Confessions of a Pediatric Practice Consultant

If you are like me, you find the AAP's NCE event overwhelming.  Too many people to see, too many sessions to attend, etc.  A big problem I have is overcoming my ADHD long enough to go through the catalog of events to find the things I should be doing.

I don't know if they've done this in years past, but our friends at the AAP assembled this catalog of "practice oriented" sessions for the NCE.  I'll highlight a few of the goodies, many of which I would have missed.  Yes, there are a lot of usual suspects here (PCC clients, PCC event speakers), but there are some awesome sessions going on.  I wish I didn't have to miss most of them thanks to the conflicts!

Don't get me wrong - there are many other amazing sessions not only in the attached PDF, but in general.  I skipped, for example, the Paul Offitt talk.  And Andy Spooner's talk about Security, the Internet, and Your Office.  But the sessions above are where you'll most likely find me in a few weeks.

Oh, and we're in booth 1827!  Stop by and say hello! 

I'm really not this lazy, it's just that what Erica has put together is really good.

If you're a pediatrcian and thinking about ARRA (as many of you appear to be), PedSource is assembling what I think are among the best pediatric-focused ARRA resources you will find anywhere.

Erica's latest piece is entitled "ARRA EHR Incentive Money Myths and Shopping Tips" and is found over on PedSource.  It's the latest piece from http://www.pedsource.com/ehrmoney, which includes the FAQ. I use them myself at least twice a week!

Enjoy.

Have you voted, yet, for AAP president?  

If not, why not?

It's easy.  Go to the voting site.  Read the bios, go to the candidate WWW pages. Read the candidate responses.  Ask your friends.  But whatever you do, vote.  The turnout has been weak the last few years.

As some folks know, I've helped Dr. Yankus a little bit with his personal campaign site.  I've known him for about 20 years - in fact, he might have been the first practice I ever demoed in person!   PCC ran an interview with him a few weeks back that we hope introduced him to many folks who haven't had a chance to meet him.

We have also interviewed Dr. Bob Block, Dr. Yankus' competition, who is well supported by a number of our clients, especially those who know and have worked with him.  I hope our interviews are the first in many steps to help get out the AAP vote!

What made me think of all this - and will lead me back to my focus of today's effort -  was Dr. Yankus' campaign blog posting about vaccines.  We have had a surfeit of excellent vaccine business pushback at the AAP level in the last 2 months.  More than I have ever seen.

First, Dr. Palfrey provides her now-famous blog entitled "Helping Pediatricians Breathe."  Do I agree with it 100%?  No, of course not.  I only agree with my wife that way.  But it provides an excellent outline of the AAP's increasing vigilance on matters related to immunization reimbursement.

Then, one of my favorites, Dr. Lessin, hit AAP News with his piece entitled, "Economic Barriers to Immunization Must Be Removed."   Here is his manifesto:

We must remove economic barriers to pediatricians by ensuring that all payers compensate vaccine services and changes in acquisition costs with immediate recognition and an adequate margin to ensure continued participation and provision of such services.

We must remove economic barriers to patients by providing first dollar coverage for services with particular emphasis on vaccines.

We must remove economic and administrative barriers to pedia- tricians wishing to participate in the VFC Program and encourage disadvantaged children to have access not only to federally qualified health centers but to non-governmental practices as well.

We must insist on interoperability of immunization registries and encourage more regional and national registries in order to make access to records seamless and easy.

We must vigorously and loudly fight back against the anti-vaccine movement with real science and data, not junk science and opinion.

We must remind young parents about the very real dangers of preventable childhood disease.

We must make ourselves more available with extended hours and avoid missed opportunities to vaccinate due to minor illness.

We must advocate for continuous monitoring of vaccine safety and ongoing research and education on this topic.

We must provide a comprehensive medical home for immunization and encourage alternate venues if such medical homes are unavailable.

EXCELLENT.

Finally, via SOAPM, I heard about Dr. Russell Libby's piece in Pediatric Annals which reads like a primer on the issues of immunization financing, on the practice level.  In fact...I think I have to reference it somehow in my upcoming chat at the AAP NCE (which will focus on this issue).  Another must read, thanks for the PDF.

At our Pediatric Practice Management and UC event 2 weeks ago (time flies!), the perennial question about whether practices are paid for their use of the VEP machine and CPT code 95930.  It seems that just under 10% of PCC's practices us a machine like the one from Diopsys while a smaller number use a machine like the one from PediaVision (CPT code 99174).  

Igor ran the numbers and they are unequivocal:  our clients get paid for this work.  The problem is that we can't properly measure when practices are not being paid and, therefore, stop performing these tests.  Let's look at the data...

Thus, approximately 9% of our clients recorded a 95930 procedure and charged, on average, $155.73 and were paid $94.14.  This seems like good news and feedback.  The problem, as I noted above, is that the practices who are not being paid don't show up here.  They simply stop doing the tests.

What I find really interesting is the use of and different results for the various CPT modifiers that were used for both the VEP and OAE tests.  Most, but not all, of our clients use some combination of -52, -25, -53, and -59 modifiers on these codes.  The -53 and -59 are the only ones with real volume.

The -53 modifier is for a "Discontinued Procedure" such as when the child is too wiggly for you to perform the test.  The OAE code (92587-53) dropped from $56.84 in payment to $33.47.  The VEP dropped from $94.14 to $64.48.  I'd say that this makes some sense.

The -59 modifier, meanwhile, is for a "distinct procedural service."  This is the cousin of the -25, which is for a distinct E&M service for the same day.  The -59 is for procedures instead.  When used, the OAE jumps to  $62.04 and the VEP jumps to $103.40.

I didn't look to see which payers preferred which modifiers, I'll leave that as an exercise for reader input.

No, PCC does not endorse any of these products nor do we get favors for this research.

At our UC and Practice Management and Coding event last week. we had the distinct pleasure of a presentation from Dr. Christoph Lehmann, the new Medical Director of the AAP Child Health Informatics Center.  Afterwards, we chatted and we agreed how useful it would be for someone to start a REC and HIE review site, especially for pediatricians.  

PCC has already experienced the conflict-of-interest challenges that the RECs often faceand, more understandably, their lack of pediatric expertise.  If there are RECs or HIEs who do get it, I want to know.

To my surprise, Dr. Lehmann had a site up and running about 2 days later.

So, folks - head to this site and provide your feedback.

From: Christoph U. Lehmann, MD, FAAP

Organization: Johns Hopkins University

To: COCIT

Dear COCIT members,

As you know, the Office of the National Coordinator released the final ruling on Meaningful Use on July 13and the AAP's Child Health Informatics Center is monitoring the latest news and updates for you. With payments for the meaningful use of Electronic Health Records expected as early as May of 2011, it is critical to provide to the AAP fellows as soon as possible the best available information resources to aid in the EHR implementations.

In collaboration with the Council on Clinical Information Technology, the AAP's Child Health Informatics Center has developed an interactive web site to collect and rate all Meaningful Use resources of importance to pediatricians available at 

http://derm.med.jhmi.edu/AAP_MU

We made an effort to start populating the web site with resources. But we urgently need YOUR help. Please visit http://derm.med.jhmi.edu/AAP_MU . We ask that you add at least one resource in your state and that you rate 3 resources already available on the site.

The combined knowledge, dedication, and expertise of COCIT members will turn this resource in a powerful tool for pediatricians - but it will only succeed with your help! So, please - go and visit the site NOW (http://derm.med.jhmi.edu/AAP_MU) - add your resources and rate some of the existing ones.

Thank you very much in advance - we appreciate your time and expertise.

Chris Lehmann, MD, FAAP

Director, Child Health Informatics Center, AAP

As you may have heard - even the AAP has announced the news - the Final Draft of the Meaningful Use Final Rule has been issued by CMS.  There are already dozens of analyses of the results posted on-line (how some of these folks read 860+ pages in a matter of hours is beyond me), but remarkably little as it relates to pediatricians.  As you know, MU and the ARRA money are really aimed at the 95% market share, namely physicians who take Medicare.

Before I give you some of the best pediatric-focused analysis of the new rules, I will give you the second best.  histalk2.com has both the original announcement as well as an amazing comparison of the Prelim and Final rules.   The comments for the original announcement are particularly important to read.  

The best analysis, especially for pediatricians, comes from within PCC, of course.  I assume she is going to share some of this on pedsource.com in general once she has looked over everything, but our own Erica Greenwood sent me a list of pediatric-focused items that I thought were worth sharing in advance of a more formal, official reading. So, approach these carefully - and any misinterpretation here is my own and not hers - but some highlights include:

•  Under the Medicaid program, EP's can participate for six years and the years do not have to be consecutive. So, if you start and then miss a year, it's okay, you can pick up the following year. This is very different -- and better -- than Medicare which offers five consecutive years.
• States can now only add criteria related to two of the measures and any criteria they add must pertain specifically to public health objectives and data registries. CMS has to approve the additional criteria. [This is very different from what I have been led to understand is happening in places like VT, DE, and PA. For example, I was told that VT practices would have to submit a complete "Blueprint For Health" data set (225? discrete items?) for each visit to qualify!]

Erica spotted many other changes, some of which haven't been picked up by any of the other places I've read, but the two items above are of particular interest to pediatricians. Unfortunately, the "20% Medicaid" bar has not been lowered, so our estimate that only 31% of private pediatric practices qualify remains unchallenged.  You can see more of PCC's running ARRA/CCHIT/MU content here.

This is a long one, but worth reading.  The names have been changed to protect both the innocent and the guilty.  

The story begins with a clever pediatric practice who decides that since Insurance Company A (we'll call them Cygnus to keep it short) does not want to pay for the 99051 code, it will send Cygnus patients to the ER or have them sign and fulfill the following waiver:

Clever 99051 Waiver

This waiver was pre-empted by the following letter from the practice too all Cygnus patients:

Warning Letter

There are a few things that I really like about the waiver and the letter, but note that great paragraph about cost-shifting.  I plan to steal, er, share it.   Note that I've removed identifying information from the letter, that part isn't important.

To no surprise, a patient called about the letter to complain.  Cygnus wrote to the practice.  Things start to get interesting here:

Our Sales department received the attached letter from a few concerned CIGNA Customers (your patients). It appears that the information noted is a little misleading. CIGNA does and have always covered specific after hour codes. Code 99051 has been set to deny since June 2008. We cover code 99050 & 99058. After running a report on pediatric groups in the Eastern Carolina, code 99050 & 99058 are the only codes they bill for after hour services. Please advise why your office can not bill with either of these covered codes?

 

Also, please explain your option # 3 listed on your letter. Why would you charge our Customers an additional $36 for services when there is a more appropriate billing code? Per your contract you should only bill patients for there coinsurance/copay and deductible.

 

Also, Section 5.8, Use of Name, in your contract agreement states the following:

 

*Group's and its Represented Providers' use of Cygnus' name or a Cygnus Affiliate's name, or any other use of Group's and its Represented Providers' name by Cyngus will be upon prior written approval or as the parties may agree.*

 

In addition our Sales department is educating our Customers to help them understand that we do cover other after hour codes. 

Bam, insurance speak!  "...always covered specific after hour codes."  The problem here is that the code Cygnus covers is not appropriate for the service performed.  Right there in the letter, the insurance company suggests that there is a "more appropriate billing code" for the procedure when, in fact, there is not.

But then it gets weirder.   They go on to claim that the practice is not allowed to refer to the insurance company in any of its patient communication without written approval.  Crazy!  Talk about restraint of trade!  Clearly, that's not the least bit enforceable, but we've got the low level account managers buying it full form.

The practice didn't back down, however.  The practice president wrote back:

I am the President of Children's Clinic. I appreciate you taking the time to respond to an insured's complaint. Children's Clinic has offered office hours on Saturday and Sunday since the 60's - over 40 years! During this time, we have always charged an extra charge to the patient for being seen in our office on the weekend and holidays.  A couple of years ago, there was a shuffling of the CPT codes used to describe the added work of seeing patients on the weekend, and we shifted from 99050 to 99051. See the standard definitions below:

 

CPT 99050

Services provided in the office at times other than regularly scheduled office hours, or days when the office is normally closed (eg, holidays, Saturdays or Sunday) in addition to basic service.

CPT 99051

Services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to the basic service.

Our weekend hours are posted and known by our patients - 8:30 -12 Saturday and 12-4p Sunday. Although our hours are not "regular" in that we do not pre-schedule, we do not allow the patient to pick which physician they see, and we do not see non-urgent problems (Well child care, ADHD follow-up, Behavior problems, etc), we switched to the newer code, 99051, thinking that was the closest "fit" to what we do.

Our policy is that we do not see patients without the extra revenue in our office on the weekends. If an insurance company would rather their clients be seen in a MUCH more expensive ER, then we are happy to make the referral. Even NC Medicaid pays for the 99051 code. Our charge for 99051 is $36. Even with the added charge, we feel we are much more cost effective than the ER and thus are confused as to why a company would prefer their patients be sent away -- but insurance companies often display confusing logic.

We have been paid by Cygnus (on appeal) for the 99051 code until this past January when the appeals were no longer allowed/honored. We were not notified prior to the change, which I think could be a violation of our contract. We subsequently notified our patients who appeared to be insured by Cygnus. Attached is a copy of the text of the letter that we sent to your insureds.

As a separate issue, I must admit I am confused by your reference to Section 5.8 where we are not supposed to use your name without permission. BCBS has the same clause and they explained it only pertained to public use - like in a newspaper ad. The letter we sent was addressed specifically to the few patients we have insured by Cygnus and by no means was it "public". We also print the name of the insurance company of each patient on the bottom of the Encounter Form which is given to the patient as a copy of their visit. I suppose we could replace the proper spelling of your company's name, but again, this seems quite silly. Perhaps not as silly as referring your insureds to the local ER to "save" money, but nonetheless, silly. Please send clarification of Section 5.8. I assume we cannot use it in public venues such as newspapers or web pages, but I would like clarification if we can use the word in spoken and written communication with patients insured by you.

If your company would like for us to use 99050 for weekend visits, we would be happy to do so and that could solve this entire mess. 99050 is the code we have used for years until the newer 99051 came out. To avoid the possibility of future accusations of insurance fraud by others in your company, please send me an email or letter stating something clear like :

"Children's Clinic is known by us to have predictable and advertised limited office hours on Saturdays and Sundays. We recognize this is a service to our patients as well as a cost savings to us and are willing to pay an extra amount in addition to the usual E&M codes.  We have asked CCC to use the code 99050 instead of 99051 so that we may pay appropriately."

Of course, the 99051 should be comparable to what we have been paid in the past. We would of course rather see out patients than have our local emergency room procedure them to pieces - but we will not violate out long standing policy to accommodate your creative bundling of the 99051 into the usual E&M codes. Either way, this will only affect a small number of patients.

So, he called them out. "Sure, I'll use the inappropriate 99050 code...just give me your permission in writing." Anyone want to guess what happened next?

As many of you know, I am on the CCHIT Child Health Workgroup, which has been both a delight and an exercise in futility.  The focus and capability of the folks on that committee is intimidating, to say the least...but, sadly, we have not met since last September, if I have my dates right.  Everyone - especially CCHIT - expected them to be named the one-and-only certification body for all things EHR, but that never materialized and now many of us are wondering what to do.

Two interesting pieces landed in my mailbox today that discuss these issues.  

• How Relevant Is CCHIT Certification In the HITECH Era?

A quick piece from the folks over at softwareadvice.com, an interesting pro/con discussion about the state of CCHIT.  Some of the points are interesting, but on the whole it borders on the naive.  I don't know a single REC, for example, that promotes a non-CCHIT vendor (example, anyone)?  Further, none of the HIEs are excited to work with a non-CCHIT vendor.  In fact, some of them refuse to do otherwise.  

• Should Doctors Reject the Government's EHR Incentive Plan? [warning: free MedScape login required]

  A very well-written piece from Dr. David Kibbe (who has a well-earned strong reputation), that has some wonderfully quotable lines:

  I'm not yet at the point where I would recommend that doctors reject the incentive program. But it's hard for me to recommend participating, given the degree of uncertainty and risk. I'd like to see evidence that the feds understand the complexity of community-based medical practices and can refine and simplify their meaningful-use criteria. And I worry a great deal that big organizations will get windfall profits out of this deal, while most family medicine practices will only get new hassles and unfunded mandates.

I couldn't have said it better myself.

I remember, quite clearly, the CCHIT committee conference call where I learned the truth.  "I'm sure there are sources for alternative growth charts.  I've seen them with my own eyes," I said as Dr. Marcus tried to convince me otherwise  I couldn't believe that the well-known, non-standard growth charts - for Downs children, preemies, etc. - weren't readily available for use in an EHR.

But they weren't.  And aren't.

Yes, we can all google around for alternative pediatric growth charts and find pictures of the graphs on-line, what you won't find is an official, peer-reviewed, AAP-approved data set that can be used to construct alternative growth charts within an EHR.  Those special growth charts some EHR vendors have?  Dangerous, imo.  Where does the data come from?!  How can you plot the digital data on it?  

COCIT has recognized the problem and are working hard to solve the problem.  Check the message below and spread the word!

From: COCIT [mailto:COCIT@LISTSERV.AAP.ORG] On Behalf Of Rosenbloom, Trent
Sent: June 02, 2010 3:04 PM
To: COCIT@LISTSERV.AAP.ORG
Subject: Updating growth charts for Down syndrome

 

Colleagues –

 

Given recent advances in medical and nutritional care, the current standard Down syndrome growth charts may no longer represent growth of children with Down syndrome today.  In addition, existing paper-based Down syndrome growth charts do not easily lend themselves to integration into electronic health record systems in an interoperable way.  To address these gaps, several colleagues and I are looking to develop a set of updated growth charts for kiddos who have Down Syndrome in a way that can be easily implemented into electronic health record systems, and which would be available along the model of the CDC growth charts for normally developing children.  These charts would also be an update on existing Down Syndrome growth charts to reflect the benefits of advances in medical and nutritional care that have occurred since the last such charts were created.  We would like the charts to reflect a large multicenter population of children to maximize their power and generalizability.

 

We plan for the charts to be freely available to all pediatricians and EHR systems, with the single goal of making it easier for healthcare providers and families to track the growth of children with Down Syndrome. 

 

We are looking for healthcare systems or centers that care for a large number of children with Down syndrome to collaborate with us.  Collaboration will involve sharing de-identified data that includes information about age, gender, growth and the presence of certain diagnoses, such as prematurity and congenital heart disease.  If you operate at such a center and are interested, please let us know.

 

Please note additional information below.  I am happy to answer any questions you may have.

 

Thank you

Trent

 

 

S. Trent Rosenbloom, MD MPH

Assistant Professor, Department of Biomedical Informatics

Assistant Professor, School of Nursing

Internal Medicine and Pediatrics

Vanderbilt University Medical Center

 

Office: (615) 936-1541; fax (615) 936-5900

Eskind Biomedical Library

2209 Garland Avenue, Nashville 37205

trent.rosenbloom@vanderbilt.edu

 

 

Background and Rationale

Pediatric growth charts have been developed by the United States Centers for Disease Control and Prevention (CDC) to help physicians assess patients’ nutritional and general health status.  Patterns of growth can then be easily reviewed to determine whether they are following the expected trajectory and to identify cases of inadequate or excessive growth.

 

Electronic Health Record (EHR) systems are increasingly being adopted by all types of healthcare providers, including those caring for children. Management and presentation of normative and patient growth data have particular importance in pediatrics, and are a minimum requirement for comprehensive EHR systems used in that setting.  This was echoed by the American Academy of Pediatrics Task Force on Medical Informatics in their “Special Requirements for Electronic Medical Record Systems in Pediatrics.” Necessary functionality includes the ability to record height, weight and head circumferences; to plot these data against normative curves such as those published by the CDC. 

 

Most Down syndrome growth charts are based on work done by Cronk, published in 1988.  The Cronk growth charts represent a cohort of children ascertained before modern advances in the treatments for prematurity, congenital cardiac disease and nutritional deficiencies.  In addition, the data underlying the Cronk charts are not available for direct implementation into EHR systems.  Other studies by Myrelid in Sweden and by Styles in Ireland, both published in 2002, report more modern estimates of growth.  However, both are restricted to relatively small geographic settings, and neither provide data that can support EHR system growth charts.

 

The primary goal of the current work is to develop modern growth curves for children with Down Syndrome that account for advances in care for prematurity, congenital cardiac disease, and nutritional challenges in infancy, then to make these charts freely available for use in paper-based medical records and for easy integration into EHR systems.

 

Anticipated Methods

All patient encounters involving children ages 0-18 years old with Down syndrome occurring during the study period will be included.  The study period has not yet been defined at this time, but will likely include at least the previous five years.  All data will be retrospective, sourced from existing medical records.  For the study, the following data points will be obtained: gender, values for weight, height and head circumference, age at the time of measurement (or dates of measurement and of birth), whether the child had congenital heart disease and the estimated gestational age at birth if measurements were taken within the first 3 years of age.  All data will need to have a patient identifier or code so that multiple data points from single patients can be linked, but the identifiers should not be tied to any clinical identifier (such as a medical record number).

 

Using statistical modeling methods such as those applied by CDC and described at http://www.cdc.gov/nchs/nhanes/growthcharts/datafiles.htm, the investigators will develop percentile curves for the 3rd, 5th, 10th, 25th, 50th, 75th, 90th, 95th, and 97th percentiles of growth (data permitting) and for the mean and standard deviations of growth.  Growth curves covering ages 0-18 and for girls and boys will be developed for the entire population.  In addition, curves covering ages 0-3 for children with prematurity and covering 0-18 for children with a history of congenital heart disease will also be developed.  The different charts will be compared to assess the impact of prematurity and congenital heart disease on growth.  Last, charts documenting the BMI of Down syndrome patients will also be developed, as weight gain frequently presents as a medical concern in both the younger and older Down syndrome population.  The investigation team’s statisticians are currently finalizing the specific modeling methods to be applied.

 

Before initiating the project, all participating sites will need to submit a request to their local institutional review board and will possibly enter into a data sharing agreement.  The data sharing agreement will basically outline that there is no intention to profit from this work, and that all data is shared freely for the development of a new free resource (i.e., the new growth charts for children with Down syndrome).  The primary research team will help with these as needed.  We will work with collaborators to facilitate this process.

 

The research team anticipates no to minimal subject risk from this research.  The data used for the research is generally of a non-sensitive nature (e.g., age, diagnoses and gender) and will be de-identified.  The research team anticipates no direct benefits to patients whose data is used for this study.  The knowledge obtained from this research is expected to improve physicians’ ability to monitor growth and to identify patients with growth delays.  Accurately identifying growth delays in children with Down syndrome may be the first step in diagnosing and treating medical and social diseases in this population.

I'm finishing up the weekend here in Skytop, PA, where I've tried to contribute to the annual Goryeb/Atlantic Health conference.  I always enjoy the experience but my family enjoys it even more...  The feedback I hear is that the clinical component is always excellent and it's a pleasure to run into old friends, especially the PCC customers.

Dr. Allen Menkin, of Main Street Vaccines fame - you may recall our piece about him in a previous installment - pointed me to the running blog at his practice WWW site.  Although this link will age out shortly because of how they designed their page, at the moment they have an interesting editorial about "Convenience Clinics" that is worth sharing.  If you're reading this sometime after June, 2010, look for their May 2010 posting.  I particularly enjoyed their graphic.