Posts tagged with immunization administration

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 35-46°F

      • Maintenance of a freezer temperature of +5°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:

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.

Item 1:

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.

Item 2:

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
and DTaP).

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.

• First, about UHC. Rather, I should say, “It’s about time, UHC.”  Although I suspect their excuse is, technically, true, it’s totally bogus for them to pretend that they didn’t realize what is going on.  Sure, this is good news and I applaud the AAP for keeping up the fight.  But ask yourselves this: if so many of these pediatricians are tied to 2004 (before the big imms admin jump), how did UHC calculate the values of the 90465 and 90466 which did not exist in 2005 and never existed with the lower RVU rates? Obviously, UHC made a deliberate decision to lock peds into 2004 during their big push to get everyone on RVU-based schedules, because it saved them millions of of dollars. DUH.
• Whoa, Humana.  A couple things:
  • ASP!  Finally!  Someone using data that’s at lease close to what the pediatricians pay.  Crazy talk.
  • Even crazier: Humana will pay extra - and decently extra - for combo vaccines with 4 or more components?  <thunk> I just passed out.  Sure, the imms admins are rolling towards counting antigens anyway, but Bravo Humana! for doing the right thing in the first place.  There is no longer an incentive for docs to avoid the combo vaccines (children throughout the country rejoice).  Good medicine.  Who made this sensible decision and, as a result, should fear for his or her job security?
  • Craziest: Humana pays for telephone care. I broke the boldface out for that line and went back and highlighted other things as a result.  What has gotten into these people?!  [I mean that in a good - no, great - way.]  It’s official - a national payer will cover telephone codes.  Awesome.

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:

•  An official study indicating that the use of an EHR can improve primary care and supports the Medical Home model.  This is something our clients have known for 25 years.
•  Again, the MGMA tells us that "Medical practice revenues fall."  At first, I was ready to write a long diatribe about how the MGMA is getting wrong, but I see that pediatricians had by far the biggest increase in revenue after costs from 2007 -> 2008 (9%!).  This is much more in line with the data we see at PCC.  Whew.
• Oxford has sent out the scary "you can't be a boutique practice and contract with us" message.  It's too bad that my conversations with "boutique" (such a bad word) practices involving Oxford always concludes with, "...and we can finally stop dealing with Oxford and United!" [The Verden Group alerted me to this one.]
  

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+.

Interesting stuff.