Confessions of a Pediatric Practice Consultant

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!

It looks like your hard work paid off!  From a CMS bulletin dated 12/29/2011:

This change resulted in many questions and potentially unintended consequences for other payers. We want to be clear that Medicaid and other private payers will be able to continue to use code 96110 even though it is a statutorily non-covered service under Medicare. In addition, many State Medicaid programs rely upon Medicare-published relative value units, including those associated with code 96110. At the request of Medicaid and concerned stakeholders, in the next few weeks Medicare will provide the relative value units for this code.

You can read the entire thing here. My thanks Robin Harpole for spotting this.  Why no word from the AAP, yet?

Update: The AAP speaks!

"Revised payment files to reflect corrections and revisions to the physician update amount will be posted on the Physician Fee Schedule portion of the CMS website in the near future. In the meantime, the payment rate for code 96110 will be based on 0.28 total RVUs (0.27 practice expense and 0.01
malpractice)."

Good work!

The AAP has issued an important call to action for pediatricians, and those who work for them, relating to a proposed change to the 96110 CPT code, a subject about which I've written many times (these are just a fraction of the blog entries, you can see them all here).

It appears that during the annual CPT review process, someone had the bright idea of changing the definition of the 96110 so that it no longer represents a crucial piece of work - something mandated by Bright Futures, in fact - and, therefore, no longer has RVUs.  Which decimates, in the true sense of the word, well visit reimbursement for physicians.

The AAP is organizing a response to CMS.  Please take the 60 seconds to participate and respond below.  It's easy and it will work if everyone pitches in.

Here's an abbreviated copy of the AAP letter:

We write to you today with a unique and urgent advocacy request due to a change in CPT code 96110, a code used to bill for essential developmental, behavioral and psychosocial screenings and services.

The U.S. Centers for Medicare and Medicaid Services (CMS) has issued a Final Rule to stop covering services associated with 96110.

Services associated with that code have become ineligible for payment within Medicare. This coding change was included in an annual review of all codes published by CMS.

Since Medicaid and private pay systems often depend on Medicare payment rules, CMS’ decision impacts children enrolled in Medicaid and in private health insurance plans.

Today, AAP president Robert W. Block, MD, FAAP, sent a letter on behalf of the Academy to CMS expressing concern with the agency’s decision and urging CMS to reinstate coverage of code 96110, among other requests. The specific portion of Dr. Block’s letter pertaining to this code is published at the bottom of this message.

Individuals can submit public comments to an online docket in response to CMS’ Final Rule. The AAP is urging its members to submit public comments between now and the deadline of Jan. 3, 2012 to urge CMS to reinstate payment for code 96110.

To submit a comment, visit the docket website and go to the upper right-hand corner to click “Submit a Comment.” You can either paste text directly into the online form or attach a separate letter with your feedback. For further guidance on how to submit comments in hard copy, please read these instructions.

Because you are submitting the comment as an individual pediatrician, you do not need to identify your AAP affiliation in the online form.

Some suggested text:

As a pediatrician, I am writing to express my concern with CMS’ recent decision to change the status of CPT code 96110, rendering the code ineligible for reimbursement under Medicare. Since Medicare payment rules often influence Medicaid and private payments, and since more than half of all Medicaid recipients are children, this decision could adversely impact children covered by Medicaid and private insurance. Please reverse this decision and reinstate coverage of services associated with code 96110. [INSERT PERSONALIZED MESSAGE: This regulatory action by CMS will directly impact my patients by…] Thank you for your consideration of my request.

Dr. Shenkin also gave me this text to help personlize the message:

CHS proposes to change the 96110 code from active test to screening, and thus exempt it from payment. This is both inaccurate and destructive. It is inaccurate because, contrary to the position taken by the American Academy of Pediatrics, many times the code does indeed represent testing. In my office I watch a child perform many tasks as I test their development. It is destructive because, by eliminating payment for 96110, CHS will deprive physicians of payment for developmental testing, and thus deprive children of rigorous evaluation of development.

I propose that no changes be made, and 96110 be retained in its former position.If there are changes to be made in the future, they should be studied more fully and better solutions developed.

Although Dr. Shenkin proposes something different from the AAP's
position, it's still something. Whatever you do, do something.  The link you need is here.

[Updated for 2013!]

[Updated on 10/11/12 to reflect the Revised RVU release.] 

Welcome to the free 2012 RBRVS Calculator.  Please note that this is in BETA, as it refers to
an annual conversion factor of $24.60. Past experience suggests that this number will change sometime between now (12/8/11) and March, 2012.

As you may know, the AMA won't let anyone provide a free RVU calculator that includes CPT codes due to their CPT copyrights. In an abundance of caution and, because in our unhappy experience, the American Medical Association interprets its rights (in our opinion) overly broadly, we created this tool for those of you who have a CPT license that allows for a use such as this. In theory, that should mean any practice that submits insurance claims.

To make a long story short, you can use this spreadsheet with the data that you can download from CMS to make a fairly sophisticated RVU calculator in about 5 minutes.

What does it do? It allows you to choose your CMS-driven location, set a Medicare Multiplier, and then, on a code-by-code basis, determine your pricing level. If you then take the time to include your code volume and pricing, it will determine your practice's FACF (i.e., how much you charge, on average, relative to Medicare). If you then provide your payment information, it will compare it to the Medicare fee schedule for you.

All around, pretty cool I say in all immodesty.

I have created both an OpenOffice version [revised 01/19/12] of the tool and, sigh, a Microsoft Excel version [revised 01/18/12] as well.

How does it work?

1. Download one of the above spreadsheets.
2. Head to CMS and download the 2012 RVU zip file. You have to agree to the license and usage rules from CMS, of course. My link above points to version A in 2012; CMS usually releases a few revisions through the year, but they usually don't affect pediatrics and primary care.
3. Extract the PPRRVU12.xlsx file from the zip file. Yes, I think it's completely lame that our federal government uses a proprietary format for this data, especially one (the new .xlsx) that not everyone who even owns Excel can open. Grrrrr.
4. Cut and paste the entire page of data from the PPRRVU12.xlsx file into the tab marked "PPRRVU12" in the RVU Calculator spreadsheet. Don't panic if it seems to freeze for a minute, it's a lot of data.
5. Choose your locality with the pulldown menu. Pick a Medicare Multiplier. Then, enter some CPT codes in column A. Gasp in amazement.
6. Put some unit volumes, prices, and payments in and watch what happens. Any field marked in a light blue-gray is a place where you can enter info.

I'd love for some guinea pigs to try this out and tell me what doesn't work. PCC clients, natch, can do this already with our reports, so I want to hear from the rest of you :-)