Same Work, Less Pay

WEBVTT
00:00:00.000 --> 00:00:05.040
Welcome to Joint Effort PAs, where two orthopedic surgery PAs get real about life in medicine.
00:00:05.200 --> 00:00:09.439
From tips and tricks to professional growth, work-life balance, and everything in between.
00:00:09.599 --> 00:00:12.240
We're here to share what we've learned and what we're still figuring out.
00:00:12.400 --> 00:00:13.599
Let's get into it.
00:00:22.480 --> 00:00:22.800
Okay.
00:00:23.199 --> 00:00:25.440
I'm hoping to not make this too boring.
00:00:25.760 --> 00:00:27.920
But I think I think we're gonna be okay.
00:00:28.160 --> 00:00:29.600
No, it it won't be boring.
00:00:29.679 --> 00:00:31.120
Um, but it is necessary.
00:00:31.280 --> 00:00:33.679
It's this is like very relevant.
00:00:33.840 --> 00:00:39.840
I fear that this topic could very much affect everybody.
00:00:40.079 --> 00:00:40.640
Yeah.
00:00:40.960 --> 00:00:52.159
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.
00:00:52.479 --> 00:00:53.840
And be like good people.
00:00:54.000 --> 00:00:54.880
And be good people.
00:00:55.039 --> 00:00:57.840
And then you have governing bodies that tell you that you can't.
00:00:58.159 --> 00:01:00.560
They make it so impossible to be good people.
00:01:00.799 --> 00:01:01.119
Yeah.
00:01:01.439 --> 00:01:02.640
Um, okay.
00:01:02.960 --> 00:01:05.359
Well, any exciting cases this week?
00:01:05.519 --> 00:01:06.159
Anything fun?
00:01:06.480 --> 00:01:06.640
Yeah.
00:01:06.799 --> 00:01:09.280
Yeah, we had a we had a um we had a good week.
00:01:09.439 --> 00:01:12.239
I did a lot of training in the OR this week.
00:01:12.480 --> 00:01:16.159
Um, so my hands didn't like get in as much as I wanted them to.
00:01:16.400 --> 00:01:16.959
It's okay.
00:01:17.040 --> 00:01:17.519
It's okay.
00:01:17.599 --> 00:01:19.760
I get like different satisfaction from teaching.
00:01:19.920 --> 00:01:20.239
Yeah.
00:01:20.480 --> 00:01:22.319
Um you were molding different hands.
00:01:22.560 --> 00:01:23.760
I was molding different hands.
00:01:24.079 --> 00:01:31.359
I have perfected suturing with a um straight clamp as a needle driver.
00:01:32.159 --> 00:01:32.879
Oh, and that's hard.
00:01:32.959 --> 00:01:33.200
Yeah.
00:01:33.680 --> 00:01:36.239
And a straight clamp as an adsin.
00:01:37.120 --> 00:01:38.319
I've perfected it.
00:01:38.480 --> 00:01:38.959
I love that.
00:01:39.120 --> 00:01:45.760
I will I refuse to have the scrub text um peel pack another pickup or a um needle driver.
00:01:46.319 --> 00:01:47.599
I have a question to ask you.
00:01:47.760 --> 00:01:52.719
Has anybody ever referred to you in these moments as Hannah with a hemostat?
00:01:52.879 --> 00:01:53.120
No.
00:01:54.640 --> 00:01:54.959
No.
00:01:55.439 --> 00:01:56.719
I wait, fill me in.
00:01:59.840 --> 00:02:00.560
Ask around for that?
00:02:00.799 --> 00:02:01.760
Ask around for that.
00:02:02.239 --> 00:02:04.799
Um yeah, no, I don't like doing it.
00:02:04.879 --> 00:02:09.439
I hate suturing with a hemostat, but we also do not open up peel-packed things if you need another set.
00:02:10.000 --> 00:02:11.199
Because the needle twists.
00:02:11.280 --> 00:02:12.159
It twists every time.
00:02:12.319 --> 00:02:13.280
You don't get a good grip on it.
00:02:13.360 --> 00:02:15.439
And it like everything's weird, but I've done it.
00:02:16.000 --> 00:02:20.639
I unplug the bow or the bipolar tip, which really doesn't grab anything.
00:02:20.879 --> 00:02:21.759
No, but that's smart.
00:02:22.240 --> 00:02:25.199
And I use that as my pickup, and I use a hemostat.
00:02:25.360 --> 00:02:27.840
Generally, I get some sort of curved hemostat.
00:02:28.960 --> 00:02:31.599
And then I'm like, oh, everything's yeah.
00:02:31.680 --> 00:02:32.879
No, I I that's interesting.
00:02:33.039 --> 00:02:34.159
Hand them with a hemostat.
00:02:34.240 --> 00:02:34.319
Okay.
00:02:34.400 --> 00:02:34.719
Yeah, yeah.
00:02:34.879 --> 00:02:36.800
No, I will use a straight and then a straight.
00:02:37.439 --> 00:02:38.159
It's really better.
00:02:38.319 --> 00:02:44.319
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.
00:02:44.560 --> 00:02:47.680
Yeah, no, I I do, I like it, but in a very obviously different way.
00:02:47.840 --> 00:02:48.240
Yeah.
00:02:48.400 --> 00:02:53.840
So, but it's also hard to teach, like, this is an acceptable way to do things, and then there's my way.
00:02:54.080 --> 00:02:54.719
Yeah.
00:02:55.039 --> 00:02:56.960
So they're two different things.
00:02:57.199 --> 00:03:02.479
As 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.
00:03:02.879 --> 00:03:11.120
For 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.
00:03:11.439 --> 00:03:16.319
Four tegoderms in four quadrants, like upper right, upper left, lower right, lower left.
00:03:16.719 --> 00:03:21.360
If you hold the tegoderms lengthwise, it gives you more coverage.
00:03:22.319 --> 00:03:26.960
Um, the P I used to work with would do like willy-nilly, and I'm like, What do you what are you doing?
00:03:27.680 --> 00:03:31.280
Then you would go, then you would go diagonal with one, and I'm like, oh my god, stop.
00:03:31.599 --> 00:03:32.319
No, I do two.
00:03:32.639 --> 00:03:34.800
But you would you Yeah, I do I do, yeah.
00:03:34.960 --> 00:03:36.400
I will do four for the coverage.
00:03:36.560 --> 00:03:39.680
So anyway, so I was like, you know, oh yeah, and then you put the tegoderms on.
00:03:39.759 --> 00:03:45.439
I was like, oh, you can put them lengthwise, and then she turns it, and I was like, just put them lengthwise.
00:03:46.159 --> 00:03:47.199
Just do it the way I do it.
00:03:47.360 --> 00:03:50.639
Yeah, anyway, but uh no, it's interesting.
00:03:50.800 --> 00:03:51.840
It's just interesting.
00:03:52.000 --> 00:03:54.080
But um, no, so yeah, surgery was good.
00:03:54.240 --> 00:03:57.120
We did uh it was a heavy shoulder week.
00:03:57.199 --> 00:04:03.680
We did one, two, three, four, five, five shoulders out of four, five, six, seven, eight cases.
00:04:03.919 --> 00:04:06.800
So a couple short days because of clinic and then because of travel.
00:04:06.960 --> 00:04:08.240
Um, we did another Misha.
00:04:08.479 --> 00:04:11.039
Misha was done in 37 minutes.
00:04:11.280 --> 00:04:12.240
Is that a record?
00:04:12.560 --> 00:04:14.960
Um, I think the implant was in in 37.
00:04:15.439 --> 00:04:19.120
Uh, skin was starting to close at 40 something, and tourniquet was down by 60.
00:04:19.439 --> 00:04:20.399
Did you guys talk about this during?
00:04:20.480 --> 00:04:21.680
Are you like, what's the time right now?
00:04:22.000 --> 00:04:23.759
Um, no, it felt very smooth.
00:04:23.920 --> 00:04:25.040
And then I I looked.
00:04:25.199 --> 00:04:25.360
Yeah.
00:04:25.600 --> 00:04:30.720
Because we've done like a 45er, but this one was 37, not because it was rushed, but because it was just space.
00:04:31.120 --> 00:04:31.680
It happened, yeah.
00:04:31.759 --> 00:04:31.920
Yeah.
00:04:32.079 --> 00:04:34.319
I mean, all the stars aligned, so to speak.
00:04:34.480 --> 00:04:34.879
Yeah.
00:04:35.040 --> 00:04:36.800
Um, but no, it was it was good.
00:04:36.879 --> 00:04:37.920
So cases were good.
00:04:38.079 --> 00:04:49.920
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.
00:04:50.000 --> 00:04:52.319
That feels like summertime when we have a lot of people watching.
00:04:52.399 --> 00:04:53.600
So I'm a little bit over that.
00:04:54.079 --> 00:04:56.000
A little bit over that, but um, but it was okay.
00:04:56.079 --> 00:04:56.560
It was good.
00:04:56.639 --> 00:04:56.879
Yeah.
00:04:57.120 --> 00:05:00.079
Some good, I had a bunch of good patient visits this week, too.
00:05:00.240 --> 00:05:00.399
Yeah.
00:05:00.720 --> 00:05:01.199
What about you?
00:05:01.439 --> 00:05:02.319
It was just a blur.
00:05:02.480 --> 00:05:03.279
We had like our weekly.
00:05:03.600 --> 00:05:04.240
It was a short week, too.
00:05:04.480 --> 00:05:10.399
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.
00:05:10.639 --> 00:05:18.480
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.
00:05:18.720 --> 00:05:21.040
Um, and so it was a lot of back and forth.
00:05:21.120 --> 00:05:35.439
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.
00:05:35.759 --> 00:05:38.480
But you know, turnover times, all that good stuff.
00:05:38.720 --> 00:05:46.240
Um, we started the case at like, I don't know, probably like 11 30 or something, maybe.
00:05:46.720 --> 00:05:52.160
And my the clinic that I was supposed to start at one is a 45-minute drive.
00:05:52.399 --> 00:05:59.360
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.
00:05:59.839 --> 00:06:01.600
So it should be quick and easy.
00:06:02.000 --> 00:06:06.000
Well, the closure is not quick and easy.
00:06:06.240 --> 00:06:14.560
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.
00:06:15.279 --> 00:06:22.000
And I was like, okay, I gotta be 45 minutes away from here in what is that, 24 minutes?
00:06:22.319 --> 00:06:24.000
Um, I don't know how that's gonna work.
00:06:24.240 --> 00:06:25.519
So I didn't change.
00:06:25.680 --> 00:06:29.759
My scrubs are actually the scrubs I wore to the hospital are still in the locker there.
00:06:29.839 --> 00:06:30.079
Yeah.
00:06:30.240 --> 00:06:34.079
Because I grabbed my stuff and I just went ran out the door and left.
00:06:34.240 --> 00:06:37.279
Um, and I called our uh athletic trainer on the way.
00:06:37.360 --> 00:06:40.000
I was like, hey, so I'm on my way.
00:06:40.079 --> 00:06:42.480
By that I mean I just walked out of the hospital.
00:06:42.879 --> 00:06:44.319
You're gonna be mad at me, but here we go.
00:06:44.399 --> 00:06:44.639
Yeah.
00:06:44.879 --> 00:06:46.079
But like it's gonna work out.
00:06:46.319 --> 00:06:57.199
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.
00:06:57.759 --> 00:06:58.720
It's like you're not even late.
00:06:58.959 --> 00:07:01.839
I was like, yeah, and that like everything is gonna be perfect.
00:07:02.000 --> 00:07:02.800
And you know what?
00:07:02.959 --> 00:07:03.839
It worked out great.
00:07:04.079 --> 00:07:07.279
It was there wasn't a single get, like, people weren't like, oh my god, and you're running in late.
00:07:07.439 --> 00:07:19.839
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.
00:07:19.920 --> 00:07:21.920
So, like, that's on them that you're waiting that long.
00:07:22.800 --> 00:07:26.720
Um, I still saw him probably 10 minutes before his scheduled appointment time.
00:07:27.199 --> 00:07:29.920
But I walk in the room and he's like, There you are.
00:07:30.160 --> 00:07:32.879
I'm like, Well, yeah, here I am.
00:07:33.120 --> 00:07:40.319
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.
00:07:40.800 --> 00:07:42.800
But I'm 10 minutes early to this.
00:07:43.839 --> 00:07:44.399
So look at me.
00:07:44.879 --> 00:07:46.480
Why'd you get here so early, dude?
00:07:46.639 --> 00:07:48.000
And like, don't you hate that though?
00:07:48.079 --> 00:07:52.480
If you have patients that like get there early and they're like, Why did it take you so long to see me?
00:07:52.560 --> 00:07:54.959
And you're like, I'm still actually seeing you at your appointment time.
00:07:55.199 --> 00:08:02.800
I had a patient who showed up this week for a 3 30 pre-op that to his credit was communicated to him via email.
00:08:03.040 --> 00:08:05.600
To my credit, nobody put it on the schedule.
00:08:05.839 --> 00:08:10.879
So when he got there, they were like, Hey, this guy says he got an email, he has a 3 30 pre-op day.
00:08:10.959 --> 00:08:13.199
And I recall saying, like, Adam on at 3 30 this day.
00:08:13.360 --> 00:08:14.240
I was like, Yeah, he's right.
00:08:14.319 --> 00:08:15.600
They're like, Yeah, but it's not on the schedule.
00:08:15.680 --> 00:08:17.040
I'm like, You are also right.
00:08:17.120 --> 00:08:20.240
Uh so I'm, you know, in my head, I'm like, who was it?
00:08:20.399 --> 00:08:21.199
What's the name?
00:08:21.360 --> 00:08:24.160
Like so, this guy's surgery is next week.
00:08:24.240 --> 00:08:25.120
So this is like the only time.
00:08:25.439 --> 00:08:28.800
He's like, All right, check him in, but just explain to him the situation.
00:08:28.959 --> 00:08:29.680
Did they explain?
00:08:29.759 --> 00:08:30.000
No.
00:08:30.079 --> 00:08:32.159
They said, Oh, yep, she said no problem.
00:08:32.480 --> 00:08:34.960
So then they come back, so it's like 327.
00:08:35.039 --> 00:08:36.080
He checks in for 3:30.
00:08:36.159 --> 00:08:38.639
I'm thinking I can definitely see him before four.
00:08:39.519 --> 00:08:41.120
So it's like four, four ten.
00:08:41.360 --> 00:08:42.799
And he says, Hey, how much longer?
00:08:42.879 --> 00:08:44.480
Because I have to go pick up my kid, bro.
00:08:44.639 --> 00:08:46.399
Like, yeah, you know what I mean?
00:08:46.559 --> 00:08:47.200
And I get it.
00:08:47.279 --> 00:08:50.879
From his point of view, he's probably like, This is my appointment.
00:08:50.960 --> 00:08:53.360
I was here, but from my point of view, I'm like, oh my God.
00:08:53.519 --> 00:08:58.559
So anyway, so I like I moved patients around, I knew some patients who wouldn't be mad waiting.
00:08:58.639 --> 00:09:04.960
And of course, the last five patients of the day after this guy, they're like, You tired?
00:09:05.279 --> 00:09:07.440
I'm like, You're saying that because I look tired.
00:09:07.679 --> 00:09:11.440
Like, I feel like I'm I'm thriving right now on all of this chaos.
00:09:11.519 --> 00:09:12.399
Yeah, but yes, I'm late.
00:09:12.480 --> 00:09:13.120
I'm a little late.
00:09:13.200 --> 00:09:15.679
Yeah, but I got this guy's pre-op done, you know.
00:09:15.759 --> 00:09:18.240
Oh, and then my last patient was like, How many more?
00:09:18.559 --> 00:09:19.200
Do you get to go home?
00:09:19.279 --> 00:09:21.200
Do you have to get to have a nice glass of wine?
00:09:21.360 --> 00:09:24.159
And I was like, I literally have a couple more patients.
00:09:25.039 --> 00:09:34.320
Like, I literally um, okay, so I thought that it would be great for us to discuss this upcoming potential change.
00:09:34.399 --> 00:09:38.480
Now, this is not full disclosure, this is not like a thing that is definitely happening.
00:09:38.559 --> 00:09:45.759
This is something that um CMS, so Center for Medicare Services, is that the appropriate abbreviation, right?
00:09:46.159 --> 00:09:48.799
Um proposed this change.
00:09:49.120 --> 00:09:54.000
So right now, how office visits, I'm sure you guys all know, are billed.
00:09:54.159 --> 00:10:06.080
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.
00:10:06.159 --> 00:10:09.519
And those are all separate codes that you build during the visit.
00:10:09.840 --> 00:10:11.919
So, and I actually don't understand it.
00:10:12.000 --> 00:10:12.720
It's kind of like math.
00:10:12.799 --> 00:10:26.799
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.
00:10:27.039 --> 00:10:40.960
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.
00:10:41.120 --> 00:10:49.200
An office visit covers you for literally seeing a patient, evaluating them with your hands, coming up with a diagnosis and a treatment plan.
00:10:49.519 --> 00:10:57.200
So that is what an EM and again, just to back up, any new provider, you learn jack shit about this in PA school.
00:10:57.360 --> 00:10:59.360
There's nothing about billing in PA school.
00:10:59.440 --> 00:10:59.919
I don't know about you.
00:11:00.080 --> 00:11:00.399
No, zero.
00:11:01.039 --> 00:11:04.559
I don't even know, like I don't even what does EM stand for?
00:11:04.879 --> 00:11:06.960
Evaluation management?
00:11:07.519 --> 00:11:07.840
I don't know.
00:11:08.399 --> 00:11:09.679
It's it's your decision making.
00:11:09.840 --> 00:11:10.080
Yeah.
00:11:10.240 --> 00:11:28.240
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.
00:11:28.399 --> 00:11:28.559
Yeah.
00:11:28.799 --> 00:11:37.039
Now, uh when you get audited, your documentation should support the level of ENM, right?
00:11:37.279 --> 00:11:37.600
Yes.
00:11:37.840 --> 00:11:47.679
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.
00:11:47.840 --> 00:11:51.360
Part of what goes into that is procedures that you do.
00:11:51.519 --> 00:11:53.759
Like if you order X-rays or do injections.
00:11:53.840 --> 00:11:59.200
So, like when you do your visit, every visit has an E and M code, technically.
00:11:59.360 --> 00:12:07.440
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.
00:12:07.679 --> 00:12:09.519
The procedure, if you will, that you did.
00:12:09.919 --> 00:12:13.120
So it's assuming you can do an EM code with zero procedures.
00:12:13.200 --> 00:12:13.360
Yes.
00:12:14.080 --> 00:12:31.039
So 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.
00:12:31.200 --> 00:12:33.679
Um, and that is your EM code.
00:12:33.759 --> 00:12:37.840
That doesn't count for you doing anything procedurally with your hands, right?
00:12:38.080 --> 00:12:44.639
Other than palpating the patient or what is this the perc percussion the tap tap.
00:12:44.879 --> 00:12:45.919
Yeah, tap taps.
00:12:46.159 --> 00:12:52.879
Um so yeah, in orthopedics and a lot of other subspecialties, it's very heavily procedural-based.
00:12:53.039 --> 00:12:59.519
Uh, and so we do a lot of things, procedures on the same day as your visit.
00:12:59.679 --> 00:13:08.080
So, for example, I could see a patient for arthritis in their thumb and tell them, hey, this is what you have.
00:13:08.240 --> 00:13:14.080
Here are all the things that we can do to treat it, one of them being a steroid injection.
00:13:14.559 --> 00:13:26.480
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.
00:13:26.639 --> 00:13:42.639
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.
00:13:42.879 --> 00:13:59.360
So, 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.
00:13:59.440 --> 00:14:01.360
We decided to do it on the day of the visit, right?
00:14:01.440 --> 00:14:01.679
Yes.
00:14:01.919 --> 00:14:11.440
25 modifier is a significant, separately identifiable evaluation and management, so EM service by the same physician on the same day of the procedure.
00:14:11.600 --> 00:14:16.799
So it's saying that you did the evaluation, that was the visit, then you also decided to do the procedure.
00:14:16.960 --> 00:14:21.279
Yes, you decided to do the procedure, and now you're getting paid for the procedure and your office visit.
00:14:21.679 --> 00:14:42.799
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%.
00:14:43.440 --> 00:14:43.600
Yeah.
00:14:43.679 --> 00:14:51.200
So CMS is proposing cutting the reimbursement for the lower valued of the same services to 50%.
00:14:51.600 --> 00:14:51.840
Yes.
00:14:52.080 --> 00:14:53.360
So it's not garbage.
00:14:53.600 --> 00:14:54.240
It is garbage.
00:14:54.559 --> 00:15:00.639
You would they're not saying, oh, you won't get paid for it, but you will get paid significantly less for doing it.
00:15:00.879 --> 00:15:06.480
So this is the only me and my supervising doc were having this conversation yesterday.
00:15:06.639 --> 00:15:21.600
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.
00:15:21.759 --> 00:15:30.000
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.
00:15:30.159 --> 00:15:44.480
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.
00:15:44.720 --> 00:15:50.399
Can you charge me 50% less for the tires since you are you're doing my bumper in the same day?
00:15:50.559 --> 00:15:52.320
Like, no, you're gonna pay for both things.
00:15:52.480 --> 00:15:52.639
Yeah.
00:15:52.879 --> 00:16:04.159
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.
00:16:04.559 --> 00:16:05.679
Yeah, that's yeah, exactly.
00:16:06.639 --> 00:16:08.399
Well, it's like getting your hair cut and colored.
00:16:08.480 --> 00:16:13.759
Like, you don't get a freaking uh um, oh my god, I can't even think.
00:16:13.840 --> 00:16:14.799
It's the end of the week.
00:16:15.360 --> 00:16:20.480
You don't get a discount, you don't get a discount on your hair cut because you're getting it colored.
00:16:20.559 --> 00:16:21.440
It just costs more.
00:16:21.519 --> 00:16:22.080
And guess what?
00:16:22.240 --> 00:16:26.159
It costs more now to get your hair cut than it did 10 years ago or two years ago.
00:16:26.399 --> 00:16:29.360
Our rates are doing nothing but dropping and going down every year.
00:16:29.519 --> 00:16:30.960
It's it's quite depressing.
00:16:31.039 --> 00:16:36.720
Um, again, this is not something they teach you in PA school at all, but like it's reality.
00:16:36.799 --> 00:16:45.120
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.
00:16:45.360 --> 00:16:47.759
But um, yeah, this is the real deal.
00:16:48.000 --> 00:16:54.240
But we also like I have um patients that come in for gel injections, and it is a series of three.
00:16:54.480 --> 00:16:57.200
Their first visit is the discussion visit.
00:16:57.360 --> 00:16:58.480
This is why we're here today.
00:16:58.639 --> 00:16:59.840
Let me review your x-ray.
00:16:59.919 --> 00:17:01.440
This is what it looked like a year ago.
00:17:01.840 --> 00:17:02.879
This is the expectation.
00:17:02.960 --> 00:17:05.039
Let's discuss how your symptoms have changed.
00:17:05.119 --> 00:17:06.720
What are we looking to get out of the gel?
00:17:06.880 --> 00:17:08.559
What's our prediction with how long this is gonna last?
00:17:08.640 --> 00:17:09.200
That's a visit.
00:17:09.279 --> 00:17:10.480
That's an EM code.
00:17:10.640 --> 00:17:18.400
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.
00:17:18.640 --> 00:17:20.960
Um, that's the first gel visit.
00:17:21.119 --> 00:17:23.759
And at that visit, I will also do a gel, right?
00:17:23.920 --> 00:17:25.359
So I'm gonna bill for both those things.
00:17:25.519 --> 00:17:28.160
The second visit, they're coming in for their gel.
00:17:28.319 --> 00:17:29.680
There's no decision making.
00:17:30.000 --> 00:17:32.480
I'm not doing the now.
00:17:32.559 --> 00:17:38.160
If they come in and they're like, hey, my knee is swollen, and can you look at my other knee?
00:17:38.400 --> 00:17:41.839
Now we're doing an EM code plus the injection visit.
00:17:41.920 --> 00:17:47.599
But there are there are certain things that like I know why you're here, we exchange pleasantries and we do the injection.
00:17:47.680 --> 00:17:49.359
Like that's not the visit we're talking about.
00:17:49.519 --> 00:17:58.079
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.
00:17:58.319 --> 00:18:01.839
Yeah, because I mean it ultimately it comes down to being a business.
00:18:02.000 --> 00:18:06.400
Like, I this toes the line of like, am I the asshole?
00:18:06.640 --> 00:18:14.319
versus like trying to to be efficient and stay afloat as a provider, private practice, as a business, as a provider, private practice.
00:18:14.480 --> 00:18:21.440
I mean, you know, medicine is unfortunately just not just as much a business as other things, but like it is still a business.
00:18:21.680 --> 00:18:26.960
Like you still have to buy supplies and have lights on at the end of the day, you know.
00:18:27.200 --> 00:18:36.240
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.
00:18:36.799 --> 00:18:37.680
I'm getting out of my own.
00:18:37.839 --> 00:18:38.799
But here's also the issue.
00:18:39.119 --> 00:18:40.559
Yeah, here's also the issue.
00:18:40.720 --> 00:18:49.519
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.
00:18:49.680 --> 00:18:51.839
Like even with my gel injections, there's three injections.
00:18:51.920 --> 00:18:53.200
They're like, hey, can I come in one?
00:18:53.279 --> 00:18:55.039
And then on my second one, you do two and three.
00:18:55.200 --> 00:18:57.759
No, like that's not how it works.
00:18:58.000 --> 00:19:07.359
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.
00:19:07.440 --> 00:19:07.599
Yeah.
00:19:07.759 --> 00:19:11.279
And also to make up for that, what do we do in our field?
00:19:11.440 --> 00:19:12.319
We see more patients.
00:19:12.559 --> 00:19:13.680
And so yeah, it's insane.
00:19:13.920 --> 00:19:14.319
It's insane.
00:19:14.400 --> 00:19:15.039
Because guess what?
00:19:15.119 --> 00:19:16.400
That can't continue to climb.
00:19:16.480 --> 00:19:17.519
You can't continue to see more patients.
00:19:17.759 --> 00:19:18.079
You have a cap.
00:19:18.559 --> 00:19:19.039
There's a cap.
00:19:19.119 --> 00:19:22.799
There's at a there's a point where you're going to Beth has basically like hit the cap.
00:19:22.880 --> 00:19:23.519
I've most doubt.
00:19:23.680 --> 00:19:24.400
I'm looking on the cap.
00:19:24.960 --> 00:19:26.640
Like, I can't, I can't do more.
00:19:26.720 --> 00:19:32.799
So so now you you're sending the message that I'm gonna give you the slam dunky valuation visit.
00:19:33.039 --> 00:19:34.400
Can you do the injection?
00:19:34.720 --> 00:19:35.680
Not today.
00:19:35.920 --> 00:19:37.359
So here's the deal.
00:19:37.599 --> 00:19:39.599
I think you make less either way.
00:19:39.680 --> 00:19:54.799
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.
00:19:55.039 --> 00:19:55.200
Yes.
00:19:55.440 --> 00:19:57.599
Um, so you can handle this two ways.
00:19:57.759 --> 00:20:03.440
I suppose one could just decide to say, I am making less money during this visit.
00:20:03.599 --> 00:20:04.400
That sucks.
00:20:04.559 --> 00:20:08.319
I mean, you're doing the same exact thing that you were doing, same amount of work.
00:20:08.480 --> 00:20:12.160
Now all of a sudden you're making significantly less for doing it.
00:20:12.319 --> 00:20:19.119
Um, or you can decide to now I'm only gonna charge one of these things and do one thing a time.
00:20:19.200 --> 00:20:24.400
So I see a new patient for CMC arthritis, I tell them, hey, these are the options.
00:20:24.559 --> 00:20:25.519
They choose injection.
00:20:25.599 --> 00:20:28.720
I say, come back on Friday and we'll do your injection.
00:20:28.880 --> 00:20:30.319
Well, that inconveniences everybody.
00:20:30.640 --> 00:20:36.240
Yeah, but I can't, but like my neighbor drove me and I can't, like, I only had time today.
00:20:36.400 --> 00:20:38.240
I'll tell you what, we were just talking about this.
00:20:38.400 --> 00:20:42.720
For me to take time off to go do the mandatory things, can't even find time for that.
00:20:42.799 --> 00:20:43.039
Yeah.
00:20:43.200 --> 00:20:48.000
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.
00:20:48.079 --> 00:20:48.880
I'm gonna be like, you know what?
00:20:48.960 --> 00:20:49.839
I'm not getting the fluoride treatment.
00:20:50.079 --> 00:20:52.960
No, because I'm not taking the time off to do it, it's not happening.
00:20:53.359 --> 00:20:55.039
I won't tell you how long it's been since I've been.
00:20:55.200 --> 00:20:56.480
I probably should edit that out.
00:20:56.640 --> 00:20:57.839
Um I won't.
00:20:58.079 --> 00:21:03.039
But I think I but it's it's requiring the patient to come back, which guess what is also another copay.
00:21:03.839 --> 00:21:04.160
It is.
00:21:04.319 --> 00:21:05.599
It's a copay for them.
00:21:05.839 --> 00:21:07.359
It's an inconvenience for them.
00:21:07.440 --> 00:21:11.200
And now that is another spot on my schedule that I could have been seeing a new patient.
00:21:11.519 --> 00:21:13.599
So I'm getting less either way.
00:21:13.680 --> 00:21:15.920
I'm I'm fucked no matter what.
00:21:16.079 --> 00:21:20.000
So super passionate over camp.
00:21:20.240 --> 00:21:28.559
Um, 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.
00:21:28.640 --> 00:21:31.440
What are things that we can do to make it make sense?
00:21:31.759 --> 00:21:36.400
But it also is the it's just like you're getting beat, like whack-a-mole.
00:21:36.799 --> 00:21:40.720
But it's the same thing, and again, this is uh you know, a sense of comparison.
00:21:40.960 --> 00:21:44.079
It's like when administration today, okay.
00:21:44.240 --> 00:21:50.000
Today, someone um someone came into urgent care because they called the call center.
00:21:50.079 --> 00:21:54.160
And again, the call center, they're not providers, they don't make clinical judgments.
00:21:54.319 --> 00:21:57.359
Are they given forms that says what is in our scope of practice?
00:21:57.440 --> 00:21:58.319
And not, yeah.
00:21:58.880 --> 00:21:59.759
Some kid came in.
00:22:00.559 --> 00:22:02.799
Because his toenail fell off.
00:22:03.519 --> 00:22:03.839
Okay.
00:22:04.160 --> 00:22:05.200
There was no injury.
00:22:05.279 --> 00:22:06.960
There was no question of a fracture.
00:22:07.119 --> 00:22:08.960
His toenail fell off.
00:22:09.359 --> 00:22:10.000
Interesting.
00:22:10.240 --> 00:22:10.480
Okay.
00:22:10.960 --> 00:22:15.920
So I was walking by and I happened to hear this interaction.
00:22:16.160 --> 00:22:20.559
The patient came in, the mom was like, Hey, my son checking in for his toenail fell off.
00:22:20.640 --> 00:22:25.279
And the front desk turned around and they were like, Hey, do you mind?
00:22:25.519 --> 00:22:29.119
Can I can I ask you, you know, do you think this is appropriate for for check in?
00:22:29.279 --> 00:22:32.079
Again, it was done in front of the patient, but like it was right there.
00:22:32.160 --> 00:22:34.319
And so the provider came over and the provider was like, What's the story?
00:22:34.400 --> 00:22:36.400
He's like, So his toenail fell off.
00:22:36.559 --> 00:22:37.759
Like, did he did he play sports?
00:22:37.839 --> 00:22:38.720
Did he like bump it anything?
00:22:39.599 --> 00:22:39.680
No.
00:22:40.000 --> 00:22:40.480
Yeah.
00:22:40.799 --> 00:22:46.720
So they were the provider was like, Oh, well, that's I mean, that's um, that's usually not an emergency, right?
00:22:46.880 --> 00:22:48.160
That's there's usually no treatment.
00:22:48.240 --> 00:22:49.519
We're not gonna sew it back on.
00:22:49.680 --> 00:22:54.799
Yeah, um, we can look at it, make sure it's not infected, but there's not, there's not like treatment for that.
00:22:54.960 --> 00:22:56.799
The treatment is wait till the next toenail grows.
00:22:56.960 --> 00:22:58.400
Yeah, I mean, like, you know, right?
00:22:58.559 --> 00:22:59.359
So I'll save you time.
00:22:59.440 --> 00:23:01.119
I'm not gonna check you in to like over that.
00:23:01.359 --> 00:23:09.119
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.
00:23:09.200 --> 00:23:11.599
We absolutely will take care of that.
00:23:12.079 --> 00:23:15.039
What did she expect the take care of it would be?
00:23:15.359 --> 00:23:18.559
I think she thought we were going to reapply the toenail.
00:23:18.720 --> 00:23:19.279
Yeah.
00:23:19.519 --> 00:23:30.000
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?
00:23:30.079 --> 00:23:32.640
What if to fall toenails falling off are bad?
00:23:32.799 --> 00:23:34.640
Like, I don't know if toenails falling off are bad.
00:23:34.720 --> 00:23:38.480
So you sure go into the urgent care, they can tell you if it's an emergency that your toenail falls off.
00:23:38.640 --> 00:23:39.680
I know I know where to send you.
00:23:39.759 --> 00:23:40.240
Yeah.
00:23:40.480 --> 00:23:47.279
Um, so like I get that, but also like, you know, from the patient's perspective, like that's the answer.
00:23:47.359 --> 00:23:49.359
I know it's just not the answer you were.
00:23:50.160 --> 00:23:54.480
But the perception of the patient is I came here, I expected something to be done.
00:23:54.559 --> 00:24:01.440
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.
00:24:01.599 --> 00:24:08.160
It's CMS deciding that the work that you're doing is not worth um reimbursement.
00:24:08.319 --> 00:24:08.480
Yes.
00:24:08.720 --> 00:24:13.920
So it's it's a governing body telling you what you can deciding what is valuable and what is not valuable.
00:24:14.000 --> 00:24:14.480
It's garbage.
00:24:14.720 --> 00:24:15.519
It is garbage.
00:24:15.759 --> 00:24:18.240
Not only is it garbage, but like where does it end?
00:24:18.400 --> 00:24:23.119
Like when do we get something good?
00:24:24.079 --> 00:24:26.240
When when do we reimburse more?
00:24:26.559 --> 00:24:32.240
Yeah, when because like everybody, you know, uh expects raises at some point.
00:24:32.480 --> 00:24:33.599
Milk is more expensive.
00:24:33.680 --> 00:24:35.519
I don't know why I just said milk.
00:24:36.559 --> 00:24:39.759
I don't even buy milk, but everything's our hair is more expensive.
00:24:40.720 --> 00:24:49.119
Um yeah, so I don't know, like at what point do we say, hey, like, how about med medicine?
00:24:49.440 --> 00:24:55.680
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.
00:24:56.000 --> 00:24:56.559
It's like the opposite.
00:24:57.039 --> 00:24:58.400
But what's crazy isn't hyper protective.
00:24:58.640 --> 00:25:09.440
Yeah, 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.
00:25:09.519 --> 00:25:12.160
Yeah, you're gonna make a plan, you're gonna talk about custom bracing.
00:25:12.319 --> 00:25:14.240
And then it come time comes time for the shot.
00:25:14.319 --> 00:25:18.880
And they think that shot is worthy of what to cut, you know what I'm saying?
00:25:19.039 --> 00:25:19.680
And by 50%.
00:25:20.079 --> 00:25:26.240
Like you can't, I mean, I think, I think if there was some medical whatever, maybe cut it by 10%.
00:25:26.720 --> 00:25:26.960
Yeah.
00:25:27.200 --> 00:25:29.759
I'll reimburse you 90% instead of a hundred.
00:25:30.319 --> 00:25:33.440
Easier to swallow, I guess, but still like, why are you cutting it at all?
00:25:33.599 --> 00:25:37.759
Like, why do you feel the need to punish me?
00:25:37.839 --> 00:25:40.960
Yeah, why am I being punished for doing more for patients?
00:25:41.440 --> 00:25:42.079
It is personal.
00:25:42.480 --> 00:25:44.960
Do you want people, everybody to be more inconvenienced?
00:25:45.039 --> 00:25:48.000
Do you want them to like miss more work and come?
00:25:48.160 --> 00:25:48.480
I don't know.
00:25:48.799 --> 00:25:52.799
Again, the question is, what behavior does this incentivize?
00:25:52.960 --> 00:25:56.960
Does it incentivize providers to become lazy and just do the bare minimum?
00:25:57.119 --> 00:25:57.599
I think so.
00:25:57.759 --> 00:25:58.480
It can, yeah.
00:25:58.640 --> 00:26:00.880
Yeah, because again, you can handle it either way.
00:26:00.960 --> 00:26:05.680
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.
00:26:06.000 --> 00:26:12.400
Or you make less money overall, which I would argue most hospitals and practices aren't gonna be happy with you doing that.
00:26:12.559 --> 00:26:17.200
They're gonna want you to do what you know is more profitable and makes more sense.
00:26:17.440 --> 00:26:25.519
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.
00:26:28.240 --> 00:26:29.519
Yeah, and then you can charge less for it.
00:26:29.599 --> 00:26:37.440
Now, but I think though when these changes come into place, some someone on CMS probably thinks that the modifier is being overused.
00:26:37.759 --> 00:26:38.000
Yes.
00:26:38.079 --> 00:26:43.359
And that is that is where you can play devil's advocate into their side of the argument.
00:26:43.680 --> 00:26:50.720
Um, so basically, there's, you know, I from their perspective, we'll have the angel and the devil on the shoulder.
00:26:50.880 --> 00:26:53.920
Uh, I don't know, which is, I guess they're the devil, right?
00:26:54.160 --> 00:26:55.039
No, they're definitely the devil.
00:26:55.119 --> 00:26:55.279
Yeah.
00:26:55.440 --> 00:26:55.519
Yeah.
00:26:55.680 --> 00:26:57.839
That's definitely not bad.
00:26:57.920 --> 00:26:58.720
Can I say that on here?
00:26:58.960 --> 00:27:06.480
Anyway, so basically, you are not having to, you know, check in the patient more than once.
00:27:06.640 --> 00:27:11.279
You're only rooming them once for both things, taking vitals, whatever, we don't do that.
00:27:11.440 --> 00:27:13.279
Um, you're not using two separate rooms.
00:27:13.359 --> 00:27:16.559
It's not like duplicating staff and other resources.
00:27:16.799 --> 00:27:20.960
So some of these resources have overlap, so why pay it twice?
00:27:21.839 --> 00:27:24.160
Like, what resources are they really talking about, though?
00:27:24.240 --> 00:27:32.079
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.
00:27:32.480 --> 00:27:32.720
Yeah.
00:27:32.880 --> 00:27:36.480
Like, why am I not getting reimbursed for doing a procedure?
00:27:36.799 --> 00:27:42.480
Like, if somebody, if I take a picture to Michael to be framed, they get paid for framing the picture.
00:27:42.559 --> 00:27:44.240
I just I can't make it make sense.
00:27:44.480 --> 00:27:47.119
So could it be abused in certain scenarios?
00:27:47.599 --> 00:27:47.839
Yes.
00:27:48.000 --> 00:27:58.400
I mean, so tell me when you might not use the modifier and only bill one or the other.
00:27:58.720 --> 00:28:00.640
Oh, I would do my second gel shots.
00:28:00.720 --> 00:28:01.759
I will not build an EM.
00:28:02.079 --> 00:28:05.039
When I know the can you even bill an EM with a second gel shot?
00:28:05.279 --> 00:28:05.519
You can.
00:28:05.920 --> 00:28:11.680
But technically, if there is no decision making and they're just coming in, this is a mechanical visit, I will do that.
00:28:11.839 --> 00:28:17.440
And sometimes when I have like, and then not a gel visit, not when it's like they are here for their shot.
00:28:17.680 --> 00:28:26.240
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.
00:28:26.319 --> 00:28:27.279
Like I just feel bad about it.
00:28:27.359 --> 00:28:29.839
I do too, because has anything changed?
00:28:29.920 --> 00:28:30.240
Nope.
00:28:30.480 --> 00:28:31.279
Do you have any questions?
00:28:31.440 --> 00:28:32.079
Just want my shot.
00:28:32.240 --> 00:28:33.359
I haven't seen you in a year.
00:28:33.519 --> 00:28:34.000
Yep.
00:28:34.640 --> 00:28:34.960
Okay.
00:28:35.119 --> 00:28:36.880
Like, I mean, they don't want anything else.
00:28:36.960 --> 00:28:37.680
I don't want anything else.
00:28:37.759 --> 00:28:38.319
Like I would hate.
00:28:38.559 --> 00:28:41.039
I'm not gonna charge them an EM to see that patient.
00:28:41.119 --> 00:28:46.079
But at the same time, what I currently do right now is I will, you know, make it like fruitful for them.
00:28:46.160 --> 00:28:48.079
Like, you know, they'll ask if anything has changed.
00:28:48.160 --> 00:28:49.279
What are you guys doing now?
00:28:49.440 --> 00:28:50.720
Maybe my x-rays look worse.
00:28:50.799 --> 00:28:51.279
Let's take pictures.
00:28:51.359 --> 00:28:53.920
But I have some patients that are just so much like, do my shot.
00:28:54.000 --> 00:28:54.240
That's it.
00:28:54.400 --> 00:28:56.960
So I want, I don't care if my x-rays x-rays look worse.
00:28:57.039 --> 00:29:07.680
So 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.
00:29:07.759 --> 00:29:09.519
It helped so much last time.
00:29:10.000 --> 00:29:10.400
Great.
00:29:10.799 --> 00:29:15.359
We do it, and I'm like, follow up in you know, three months or whenever it comes back.
00:29:15.519 --> 00:29:18.240
Yeah, I'm not gonna charge them an office visit code now.
00:29:18.400 --> 00:29:27.359
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?
00:29:27.440 --> 00:29:27.839
Yep.
00:29:28.319 --> 00:29:33.119
I think that my time is worth being compensated for.
00:29:33.279 --> 00:29:35.440
So yes, I will charge an EM code for that.
00:29:35.599 --> 00:29:35.920
Yeah.
00:29:36.079 --> 00:29:37.440
Um yeah.
00:29:38.160 --> 00:29:45.920
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.
00:29:46.799 --> 00:29:50.400
I mean, do you do you use 25 modifier for anything else butter procedure?
00:29:51.119 --> 00:29:53.279
Uh I guess not.
00:29:53.440 --> 00:30:01.920
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.
00:30:02.079 --> 00:30:02.400
Yeah.
00:30:02.720 --> 00:30:04.000
But that's like the add-on.
00:30:04.240 --> 00:30:04.480
Yeah.
00:30:04.640 --> 00:30:04.960
You know?
00:30:05.119 --> 00:30:05.359
Yeah.
00:30:05.440 --> 00:30:06.480
I did something extra.
00:30:06.640 --> 00:30:18.160
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.
00:30:18.480 --> 00:30:18.640
Yeah.
00:30:18.799 --> 00:30:22.319
So Well, again, all of these, like all of these examples, right?
00:30:22.400 --> 00:30:25.440
It's gonna be new patient and you do the knee injection.
00:30:25.519 --> 00:30:33.359
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.
00:30:33.519 --> 00:30:37.440
Um, patient presents for a scheduled shoulder injection, but also has neck pain.
00:30:37.519 --> 00:30:37.680
Yeah.
00:30:37.839 --> 00:30:39.119
That's a 25 modifier.
00:30:39.200 --> 00:30:43.680
Um, chronic shoulder pain, but has new acute knee injury, and also I did a shoulder injection.
00:30:43.759 --> 00:30:45.759
Like it again, it's all of our visits.
00:30:45.920 --> 00:30:46.799
100% of our visits.
00:30:47.119 --> 00:30:50.640
Yeah, this is orthopedics, and I think this would affect us the most.
00:30:50.799 --> 00:31:02.400
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?
00:31:02.480 --> 00:31:05.680
Like, don't doctors and medical practices, they're already sucking me dry.
00:31:05.759 --> 00:31:12.640
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.
00:31:12.880 --> 00:31:13.440
Correct.
00:31:13.680 --> 00:31:20.880
Um now the AMA is fighting this, and I mean, I think appropriately so, yeah.
00:31:20.960 --> 00:31:30.960
That it's gonna make it very difficult for office-based providers um to perform procedures and deliver quality care.
00:31:31.279 --> 00:31:37.680
Yeah, 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?
00:31:38.000 --> 00:31:41.839
Do I I mean I've normally I make my decision on do I have time?
00:31:42.000 --> 00:31:42.559
Yeah, yeah.
00:31:42.799 --> 00:31:44.160
If I have time, I will do it.
00:31:44.240 --> 00:31:52.640
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.
00:31:52.880 --> 00:31:53.119
Yeah.
00:31:53.359 --> 00:31:53.920
I don't know.
00:31:54.160 --> 00:31:54.480
Yeah.
00:31:54.720 --> 00:32:05.440
So let's say this were to happen in my personal hell, this passes and this becomes reality for us.
00:32:05.680 --> 00:32:14.160
How would you handle if somebody like say a patient comes in that like drives from the beach?
00:32:14.319 --> 00:32:24.799
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.
00:32:24.880 --> 00:32:25.440
What do you do?
00:32:25.519 --> 00:32:26.799
Do you just do it?
00:32:28.000 --> 00:32:32.400
Um you know what I would do, and again, I will put my name on it.
00:32:32.640 --> 00:32:39.519
I will charge a higher ENM code and do my injection to try to make up the difference.
00:32:39.759 --> 00:32:44.960
So yeah, and this is uh these are things that would potentially happen too, right?
00:32:45.279 --> 00:33:00.799
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.
00:33:00.960 --> 00:33:03.279
So they will have to find ways to compensate.
00:33:03.519 --> 00:33:05.599
And you're not gonna like those ways either.
00:33:05.839 --> 00:33:10.240
Like, do you, you know, they're gonna be constantly fighting up charged ENM codes.
00:33:10.480 --> 00:33:14.480
Um, but yeah, I mean, I guess that's one way, one way to handle it.
00:33:14.720 --> 00:33:25.359
It'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.
00:33:25.519 --> 00:33:29.839
We're trying to use AI to help us document so we're not doing all this stuff.
00:33:30.000 --> 00:33:44.319
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.
00:33:44.400 --> 00:33:46.400
Yeah, it's just for the patient, too.
00:33:46.640 --> 00:33:47.359
It's very contradictory.
00:33:47.519 --> 00:33:54.880
Yeah, we're getting penalized for, and again, we're not getting penalized, but this theoretically would I feel personally victimize.
00:33:55.440 --> 00:34:03.200
And 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.
00:34:03.359 --> 00:34:03.599
Yeah.
00:34:03.759 --> 00:34:08.320
Yeah, at least it's pretty much like all I'm doing that's not post-op visit is injection.
00:34:08.480 --> 00:34:10.880
So like I become obsolete.
00:34:12.000 --> 00:34:25.840
But 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.
00:34:27.119 --> 00:34:27.760
It's insane.
00:34:27.840 --> 00:34:28.079
Okay.
00:34:28.480 --> 00:34:29.760
For all total joints, right?
00:34:30.000 --> 00:34:32.480
In all total joints for the codes for total hip and total knee.
00:34:32.719 --> 00:34:33.679
Oh, yeah, shoulder.
00:34:33.920 --> 00:34:37.119
No, live to see another day back out there.
00:34:37.360 --> 00:34:45.840
In 2027, they're proposing a 20% additional reduction in surgeon professional reimbursement.
00:34:45.920 --> 00:34:49.440
Now, just so everybody who is not in total joint world, guess what?
00:34:49.599 --> 00:34:51.760
They're not doing 20% less work.
00:34:51.840 --> 00:35:01.199
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.
00:35:01.440 --> 00:35:02.960
Why are you taking pay cuts?
00:35:03.039 --> 00:35:05.840
This is the only profession doctors are taking pay cuts.
00:35:06.000 --> 00:35:06.800
I know it's insane.
00:35:06.880 --> 00:35:09.119
It's while everything gets more expensive.
00:35:09.280 --> 00:35:09.599
Yeah.
00:35:09.840 --> 00:35:17.440
So, 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.
00:35:17.679 --> 00:35:19.519
Now, now what is happening?
00:35:19.599 --> 00:35:20.960
Yeah, it's it's wild.
00:35:21.199 --> 00:35:21.840
It is wild.
00:35:21.920 --> 00:35:24.079
But also, and again, the whole picture.
00:35:24.239 --> 00:35:29.760
So now, if you're a total joint surgeon, for you to make up that deficit, you have to do 20% more cases.
00:35:29.920 --> 00:35:32.960
If you're trying to do 20% more cases, you have to be in clinic less.
00:35:33.119 --> 00:35:36.239
If you're in clinic less, you can't have people come back for their second visit for their shots.
00:35:36.400 --> 00:35:37.599
Like you have to do it all at one time.
00:35:37.920 --> 00:35:38.400
It's insane.
00:35:38.480 --> 00:35:40.880
Yeah, like a vicious cycle.
00:35:41.199 --> 00:35:44.559
It's a very vicious cycle, and it leads ultimately to worse patient care.
00:35:44.800 --> 00:35:47.599
This is what Because you're not able to, you you can't focus.
00:35:47.760 --> 00:35:59.199
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.
00:35:59.360 --> 00:36:00.079
It's insane.
00:36:00.159 --> 00:36:00.400
Yeah.
00:36:00.639 --> 00:36:01.599
Truly insane.
00:36:01.840 --> 00:36:06.079
I mean, like these some some of the things that already exist now are insane to me.
00:36:06.239 --> 00:36:14.320
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.
00:36:14.480 --> 00:36:18.480
You could pay less for one of them if you do two procedures.
00:36:18.559 --> 00:36:25.920
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.
00:36:26.400 --> 00:36:27.280
I think it's united.
00:36:27.440 --> 00:36:38.000
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.
00:36:38.079 --> 00:36:38.159
Yeah.
00:36:38.320 --> 00:36:39.039
Because we won't pay for it.
00:36:39.119 --> 00:36:39.280
Yeah.
00:36:39.440 --> 00:36:42.320
Or AC joint um debrisment won't pay for it.
00:36:42.559 --> 00:36:44.559
So you just do it and don't pay for it, I guess.
00:36:45.039 --> 00:36:47.280
But you you are forced to choose what's right for the patient.
00:36:47.440 --> 00:36:47.599
Yeah.
00:36:47.760 --> 00:36:47.920
Right?
00:36:48.000 --> 00:36:51.679
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.
00:36:51.920 --> 00:37:01.199
Most 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.
00:37:01.519 --> 00:37:05.119
Um, so we just do it and bite the bullet.
00:37:05.760 --> 00:37:06.960
So it sucks, isn't it?
00:37:07.199 --> 00:37:09.679
Like, these are this is reality, guys.
00:37:10.400 --> 00:37:14.000
Listen, I mean, those of you practicing, you know it, I'm sure.
00:37:14.239 --> 00:37:18.960
Those of you who are in school or aspire You don't know any of it.
00:37:19.199 --> 00:37:19.599
Yeah, yeah.
00:37:19.840 --> 00:37:21.360
Listen, well, I buckle up.
00:37:21.599 --> 00:37:30.719
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.
00:37:30.800 --> 00:37:32.079
I've never been offered that.
00:37:32.239 --> 00:37:39.039
And it's funny because when I hire new PAs, um, the administration's like, okay, well, they'll just do their own billing.
00:37:39.119 --> 00:37:44.239
And I'm like, you have to understand when you say the words do their own billing, that means nothing to them.
00:37:44.400 --> 00:37:45.360
They have no idea.
00:37:45.519 --> 00:37:46.639
That's not a class.
00:37:46.800 --> 00:37:55.679
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.
00:37:55.840 --> 00:37:56.559
It's never a thing.
00:37:56.719 --> 00:37:56.800
Yeah.
00:37:56.960 --> 00:37:58.880
I'm like, wait, doesn't a billing department handle that?
00:37:58.960 --> 00:38:02.159
Like the billing people in the hospital, they do the billing, right?
00:38:02.400 --> 00:38:02.639
Yeah.
00:38:02.800 --> 00:38:03.039
Right.
00:38:03.199 --> 00:38:04.159
I just like do the work.
00:38:04.960 --> 00:38:05.840
I don't have to do the billing.
00:38:05.920 --> 00:38:06.320
Like, come on.
00:38:06.480 --> 00:38:07.039
That's not a thing.
00:38:07.360 --> 00:38:07.840
Surprise.
00:38:08.000 --> 00:38:08.239
Yeah.
00:38:08.400 --> 00:38:10.719
But anyway, it's it's very relevant information.
00:38:10.880 --> 00:38:16.960
Um, and unfortunately, that is the the uh commercial insurances tend to follow Medicare.
00:38:17.119 --> 00:38:21.840
Not a hundred percent, but if you see a big change coming down the pipe from Medicare, it trickles down.
00:38:22.000 --> 00:38:22.559
So it does.
00:38:22.719 --> 00:38:27.519
That's why the the flags are up and the alarms are are going off, and that's why Hannah is super fired up.
00:38:27.760 --> 00:38:28.239
Fired up.
00:38:28.400 --> 00:38:31.360
But just so everybody knows, this is again, this is just proposed.
00:38:31.440 --> 00:38:33.119
This isn't something that's definitely happening.
00:38:33.199 --> 00:38:34.880
I'm trying to jump scare anybody.
00:38:34.960 --> 00:38:36.480
Um jump scare me.
00:38:36.800 --> 00:38:38.639
We're just here also to validate ourselves.
00:38:39.039 --> 00:38:40.079
This is this is for me.
00:38:40.239 --> 00:38:41.760
This is like my therapy right now.
00:38:42.480 --> 00:38:48.320
You guys, if you take away the procedures in your visits, then that's gonna be very upsetting.
00:38:48.559 --> 00:38:50.159
It will be very upsetting to me.
00:38:50.559 --> 00:38:56.480
So anyway, I suppose you could go to some sort of website.
00:38:56.559 --> 00:38:57.599
Uh, I don't know.
00:38:57.840 --> 00:39:00.079
I should have like made something to sign it.
00:39:00.239 --> 00:39:04.239
Yeah, petition, but the petition is due by September 14th.
00:39:04.320 --> 00:39:05.360
So I think that was Monday.
00:39:05.679 --> 00:39:06.000
Monday, right?
00:39:06.239 --> 00:39:11.119
Nobody I'm gonna link something in the Instagram, a petition to fill out.
00:39:11.440 --> 00:39:13.440
Can you make a cartoon for like picketing CMS?
00:39:13.599 --> 00:39:14.159
Yeah, like I was thinking.
00:39:14.800 --> 00:39:16.880
Speaking of the Instagram, did you take your videos?
00:39:17.679 --> 00:39:18.559
I have some videos.
00:39:18.800 --> 00:39:23.519
I do not have any soccer videos because I arrived late given the circumstances of yesterday.
00:39:23.760 --> 00:39:24.719
Yeah, it's fair.
00:39:24.880 --> 00:39:27.119
I do I we I will I will get the archive together.
00:39:27.199 --> 00:39:28.320
You gotta give me the weekend though.
00:39:28.400 --> 00:39:28.559
Okay.
00:39:29.199 --> 00:39:33.840
The weekend for the archive, and then then I just need the raw footage.
00:39:34.079 --> 00:39:34.800
All right, fine.
00:39:34.960 --> 00:39:35.440
Fine.
00:39:35.679 --> 00:39:41.519
I made requests for somebody to take videos of you playing soccer, but I was told that it's simultaneous.
00:39:41.679 --> 00:39:42.159
So that can't be happening.
00:39:42.320 --> 00:39:43.119
It was simultaneous.
00:39:43.199 --> 00:39:43.360
Yeah.
00:39:43.440 --> 00:39:44.079
So that can't happen.
00:39:44.320 --> 00:39:45.199
I'll have to bring one of my kids.
00:39:45.280 --> 00:39:46.880
Maybe I'll bring one of my kids next week and they can.
00:39:47.119 --> 00:39:48.079
Actually, they don't have school on Friday.
00:39:48.159 --> 00:39:49.360
Someone doesn't have school on Friday.
00:39:49.840 --> 00:39:50.079
Perfect.
00:39:50.159 --> 00:39:50.639
There we go.
00:39:50.800 --> 00:39:51.679
Problem solved.
00:39:51.920 --> 00:39:52.880
All right, guys.
00:39:53.119 --> 00:39:56.800
Well, this is something to think about over the weekend.
00:39:57.199 --> 00:39:58.800
A call to action, if you will.
00:39:59.039 --> 00:40:02.400
I think though, if nothing else, compartmentalize it somewhere in your head.
00:40:02.480 --> 00:40:04.079
If you're like, what the hell's a modifier?
00:40:04.239 --> 00:40:05.199
Remember this talk.
00:40:05.440 --> 00:40:07.440
Start thinking about billing.
00:40:07.599 --> 00:40:08.000
Yes.
00:40:08.159 --> 00:40:08.639
Yeah.
00:40:09.199 --> 00:40:09.679
All right.
00:40:09.920 --> 00:40:11.039
Until next time.
00:40:20.719 --> 00:40:23.199
Thanks for tuning in to Joint Effort PAs.
00:40:23.360 --> 00:40:29.360
If you enjoyed this episode, be sure to subscribe, leave a review, and share it with a fellow PA or med minded friend.
00:40:29.519 --> 00:40:34.320
You can also follow us on Instagram at Joint EffortPAs for updates and extra content.
00:40:34.559 --> 00:40:35.199
See you next time.