Get your letter writing implements out, spread the word, tell everyone you know.
Really. I can't over-dramatize this issue.
I reported the expected pediatric-focused changes to the 2009 RVUs two weeks ago and pointed out how CMS is not planning to add the appropriate value to the PE elements of immunization administration. IIRC - and of course, I do, because I went back and checked - I called this pathetic. Now the AAP agrees, but they are far more mature and constructive in their language.
Here is copy from a draft letter that the AAP plans to send to CMS before the 08/29/08 comment deadline. I have been asked to share this with as many practicing physicians as I can and encourage you to send your comments to CMS in an effort to get them to recognize the significant and growing cost of providing immunizations in this country. You are welcome to use and adopt the points made below.
From the letter, which is not official nor approved by the AAP, yet:
Immunization Administration: Practice Expense Inputs
In February 2008, the RUC Practice Expense (PE) Subcommittee approved the movement of some of the indirect PE into the pool of direct PE inputs for the immunization administration (IA) codes. During that meeting, the RUC approved moving the following, additional PE inputs into the existing pool of direct PE inputs for the IA codes:
For the "initial" codes (90465, 90467, 90471, 90473):
4 minutes RN/LPN/MA ($0.37 per minute) for:
Vaccine registry input
Refrigerator/freezer temperature log monitoring/documentation [2 times per day; logs kept for 3 years]
Refrigerator/freezer alarm monitoring/documentation
17 minutes for dedicated full size vaccine refrigerator with alarm/lock [commercial grade]
17 minutes for refrigerator/freezer vaccine temperature monitor/alarm
For the "each additional" codes (90466, 90468, 90472, 90474):
1 minute RN/LPN/MA ($0.37 per minute) for:
Vaccine registry input
Refrigerator/freezer temperature log monitoring/documentation [2 times per day; logs kept for 3 years]
Refrigerator/freezer alarm monitoring/documentation
8 minutes for dedicated full size vaccine refrigerator with alarm/lock [commercial grade]
8 minutes for refrigerator/freezer vaccine temperature monitor/alarm
In the 2009 RBRVS proposed rule, however, CMS states,"...we are in agreement with the RUC (PE) recommendations...except for inclusion of the clinical staff time related to quality activities for the following immunization administration codes: CPT codes 90465-90474. While we allow this time for mammography services due to the specific regulatory requirements required by the Mammography Quality Standards Act (MQSA) of 1992, such MQSA time is not required for immunization services."
This means that CMS is proposing to exclude the clinical staff times (as listed above) when calculating the 2009 PE RVUs for the IA codes. The Academy strongly urges CMS to reconsider this decision for the following reasons:
1) During the course of RUC deliberations, it was noted that in August 2003, the Practice Expense Advisory Committee refined code 77057 (screening mammography, bilateral (2-view film study of each breast), allotting clinical staff time for "quality services" based on MQSA regulatory requirements. This, however, was not the basis of the RUC's recommendations with regard to IA. It was simply recognition of a precedent for moving practice expenses previously designated as "indirect" into the pool of direct PE inputs.
2) While MQSA does not apply to the provision of vaccines, there are several federal/state programs that require quality assessment for the following immunization services
Vaccine registry input
Thirty states have laws authorizing a vaccine registry. Of those 30 states, 14 mandate reporting (Source: Unpublished data, Immunization Information Systems Support Branch, Immunization Services Division, Centers for Disease Control and Prevention)
One of the objectives of Healthy People 2010 is to increase to 95 percent the proportion of children younger than 6 years of age who are enrolled in fully operational, population-based immunization registries (http://www.healthypeople.gov/Document/HTML/Volume1/14Immunization.htm)
Refrigerator/freezer temperature log monitoring/documentation and refrigerator/freezer alarm monitoring/documentation
The Vaccines For Children (VFC) program requires providers to participate in an annual Assessment, Feedback, Incentives, and eXchange (AFIX) program, where clinical staff visit offices to conduct quality checks, including vaccine temperature monitoring (http://www.cdc.gov/vaccines/programs/afix/default.htm)
The Centers for Disease Control and Prevention has "Recommendations and Guidelines for Vaccine Storage and Handling" (http://www.immunize.org/catg.d/p3035chk.pdf), which include the following:
A designated person in charge of the handling and storage of vaccines
A back-up person in charge of the handling and storage of vaccines
A vaccine inventory log
Maintenance of a refrigerator temperature between 35-46Â°F
Maintenance of a freezer temperature of +5Â°F or colder
A posted temperature log on the refrigerator door where the refrigerator and freezer temperatures are recorded twice a day, as well as notation as whom to call if either temperature goes out of range
A contingency plan in the event of refrigerator/freezer failure
The aforementioned federal/state requirements and guidelines provide compelling evidence for the RUC-recommended clinical staff times for "quality activities" to be included in the 2009 PE RVUs for the immunization administration codes.
All letters must be sent to:
Acting Administrator Kerry Weems
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Hubert H. Humphrey Building
200 Independence Avenue, SW
Washington, DC 20201
Re:Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2009; Proposed Rule; CMS- 1403-P
Those of you who have had to pay for immunization registry interfaces (not our clients, but the rest of you), those of you who - as outlined nicely above - are dealing with fridge management (and I know three practices, personally, who have had this process fail spectacularly leading to $thousands$ lost), or are simply paying to double-enter your registry data should feel obligated to write to Acting Administrator Weems and give CMS an understanding of your daily chores.
Wow, that was long-winded. Sorry. Just send a letter! The deadline for commentary is August 29.
I am in lovely Columbus, OH, about to meet Dr. Lander, Donelle Holle, and some clients for dinner as we prepare for our pediatric coding and practice management event tomorrow morning. We obviously won’t have the crowds we get in Washington or NYC, but it will be a pretty full room still! If you are one of the blog readers, say hello.
Two vital pieces of pediatric insurance information for those of you who aren’t PEDCOUNCIL members or on the SOAPM mailing list.
UHC moves to enhance immunization administration payments
After receiving input from the AAP regarding low immunization administration pricing, UnitedHealthcare (UHC) found the main reason for this is that pediatricians are on contracts with fee schedules tied to 2004 CMS Medicare rates or prior years. UHC reported that, to a lesser extent, it also found that some markets set immunization administration pricing at a lower percentage of the CMS Medicare rates. Most markets are currently using 2008 CMS for physician contracting. UHC has identified those pediatricians whose contracts with fee schedules set at or prior to the 2004 CMS Medicare rates and will be working over the next several months to update the fee schedules and migrate those impacted to a more current CMS year in order to increase immunization administration pricing.
UHC will provide written notice of the fee schedule changes for immunization administration codes in conjunction with other fee schedule maintenance in some cases per the terms of the contract. UHC expects that this initiative will take several months in order to complete financial analysis, complete the revised contracts and mail to physicians, load the new rates and provide the appropriate notice per the contract.
The AAP will continue to dialogue with UHC regarding the timing of the effective dates of the updated fee schedules and to monitor UHC review of its vaccine payment methodology.
As follow-up to a recent meeting with the AAP, Humana has announced that it will revise its pediatric immunization payments, as well as pay for telephone care.
Vaccine payments: As of October 1, 2008, Humana will increase payment for pediatric immunizations that will based on a percent of the current average sales price (ASP). Humana will also reimburse vaccines that are not based on ASP to a percent of average wholesale price (AWP). Details regarding reimbursement on the Humana National Drug and Biologicals Fee Schedule can be viewed by participating providers via the secure area of www.Humana.com ( http://www.humana.com/ ) In addition, for pediatric combination vaccines containing four or more vaccine components, Humana will pay the immunization rate plus an additional $11 to the allowable fee. This would not apply to those combination vaccines with fewer than four vaccine components (e.g., MMR
This reimbursement methodology applies only to providers that have either received written notification or signed an addendum indicating transition to the Humana National Drug and Biologicals Fee Schedule. For more information regarding the transition to the national drug schedule, please contact the Humana contracting representative in your market.
Telephone care: Humana has established processing rules for the new telephone CPT codes 99441-99443. these codes will be processed as covered services; however, the and the plan member will be responsible for standard office co-payments or other cost-share amounts applicable to any other office visit. Medicare does not cover those telephone consultation codes nor does the Department of Defense (TRICARE) so neither Humana Military Healthcare Services (HMHS) nor Humana Medicare will cover the telephone care codes. Only Humana commercial health plans will provide payment for telephone care. Payment for the telephone consultation codes will be based upon the current RBRVS system.
For information on coding and billing for telephone care, see the AAP Payment for Telephone Care Toolkit, available on the PMO at: http://practice.aap.org/telecarepmt.aspx
AAP private payer advocacy will continue to work with Humana and shareadditional details of these payment enhancements.
A lot to comment about.
Honestly, I am going to tell all my friends to choose Human if they can. Not because these dollars make some huge difference, but because it’s a sign that someone in that company gets it and they should be applauded.
More tomorrow, perhaps “live” from the coding conference!
First, some amazing news. I understood that it might happening, but I guess it's official: new admin codes:
The American Academy of Pediatrics (AAP) was successful in obtaining new CPT codes for immunization administration. The new codes will replace the 90465-90468 immunization administration codes starting January 1, 2011 to better reflect the work associated with administering combination vaccines.
AAP will present valuation recommendations for the new codes during the October 2009 American Medical Association/Specialty Society Relative Value Scale Update Committee (RUC) meeting. Final RUC recommendations will be forwarded to the Centers for Medicare and Medicaid Services (CMS) for consideration in the 2011 Resource-Based Relative Value Scale (RBRVS).
I believe this effort is related to the disparity between the payment for a one-antigen vaccine and a 5-antigen vaccine. Rather, there is no disparity between those payments and perhaps there should be.
Meanwhile, the AAP has updated its Vaccine Coding Table. I've hosted my own flavor here (complete with ICD9 info), perhaps I'll update ours.
Buried, which seems to be my status since August. Some interesting items:
Finally, here's the big one today. What is the purpose of the new Swine Flu admin code? It makes no sense to me. Pediatricians are finally getting their heads around admin codes vs. product codes and the AMA races in to create a new product-specific admin code?
It used to be important to distinguish how the vaccine was given - oral/intranasal vs. injection. Now, all that is tossed out just for this one strain of the flu. What's going to happen when some avian strain hits? Or Swine Flu II? Keep adding new admin codes?
I am upset about this because we have two new sets of codes, admin and product, to record the swine flu, doubling the number of codes that will be rejected by the payers when the time comes. Note that I said, "will." But we gain nothing, as far as I can tell, in terms of data tracking...I can't tell how the immunization is given (fat luck comparing efficacies). I don't know if counseling was given or if the recipient us under 9yo.
Someone smarter than I am, and that's most of you, tell me what I'm missing.
I had grand plans to keep track of all the different payers and publicize/shame many of them, but by the time the data came in...it was too late.
Still, how have PCC clients fared with the new H1N1 administration code?
Better than I would have guessed.
The bottom line is that PCC clients averaged $14.90 from insurance companies and $16.73 from patients when they billed for the H1N1. That's actually higher than our clients average for the 90465 or 90471, at least when I looked at it last year.
Of course, the variance is large, but not entirely the fault of the payers. I might look at a state - like AZ - and see that 1/2 of our clients are using the Medicare Code (G9141) and getting paid a penny because they charged a penny...while their neighbors use the 90470 and charge $25 and get paid $20. Same procedure, two very different billing methods.
However, there are clearly some super-lame payers out there. A payer in NY - let's call them United - might pay $25+ to one practice and then $7 to another in the same county.
The clear "winner" for our clients is Tufts, available to folks in Massachusetts, often paying is excess of $40 per H1N1 admin. Many of the payers in New England paid higher than the rest of the country, no question. $25-35+.
I could probably publish a full-time blog just on the materials that The Verden Group produces.
The latest comes from an effort on SOAPM to construct a letter that every pediatric practice should send to ever payor to which it submits claims in order to jump start the process of finding out how imms admin coding will work in 2011. There are a lot of unanswered questions right now and the imms admins codes are the 4 of the most common 5 pediatric CPT codes.
First, the pre-amble and explanation:
Well, this took a little longer than I hoped, but attached please find a template that you can use to send to the CEOs and Medical Directors at the plans in which you participate.
A big THANK YOU to Dr. Jesse Hackell, who assisted me with this and helped create the content (enjoy Paris, Jess!)
In this letter, you will note sections in red – those are the elements that you will need to fill in / modify. For those not too MS Word savvy, double-clicking on the header (where it says ‘your practice name and address here’) will allow you to edit that text and drop in your details / logo.
I’ve also incorporated language regarding reporting HIPAA violations and filing complaint under prompt pay laws for your state (see Jill Stoller’s latest post). If you need to file a HIPAA complaint, you will find information on how to do that here and click on the magnifying glass icon / text on the left-hand side of the page.
PLEASE FEEL FREE to edit the letter in any way you see fit to suit your needs / comfort level.
Next, where and to whom to send the letters? Do a google search for the parent insurance company and navigate to the ‘contact us’ page. You’ll find the corporate address listed there. Send the letter to the CEO to that address. Next, call the corporate number and ask who the Medical Director is for your region and where you can send a letter to them. Usually they will give you this information. For anyone having difficulty tracking down information, we have a (slightly outdated, 2009) dataset but it is copyrighted so I can’t just post the whole thing here. However, I can release portions of that data upon request, so please email me offline with the insurance company for which you need help and we can get that information to you / posted here.
I am looking forward to hearing what responses you receive from the Payers, and how promptly. Hopefully this will prompt them to take immediate action. At the very least, it puts them on notice that you are aware, organized, and willing to take action against them!
Susanne Madden, President & CEO
The Verden Group
My only question about the letter, which is otherwise superb, relates to the AAP's comment that electronic claims have a limit of 8 codes...which they don't. I'd just recommend changing the word "electronic" to "paper" in there.
PLEASE PLEASE PLEASE share any responses you receive!
Oh yeah, here's the letter!
About a month ago, I published a letter written by the AAP that I encouraged dear readers to submit to their local MCOs and other payers in an effort to straighten out the upcoming imms admin debacle in advance. I know that some local AAP chapters have been very active with this endeavor but I suspect that others haven't. I'll bet, sadly, that Vermont has done nothing, for example (I'd appreciate being wrong on that count).
In North Carolina, the Pediatric Society has received not only a detailed response from their massive payor, NC BCBS, but they helped guide some of the answers! For those of you out there without response from payors yet, here's a) proof that it can be done b) proof that you can be involved and c) a template for your use.
As it relates to the definition of "qualified healthcare professional," I am going to work with my SOAPM and Verden friends to create a chart, by state, indicating what I can learn from locals there. More on that in a bit.
Meanwhile, enjoy the NC BCBS response to Imms Admin 2011. Kudus to the NC Pediatric Society and nice response from NC BCBS. Proof that at least one payor isn't all bad!
After bantering around with some SOAPM and PedTalk folks off-line about the impact of the 2011 IA codes, I decided to whip together a quick tool to allow you to compare the potential income difference between the new codes and old. It'll let you compare, say, a kindergarten visits being coded both ways. Or let you compare the impact of a combination vaccine vs. two seperate vaccines (without the product cost/revenue).
There's no layout, it may have errors in it, and you have to use a spreadsheet (hey, I'm in a hurry and I'm slow at Flash). But the price is right and I think it does the job. By all means, input and corrections welcome.
OpenOffice and Excel versions available below.
[Note the continued updates at the end]
I have avoided blogging for over a week as I tear my hair out dealing with the transition to the 2011 Immunization Administration codes for our clients. I am going to name names below and if anyone representing any of these organizations would like to correct my information, I will give free reign to do so, here.
We knew this would be a problem. But even in my most cynical moments, I failed to estimate exactly how far this problem would go.
On the SOAPM and PedTalk mailing lists, we received reports of expected payment on the new codes in dribs and drabs, sometimes in interesting bursts. The AAP did much more than usual to work with payers to find out how they would transition to a new CPT set and SOAPM even tracked the status of some of the major payers. Internally, at PCC, we were also tracking the various messages we were getting from different payers.
At first, the bad news was limited to local reps from national payers giving out some bad, weird advice. I helped straighten out a UHC rep in TX who told one of our clients that the new imms codes were not "appropriate for immunizations that require boosters" and, therefore, they shouldn't be used.
Then, a few big payers showed up trying to game the system. BS of California, which should be using RBRVS-based contracts, says it will pay only $2 for the 90461. BC in upstate NY - $11 for the 90460 and $1.50 for the 90461.
And then it got even more interesting
BCBS of Illinois reported the following:
The specific fees are:
90460 = $29 for firsttime billed on claim, $6 each additional
90461 = $16 forfirst time billed on claim, $4 each additional
90460 = $25 forfirst time billed on claim, $6 each additional
90461 = $13 forfirst time billed on claim, $4 each additional”
Do you see what they are doing here? They are literally changing the value of the code based on the the number performed at the visit. This is in total violation of the HIPAA laws which the physicians are required to follow. Yet, because of how the rules are written, it's legal for the insurance companies to do this. As Herschel Lessin put it nicely: "If we break the HIPAA laws, we go to jail. If they break the HIPAA laws, they go to the bank."
But then it gets more interesting. And this is where I think the Federal Trade Commission and Department of Justice need to take notice.
Our EDI department, in whom I have a lot of trust and faith, reported to us that many, if not most, of the clearinghouses our clients use were rejecting any claims with a 90460/90461. That's right. Even though 100s of CPT codes are changed, deleted, or added every year, the people being paid to manage these things had their programs set on automatic delete. Here's an example of it happening at the payer level.
One particular clearinghouse had what I'd call a lower quality of service response to the issue. Not only will they not expect the codes to be accepted until mid-January, they do not plan to resubmit any affected claims. To make sure I didn't misunderstand their position - which is, essentially, "It's broken, we'll fix it later, you'll have to redo everything" - here's a copy of the email our crew received:
As I indicated previously, we expect that the update will go in mid-January.
Any rejected claims will need to be re-submitted after the update. Availity will not be able to manage resubmissions on behalf of our customers.
Did you catch the name of the clearinghouse? It's Availity. What makes Availity special? Availity isn't simply a clearinghouse. Availity is owned by the insurance companies themselves. That's right - a combination, I believe, of IL/NM/OK/FL BCBS and Humana. Maybe some others.
And this clearinghouse, owned by the insurance companies, is rejecting legallly required claims and not resubmitting any affected claims. Once those claims get through in a few weeks (one presumes), the payers are not following HIPAA/RBRVS rules.
How is this not a conspiracy to defraud physicians?
How can our federal government not understand that this behavior is a huge part of the problem we have with health care funding in this country?
How can these businesses operate with one completely different set of rules from the rest of us?
Someone from BCBS of IL or Availity or somewhere step up and tell me. I have a few thousand pediatricians listening.
In the meantime, what can we do about it? Not much. AFAIK, I there hasn't been a single instance of a payer paying a fine for breaking HIPAA rules. But if we start complaining, maybe people will listen. There is a federal complaint form you should complete. Fill it out. For every one of the 100s of claims you have a problem with (computers make that easy).
Anthem BCBS, which is significantly larger (BCBS NH, CT, GA, IN, KY, ME, OH, VA, MO, CO, NV, WI, and Blue Cross of CA), has the same problem.
We received the following from Availity (01/07/11, 4:30PM).
HCPCS Issue: Claims with new codes being rejected
Availity is resolving a temporary issue involving the new HCPCS codes that became effective January 1, 2011.
Claims filed using the new 2011 codes were rejected by Availity, beginning January 1, 2011. *Availity is addressing the situation and expects to be able to process incoming claims with the new codes beginning Monday, January 10, 2011.*
We will notify you accordingly on Monday morning to confirm that the new HCPCS codes have been installed.
Unfortunately, Availity is not able to re-process any previously rejected claims. *Submitters will need to resubmit any rejected claims once the new 2011 codes have been implemented.*
Please monitor your resubmitted claims to ensure they made it all the way through to their respective health plan destinations, since some plans are similarly unable to process new HCPCS codes yet at this point in the year.
- Availity Client Services
According to our EDI folks, the Availity claims are going through now. 11 Days late, but it's working. They won't resubmit anything.
Update #4: Anthem's "solution" to the problem is slick double-speak. Check it:
Upon a little more digging on Anthem’s end it was identified that the denial of codes 90460 & 90461 was occurring at the EDI gateway and not on the Anthem claim adjudication system. Anthem EDI made the corrections over this past weekend and issued the attached statement to all of our Electronic Trading Partners. Now when these codes are (re)submitted they will pass through and pend (not reject) on the Anthem claim system until the codes are loaded. Once loaded the pended claims will be released requiring no further action on the part of the provider.
In other words: they've now just kept the claims from rejecting at the EDI level...but now they'll just hold them until "the codes are loaded." How nice of them!
Update #5: Availity Calls to Apologize
The folks from Availity reached out to our clients, both directly with an electronic message, and indirectly through PCC to apologize for the problems they had with the new codes. Yes, it's still lame that they couldn't resubmit the claims that were rejected (which creates automatic money savings for their owner/customers), but they did fix the problem and admitted responsibility.
I was also told to pass along the suggestion that ANY time someone has an issue with their service to please pick up the phone and call 1-800-AVAILITY because they want to hear from you.
Here's a little glimpse behind the magic curtain.
Usually, I'll stew at my desk at work or when driving home thinking about some pediatric issue that's bothering me. After a while, if I get some free time, I'll do a little research and see if I can reach a useful conclusion that's worthy of sharing with others. I have a lot of resources at my disposal here at PCC...but, often, I turn to Igor to help me with the research.
Recently, I'd asked him for some data about the immunization admin usage among PCC clients and I think he got sick of waiting for me to review it, so he did it himself. I won't bother rewriting his comments to pretend it's my work, here's Igor! My comments are highlighted.
- 77% (119 of 155) of our pediatric clients use the new admin codes. [Definitely higher than I would have guessed!]
- For the clients who use the codes, most are using adequate prices:
AVG charge amount for 90460 = $38.05 = 166% of 2011 Medicare rates
AVG charge amount for 90461 = $23.22 = 203% of 2011 Medicare rates
- For the clients who are actually getting paid for the codes, most are getting paid extremely well:
AVG dollars collected for 90460 = $19.64
AVG dollars collected for 90461 = $10.48
To put this in perspective, these collection amounts are in-line with what clients were getting for 90465 ($19.02) and 90466 ($11.31) in 2010.
- The catch to all of this is that most clients have some insurance companies who aren't paying at all for the new admin codes. Some practices have had all of their claims held! [We can easily identify the payers who are causing problems.]