh resources to do that.
SPEAKER_01Why are you taking pay cuts? This is the only profession doctors are taking pay cuts. I know it's insane. It's while everything gets more expensive.
SPEAKER_02Yeah.
SPEAKER_01So, like, I mean, you know, 20 years ago, that was looked at as the profession that, like, oh, you're rich, you've made it in life. Now, now what is happening? Yeah, it's it's wild.
SPEAKER_00It is wild. But also, and again, the whole picture. So now, if you're a total joint surgeon, for you to make up that deficit, you have to do 20% more cases. If you're trying to do 20% more cases, you have to be in clinic less. If you're in clinic less, you can't have people come back for their second visit for their shots. Like you have to do it all at one time.
SPEAKER_01It's insane.
SPEAKER_00Yeah, like a vicious cycle.
SPEAKER_01It's a very vicious cycle, and it leads ultimately to worse patient care. This is what Because you're not able to, you you can't focus. I mean, people are you're out here in the friggin', you're you're in the trenches and you're just trying to like dig yourself out to stay afloat and having to do, you know, 20% more just to make what you made six years ago. It's insane. Yeah. Truly insane. I mean, like these some some of the things that already exist now are insane to me. And like, I don't know how many combo procedures you guys do, but like for us, we do a lot of combo procedures like oh, carpal tunnel and cubital tunnel release at the same time. You could pay less for one of them if you do two procedures. So you're trying to do the patient a favor by only being under anesthesia once, taking care of multiple problems at the same time, and you're penalized for it.
SPEAKER_00I think it's united. United, um, if we do a rotator cuff repair two nine eight two seven and a biceps tenodesis two nine eight two eight, they will not pay for a third code, which is let's say subacromial decompression. Yeah. Because we won't pay for it. Yeah. Or AC joint um debrisment won't pay for it. So you just do it and don't pay for it, I guess. But you you are forced to choose what's right for the patient. Yeah. Right? You're so you're putting in the time and the effort to do an extra procedure and just knowing you're not gonna get paid for it.
SPEAKER_01Most of a um, a lot of insurances, I won't say all of them, don't pay for a biceps tenidesis with the rotator cuff or with a uh reversible shoulder. Um, so we just do it and bite the bullet. So it sucks, isn't it? Like, these are this is reality, guys. Listen, I mean, those of you practicing, you know it, I'm sure. Those of you who are in school or aspire You don't know any of it. Yeah, yeah.
SPEAKER_00Listen, well, I buckle up. When I when I started at my first job, I did, I think it was like an hour and a half to two hours of a billing conference that has never been talked about since then. I've never been offered that. And it's funny because when I hire new PAs, um, the administration's like, okay, well, they'll just do their own billing. And I'm like, you have to understand when you say the words do their own billing, that means nothing to them. They have no idea. That's not a class. That's not like none of my preceptors ever was like, hey, let me take five minutes to give you like the the quick and dirty on um billing. It's never a thing. Yeah. I'm like, wait, doesn't a billing department handle that?
SPEAKER_01Like the billing people in the hospital, they do the billing, right? Yeah. Right. I just like do the work.
SPEAKER_00I don't have to do the billing. Like, come on.
SPEAKER_01That's not a thing.
SPEAKER_00Surprise. Yeah. But anyway, it's it's very relevant information. Um, and unfortunately, that is the the uh commercial insurances tend to follow Medicare. Not a hundred percent, but if you see a big change coming down the pipe from Medicare, it trickles down. So it does. That's why the the flags are up and the alarms are are going off, and that's why Hannah is super fired up.
SPEAKER_01Fired up. But just so everybody knows, this is again, this is just proposed. This isn't something that's definitely happening. I'm trying to jump scare anybody. Um jump scare me.
SPEAKER_00We're just here also to validate ourselves.
SPEAKER_01This is this is for me. This is like my therapy right now.
SPEAKER_00You guys, if you take away the procedures in your visits, then that's gonna be very upsetting. It will be very upsetting to me.
SPEAKER_01So anyway, I suppose you could go to some sort of website. Uh, I don't know. I should have like made something to sign it. Yeah, petition, but the petition is due by September 14th. So I think that was Monday. Monday, right? Nobody I'm gonna link something in the Instagram, a petition to fill out. Can you make a cartoon for like picketing CMS? Yeah, like I was thinking. Speaking of the Instagram, did you take your videos? I have some videos.
SPEAKER_00I do not have any soccer videos because I arrived late given the circumstances of yesterday. Yeah, it's fair. I do I we I will I will get the archive together. You gotta give me the weekend though.
SPEAKER_01Okay. The weekend for the archive, and then then I just need the raw footage. All right, fine. Fine. I made requests for somebody to take videos of you playing soccer, but I was told that it's simultaneous. So that can't be happening. It was simultaneous. Yeah. So that can't happen.
SPEAKER_00I'll have to bring one of my kids. Maybe I'll bring one of my kids next week and they can. Actually, they don't have school on Friday. Someone doesn't have school on Friday. Perfect. There we go. Problem solved.
SPEAKER_01All right, guys. Well, this is something to think about over the weekend. A call to action, if you will.
SPEAKER_00I think though, if nothing else, compartmentalize it somewhere in your head. If you're like, what the hell's a modifier? Remember this talk. Start thinking about billing. Yes.
SPEAKER_01Yeah. All right. Until next time.
SPEAKER_00Thanks for tuning in to Joint Effort PAs. If you enjoyed this episode, be sure to subscribe, leave a review, and share it with a fellow PA or med minded friend. You can also follow us on Instagram at Joint EffortPAs for updates and extra content. See you next time.