Confessions of a Pediatric Practice Consultant

Whether or not you have an EHR, having consistent clinical protocols is vital.  I am a fan of the oft-misunderstood Bright Futures, myself, but even BF doesn't cover everything.  One missing piece of the puzzle was filled about a year ago when MedImmune, in collaboration with NICHQ,  unveiled what I call the "Preemie Toolkit."  Acually, that's what they call it too, now that I think about it.

I was really interested in the project because it gave PCC an opportunity to include some crucial pediatric content in our EHR.  The toolkit includes a wide (and deep) variety of preemie tools, from handouts to checklists to actual chart note templates.  PCC incorporated them into our EHR last January (I think we're the only ones to do so) and they are free to any PCC client. [You can see what we did here.]

I just heard that the Toolkit has been updated, which is delightful, as we know it's a living project.  Updates include:

• The various forms can now be either a) printed blank and completed manually (previous feature) or b) the editable pdfs can be downloaded and saved to the user’s desktop for electronic completion (new feature). None of the forms can be completed directly on the website itself;
• Additional content resources have been included in each section;
• Indexed quick links appear at the top of each respective section;
• A Site Map is now featured;
• A Feedback button is now featured, without asking for the user’s e-mail address or contact information. Once the user clicks the Submit button, the comments are sent to a monitored e-mail inbox. No comments are displayed on the website or in any public forum; and
• The website has been optimized for viewing on mobile devices

It doesn't matter who your EHR vendor is or even if you have one - this is protocol gold and it's free.  Can't beat that.

Many of you are familiar with the 96110 RVU snafu at the beginning of 2012.  CMS removed all the RVUs for the 96110 and then, with the help of the AAP making noise, replaced the values.

Apparently, a number of  payers took this as an opportunity to stop paying on the 96110 altogether. Sigh.

We did a quick check after hearing numerous complaints on SOAPM and PedTalk - it looks like there has been a slight tick in 96110 payments, but not an outright denial.  Please share your experience!

[click on the image to get a close up]

 It looks to me as though the payments started slowing pre-2012, so we can't blame CMS.  Note that our client charges also drop - perhaps PCC added enough new clients using this procedure that our sample changed?

Input welcomed.

Brandon Betancourt ensures that things I write to SOAPM after I have a few beers remain memorialized indefinitely.  This time, it's about automated patient communication tools.

I am guilty of blog neglect.  The busier I am, the more I have for the blog, but the less time I have to do it.  Here's an interesting one that I've saved for a few weeks - an analysis of the immunization administration fees paid in Universal vs. non-Universal states.

The analysis was based on the question of whether or not states that cover vaccines for all patients tend to pay well for the admins.  Some folks on SOAPM posited that without the possibility of even a small profit on vaccine products, physicians in Universal states might really suffer financial hardship.  I thought about the Universal states for a second and said to myself, "Wait.  I bet they get paid better."  and I think they do.
In fact, I think that many of them are paid well enough that they might fare
better with their overall vaccine "profit" than non-universal states.

I had Igor @ PCC look into it for me.  This isn't entirely scientific, and I
certainly welcome comments/questions/complaints, but if you want to see
something shocking:

Universal States: VT, MA, NH, NC, WA, NM

[we forgot the 90472, but it's nearly identical for both sets of states]

Fascinating, indeed.  Again, non-scientifically, it would appear that our
universally-stated clients get a ~30% boost on their admins *when they use the
new codes* yet are effectively the same with the older codes.
The now-expired 90465/90466 codes showed a similar boost for non-Universal states.

So, here's the question.  Let's say we've got a 15m well visit at hand.  A
U-state could easily generate $30-80 more in admins.  Can every Non-U practice
say that their real margin on their products is that high?  No, they can't.
In fact, for too many, it's negative.

FTC nerds: this data is from a huge data sample across many practices in many states who
can't possibly compete against or conspire with each other.  And it's >3m old so we could look at
paid claims.

I've been given the wonderful opportunity to present at the annual Pediatric Gurus event hosted by Goryeb Children’s Hospital again this year.  At one point, I am sandwiched between two very heavy-hitters, Dr. Rick Oken and Shireen Hart, which means I'll have to bring the A-game.

Topics include:

•  2012 Pediatric Benchmarks (me)
• Strategies for Economic Survival
• Practical Pediatric Legal Update
• Make the RBRVS Work for You (me)
•  A Day in the Life: Coding
• Secrets to Success in Contract Negotiations
•  Social Media: Building a Positive www Presence (me)

The Skytop location makes this one of my favorite events of the year (plus, I get to see so many PCC clients). If you're in the northeast, I hope I see you there!

Attendees of the AAP NCE are surely familiar with the Office of the Future exhibit that has grown in size and scope over the past few years.  I don't know if it began that way, but since at least 2010, the project has been the baby of Dr. Gregg Alexander, a pediatrician also well known for his DOCTalk role over on histalkpractice.com.

PCC has supported the AAP by sponsoring the booth and extending our display into one of the "quadrants."  And, last fall, I gave two brief presentations along with a dozen+ other folks.  Although I'm not a fan of my results, many of them are very much worth the time to watch them - and you can now see them on-line (here and here)!  I know it's impossible to see and do everything you want at the NCE, so for Dr. Alexander to take the time to put these talks on-line is a wonderful effort (I believe we have to thank PCC competitor, Nuesoft).

Dr. Alexander also let me know that there are great changes in store for the Pediatric Office of the Future, including a potential name change.  I'll quote him rather than mangle it:

...the “Pediatric Office of the Future” is not about “the Future”, but about technologies, of all sorts (not just electronics) that are available today to help pediatricians provide better care, have better lifestyles, and increase their bottom line. In fact, we’re going to use this year as a transition year away from the current “Pediatric Office of the Future” name. It will now come under the COCIT (Council On Clinical Information Technology) management and we will have a very different approach. We will be able to have all of the educational sessions we want, not CME of course, but without any of the restrictions (such as no presentation slides on large screen monitors) as we did this year. We are going to change the exhibit’s name (final name yet to be determined.) This year, we’re going to do a red strike-through of “the Future” and write “Today” off to the side, sort of like “Pediatric Office of the Future Today.” It seems the future” term throws the concrete thinkers into assuming it isn’t useful for today’s practices.

He let me in on some other changes, including a reference to a possible return to the Pediatric documentation challenge! Glad to see the AAP supporting this development.

Sometimes, I don't have to do any of the work except to make friends and provide attribution.  Today's installment features a wonderfully concise, helpful guide to CPT coding for breastfeeding related services, care of the National Breastfeeding Center.

Some sample text:

Billing for problems with breastfeeding and lactation is just like billing for any other problem. Using standard evaluation and management codes (E & M) [e.g. Current Procedural Terminology (CPT) codes such as 99212-99215] and diagnosis codes, physicians and other billable licensed practitioners (such as nurse practitioners and physician assistants) may:

• Code based on time, if greater than 50% of time is spent in counseling, education, or coordination of care
• Use modifier 25 appended to a problem-focused visit to bill in conjunction with the well baby visit, when there is extended time spent on feeding problems.
• Bill for care provided for the mother, often as a new patient, in addition to billing for the baby, if history exam, diagnosis and treatment are done for her.

Wow, top-shelf content. Use it.

The free RBRVS calculator has been updated for the 2012 Revised CPT data, which includes a return of the 1.000 GPCI floor, some updated codes, and an increase to the new CF. 

You can see it all here.

At our Users' Conference last summer, Brandon Betancourt gave a presentation entitled, "Practice Makeover: 101 Ways to Transform Your Practice."  I was teaching at the same time, so I couldn't attend, but I did hear the applause at the finish.

I knew PCC had his handouts, so I went through them and was blown away.  Brandon did a tremendous amount of work here!  What an amazing document.  I encourage you all to download this presentation and share it with your office.  He has recently updated it and I am sharing that version of it with you here.

The point of the effort isn't that you must or even should do all of these suggestions.  Some of them will be completely inappropriate for your office.  But, somewhere in this list, there will be a small gem that could transform your practice.  Given the small 10 minute investment to read, I don't know who could reasonably object.  Take a few minutes, and then don't forget to visit his blog.

My only complaint is that item #1 isn't "Work with PCC!"

Holy smokes.

The Governor of NC just issued quite a press release:

"Care management saved N.C. Medicaid nearly $1 billion over four years, according to a new analysis by a national health care consulting firm."  You can read the rest here.

Given that there isn't anywhere close to full PCMH coverage in the NC Medicaid program, these savings are enormous.

I don't have enough details to be satisfied, but this bodes well:

In North Carolina, Milliman used Medicaid claims data to compare the costs incurred by recipients enrolled in one of the state’s 14 regional medical home programs to those of patients that were not. Researchers found that more frequent office visits and treatment of newly diagnosed conditions initially added to per person costs in the medical homes program. But fewer emergency room visits and hospital admissions, combined with greater efficiencies and improved care resulted in better health and sizeable savings over the longer term, the report says.

I like claims-based data, perhaps I'm biased. You can read the rest of this analysis here.

All of this just after the AAP announces that PCMHs benefit kids without special health care needs by lowering their need for sick visits and that parents spend less out of pocket with PCMHs.

In pediatrics, the PCMH concept is going to have a greater effect than MU.  I really believe that it works.  For those of you fighting for payment, I just gave you 4 links to support your cause.  Keep at it!