99058

I have written here extensively about the various "scheduling based codes" and their usage - or lack of usage - among pediatricians, but have made the mistaken assumption that most of you reading here actually have extended office hours.

It is this pediatric practice management consultant's position that if you are not offerring office hours to your patients outside standard working hours, you're not only doing your patients a disservice, but yourself as well.

Yes, I'm breaking my promise to post the appeal letter today. However, that's not the promise for which today's entry is titled. Something more important needs to be communicated.

I've written many times about Susanne Madden and her Verden Alerts. Why the world hasn't pounded down her door and signed up for her service is beyond me. Fortunately, in her own version of herd immunity, Susanne sometimes makes important information available to us all for free. Below, please find an update about some recent UHC payment/policy changes that will affect any pediatrician who participates with them.

Thank you, Susanne. The rest of you: start your engines. [Note that the Synagis change may even be retroactive.]

For those of you that are not Verden Alert subscribers, I wanted to make you aware of a couple of UHC policy changes that will affect Pediatrics:

Please note that 1. is titled After Hours and Weekend Care but only addresses services provided on an emergency basis . . .

1. After Hours and Weekend Care Policy

Under the current UnitedHealthcare policy for reimbursement of services provided in the office on an emergency basis, CPT code 99058 is reimbursed in certain places of service when reported with basic service codes. This CPT code has a status of 'B" (bundled into payment for other services not specified) on the National Physician Fee Schedule resulting in no additional CMS reimbursement. Effective in the fourth quarter of 2008, UnitedHealthcare will align reimbursement of this code with the Centers for Medicare and Medicaid Services (CMS) National Physician Fee Schedule (NPFS). As a result, reimbursement for services provided on an emergency basis, CPT code 99058, will not be separately reimbursed.

Go to http://content.4at5.net/email_domains/unr/21553/hosted/reimburse_6.html

2. New Synagis Drug Procurement Protocol Effective July 1

A new protocol for the ordering, clinical coverage review and purchase of palivizumab (Synagis) takes effect July 1 for all participating physicians and health care providers. Beginning on that date, Synagis must be procured from our preferred specialty pharmacy provider, PharmaCare/CVS Caremark.

Palivizumab (Synagis) - Requirement to Use Participating Specialty Pharmacy to Obtain Synagis

UnitedHealthcare has selected PharmaCare/CVS Caremark, a national distributor of Synagis, as our preferred specialty pharmacy provider. PharmaCare/CVS Caremark's national network provides timely Synagis prescriptions and clinical services to meet the needs of participating physicians and our members. PharmaCare/CVS Caremark has been instructed to deliver Synagis consistent with UnitedHealthcare's Drug Policy for Synagis. PharmaCare/CVS Caremark works directly with our Clinical Coverage Review team in the Consumer Decision Support Advocacy unit to determine whether proposed Synagis use is consistent with the member's benefit plan.

Continued Use of a Non-Network Specialty Pharmacy for the Acquisition of Synagis Effective July 1, 2008, continued use of a non-specialty network pharmacy, wholesalers, or direct purchase from the manufacturer of Synagis, without prior approval from UnitedHealthcare may result in the physician or other health care professional not being reimbursed in whole or in part, as provided in the Participation Agreement. In addition, the physician or other health care professional must not bill our members for any amounts not paid due to non-compliance with the Synagis drug procurement policy.

Physicians who prescribed Synagis in 2007 will be sent a letter about the preferred specialty pharmacy providers to obtain Synagis and the drug policy for Synagis.

For more information, view the above protocol in the 2008 Physician Administration Guide and the drug policy at UnitedHealthcareOnline.com>Policies & Protocols> Medical Policies.

As promised, I will show you the money.

Click on the picture below (or here) for a better view of the average reimbursement for these scheduling based codes.

What we see are fairly consistent reimbursement for the codes with the variation being explained by the additional payers being added on all the time (look at the data showing the big increase in usage).

So, there ya' have it without a lot of comment...pediatricians are getting paid for these codes, even by the Medicaids.

Hit the poll to your left to show the world whether you are a good coder or not (don't worry, it's anonymous).

In 2008, the CPT definition of the classic "after-hours" codes changed. Gone is all the rigmarole about whether your hours are "posted" or whether your patients know you are open on weekends and all the other commentary that used to convince our clients not to use these important codes. The bottom line: if you see patients in any of the following circumstances, there is an add-on code that you should be using:

• Any patients seen "after normal business hours" (definition below)
• Any patients seen in the evening (8pm and later)
• Any patients seen on a weekend
• Any patients seen on a holiday (definition below)
• Any patient seen between 10pm and 8am if you are open 24 hours
• Any patient who is forced into your appointment schedule (definition below)

"Oh, the insurance companies never pay for these codes," I hear the complainers saying. Baloney. I am going to post some surprising reimbursement data later, but I wanted to start with the 2008 changes. These codes are no longer confusing, they are really simple.

What does "after hours" mean? For me, it's easy - when do the insurance companies stop taking your calls about their bad claims? 4:30? 5:00pm? 5PM IS AFTER NORMAL BUSINESS HOURS. If you regularly see kids after 5pm, every one of them ought to walk out of your office with a 99050 attached to the E&M/Well Visit. Remember, you are saving the inscos tens-of-thousands of dollars a year by providing this service (I'd put it at $300 a visit). Stop being a wimp.

What is a holiday? At the very least, it's the official list of "bankers' holidays" for your state. Here is a list of Federal Holidays - note that it doesn't include things like MLK Day (that's an enlightened state thing) and any of the Jewish holidays. This is the only grey-area in this arena, imo - if the physicians and patients in your area happen to celebrate Yom Kippur, for example, I'd bill an extra code for patients you see during that time. If every one else is working, though, it's a hard sell. Celebrating Election Day or Inauguration Day or Halloween or May Day - not so much.

Finally, patients forced into your schedule. This really is obvious 99% of the time - if the treating the patient in question disrupts your existing schedule then you are on the board. Walk-ins who pop into your sick blocks don't count. The mom who insists on being seen today for an hour in your waiting room doesn't count. These are for the accidents who rush in the door and the asthma attacks who pull you out of the room you are in.

Great, these are easier to use now...give me some real info. I'm going to tease you and hold off on the $$ until next time, but get this:

I realize it's tough to read, so click here or on the picture for more detail.

What do we learn? I'm sorry for the complexity of the graph, but we see that each valid code schedule-based code (99050, 99051, 99053, 99058) is used by more and more PCC clients every year with a fairly steady volume. In my next episode, I'll show you the money!