aap

[Note: Since this post, there are have been major changes to the RVUs. Check more recent posts in this blog, like this one.  You may also want to go directly to PCC's on-line RVU tools.]

First, a sincere thank you to Linda Walsh at the AAP for this update. Linda is like a sharp dagger who cuts through all of the baloney for me when I get confused about some CPT or RVU issue. She must get a dozen questions (or more) a day from AAP folks and always answers them quickly, graciously, and - most importantly - correctly. And she even responds that way to me!

So...race to the URLs below to see the latest information from the AAP about 2008 RVUs, etc.:

• http://www.aap.org/visit/coding.htm
  (AAP public site)
• http://www.aap.org/moc/reimburse/codingrbrvsresources.htm
  (AAP Member Center)
• http://www.aap.org/visit/rbrvsbrochure.pdf
  (direct link to RBRVS Brochure)
• http://www.aap.org/visit/RBRVSConversionSpreadsheet.xls
  (direct link to RBRVS Conversion Spreadsheet)

Here's the most important section from the brochure:

2008 Medicare Conversion Factor = $34.0682 (Note that this is an 11% reduction!)
Additional components of the Medicare RBRVS physician fee schedule factored into the payment structure include the following:

MEI: The allocation of RVUs to pools for physician work, practice expense, and professional liability insurance, have been revised to correspond with the Medicare Economic Index. Work is now allocated 52% of the total RVUs, practice expense is 44%, and professional liability insurance is 4%.

HPSA: Incentive payments for physician services provided to patients in Health Professional Shortage Areas (HPSAs), which are medically underserved communities, urban and rural locations that have a documented shortage of medical professionals.

Non-Par Physician: Reduced payments for physicians, called “non-participating” physicians, who do not accept “assignment,” the Medicare approved amount that consists of the 80% Medicare payment and the 20% patient co-payment, as payment in full for services rendered to Medicare recipients.

Budget Neutrality: Statutory guidelines indicate that revisions to the RVUs for physician services may not alter physician expenditures within the Medicare RBRVS physician fee schedule by more than $20 million from the principal expenditures that would have resulted if the RVU adjustments were never initiated. CMS normally maintains Medicare budget neutrality exclusively via annual adjustments to the Medicare Conversion Factor. However, in 2008 the Medicare program will additionally apply a separate budget neutrality adjustment factor to the physician work RVUs to ensure Medicare budget neutrality in light of work RVU increases tied to the 2005 Five-Year Review.

By the time any reasonable person reads this, I will be giving or have given a talk at the local AAP VT Fall meeting here in Burlington. I am quite flattered that Dr. Aakre thought me capable of being sandwiched in among the likes of Drs. Barry Heath and Wendy Davis. My talk will be something along the lines of "Preparing for a Pediatric Electronic Health Record." I won't give away all the best lines, but the opening slide reads something like this:

The single biggest and most common mistake practices make when
choosing an EHR is to learn what they need after they purchase
the system.

The second most common mistake...

You'll have to ask me for the rest of that sentence.

Meanwhile, we are working with Dr. Lander and the helpful SOAPM admin folks (shout out to Heather to see if she's reading) to figure out where and what to do next after our kick-butt pediatric coding and practice management event in NYC in August. In addition to a practice management and clinical event our massive UC in late July, we're considering doing two more all-day events (with the same and additional speakers - how can we turn down Lander, Harbaugh, Tuck, and Bradley?!) and perhaps some 1/2 day events.

One of the first considerations in this process is where to do them. Using a cool map that I helped SOAPM put together to show the locations of all their members - Google is the coolest - we have a couple places in mind:

• Washington DC / Baltimore / Alexandria (somewhere in there)
• Cincinnati
• Detroit / Buffalo / Rochester
• San Francisco / Seattle
• Philadelphia

Here's what we're thinking:

The DC-metro area has a lot of pediatricians and, in particular, a lot of SOAPM folks. Plus, it's a family-friendly place. And maybe I'll stop by Volker's place and have the best beer in the world. We're looking there for an April meeting.

Cincinnati is smack in the middle of a lot of small hot spots and part of the country that the AAP and other educational resources often passes over. We have customers it would reach, too, which is always a bonus.

I don't know if Rochester will support a full-day meeting (~60-100 people), but we do have an amazing location and, though I haven't asked her yet, the support of Dr. Francis. I'm definitely interested in doing at least a 1/2 day there.

San Fran seems a little redundant, considering everyone was just out there, but we may get some local support and there are lots of pediatricians. Alternatively, we will shoot for Seattle, another corner of the world that doesn't get requisite AAP attention and has a good crowd. It would be a lot less expensive to simply stick to Philly, but we can't ignore the west coast.

Why do I ramble about this? Besides it being my nature, I'm looking for feedback and comments. You want the best Pediatric Road Show in your town? Let me know.

Announced by SOAPM and the AAP today:

United Healthcare (UHC) announced today that it will implement its Preventive Medicine Policy effective December 8, 2007. UHC will now pay for both a preventive medicine E/M service plus 50% of a problem-oriented E/M service when the problem-oriented service represents a significant, separately identifiable service and is submitted with modifier-25 appended.

The AAP has advocated for separate payment for both E/M codes and expressed dissatisfaction with UHC delays in implementation. Because of the advocacy of SOAPM members and others, UHC will adjust all
affected claims with a date of service as far back as October 15, 2007. Physicians will not need to adjust any of these claims as it will be done automatically.

Dr Lander and others will contiue to watch this situation closely to ensure that UHC abides by its commitment.

It's lame that they are only paying 50% (totally not CPT kosher), but it's a start. And, do we really think that "...Physicians will not need to adjust any of these claims as it will be done automatically"?

Still, good work Dr. Lander.

I didn't think I'd have time this morning, but here's what I can do in 15 minutes:

• Bright Futures 3 was released yesterday, officially.  I will get the press release when I remember to track it down.  This isn't Bright Futures of old, this is the new gold standard for preventive care.
• In a related matter, we have an unofficial, informal agreement with our first EHR beta-tester.  Whoo hoo.  IIRC, we'll be installing right after the winter holidays.  Sure, plenty of people have played with the program from our design site, but this will be real.  Cool.
• Dinner last night with 30 customers and friends was a great time, though too much like a wedding where you can't possibly spend time with everyone you want.  I did hear from a number of folks that the speech by James Heckman about the economic impact of early development (vs. later intervention) for children. I regret not seeing it - if anyone knows where to get a transcript, please let me know!
• I also regret not being able to attend Drs. Lessin's and Harbaugh's discussion about growing a practice.  If only to heckle them :-)  I cornered poor Dr. Zarin about it later and then Dr. Lessin appeared to pitch in.  It sounds like it, too, was an excellent talk.
• I also heard some pleased amazement that Dr. Berkelhamer's address mentioned SOAPM directly.  Also cool.
• Ran into Dr. Ginny Marcus who was instrumental in the success of the recent Imms Registry meeting we helped with at the AAP recently.  I thank [fill-in-your-deity] for active AAP folks like her.

Whoops, gotta' run to the convention center!  See you there!

How's this for breaking news? Here's a sneak phone-camera shot of Dr. Lander presenting a well deserving Dr. Francis with the Buzzy award.

Quite a day.

• We all heard the great news (though overdue) about United and the -25 modifier from Dr. Lander. I'll get the official announcement shortly and post it. Great work.

• The presentation and acceptance from Dr. Francis was wonderful. We are very proud and honored to sponsor the award.

• Wow, the SOAPM room was full of friends and family. I had a chance to say hello to Drs. Lessin, Lander*, Sutter, Stoller*, Simon, Cain*, Bienstock, Craig*, Schaffer, Katz, Oken*, Bradley, Shenkin, Pillsbury*, Diasio*, Khort, and many more - I can't forget Lynn Cramer* and JR Vaught*. (* = PCC client).

It has been interesting to me, as an outsider, to witness the maturation of SOAPM over the last few years. They are clearly on the verge of something great, but they are also struggling with some social management issues that any organization of its size and energy has. They have to do decide what they want to be, where they want to go. It will be interesting.

During some of the conversations (with the AAP board, the medical directors), a number of folks kept referring to medicine as a "market based system." The implication is that the "market" decides what pediatricians are paid. Adam Smith would turn over in his grave - pediatrics is may be a market, but it's not a free market. In a free market, there are not protected monopolies. Information moves freely. Consumers have choices. Consumers understand the value of their decisions. That's not true when it comes to medicine, especially caring for kids.

Drs. Oken and Shenkin both made very good, insightful comments that weren't given enough attention, imo. The former was, essentially, pushing hard on the market conditions pediatricians face (I've heard him ask the same questions every year and beg that he not stop until they are answered). He's the one who, like me, keeps pushing for a standard for payment levels for pediatricians - and I thank him for it. Dr. Shenkin mentioned the concept of Facebook/MySpace for SOAPM and a lot of people chuckled...but couldn't be more correct in his thoughts about where the group should be looking in the future. Sure, it would seem silly - at first - for the AAP or SOAPM to have a Facebook entry, but the more you think about it, the more sense it makes. Especially if you actually try to navigate the AAP site.

Finally, the line of the day came from one of the managed care executives. I don't mean to speak out of school here, and who actually said it doesn't matter, but can you beat this message come from the payers themselves?

"If you don't like what someone is paying you, don't sign the contract."

He was right.

My meeting with the Pediafed folks was fascinating! I'll have some more to report in the not-too-distant future, I suspect, but it turns out that we have more common goals than I originally understood. One thing that impressed me was how, when I described the challenge of figuring out which of the different buying groups made sense for our customers, they were very open to making the details of their offers available so that smart practices can compare!

Sadly, too many practices don't do anything at all. So, here's my $50,000/year piece of advice: if you are not presently in an immunizations purchasing group, JOIN ONE. If you're in one, call Pediafed to see if they make sense for you. I can't judge, obviously, but the call is free. I had dinner with the doctors from four different practices last night, and two of them don't belong to buying groups! They know better, but just get "too busy" to deal with it or distracted by something else. But we're talking about tens of thousands of dollars a years, maybe more!

Meanwhile, I was told, yesterday, that the AAP is putting together a "shopping list" (my words, not theirs) of the various buying groups and assembling information about them in a central location. Cool.

In addition to some mutual projects we are both considering, Pediafed told me about docsbuyonline.com, their expansion into the medical supply business. Again, if your practice is paying list price on anything from exam table paper to office supplies...stop. Pediafed, Physician's Alliance, someone will take care of you.

I know it's only Saturday, but I have two huge news items (one involving our favorite MCO and another involving pediatric clinical content) that I have to sit on until Monday. Both good news.

More later, as I sit through the SOAPM meeting.

I am in San Fran, getting ready for tomorrow's AAP NCE meeting. Well, many of the meetings have already started, but the big exhibit hall doesn't open until tomorrow. I had hoped to pick up some of the PCC crew at the airport, but I have a lunch meeting with my friends from Pediafed that will conflict instead.

If you are in town, email me (chip @ pcc dot com) or meet me at our booth (#1519). We are going out to dinner every night, so come join other interested folks.

I mention Pediafed because I am always surprised by how many offices I meet who are not part of one of the many different immunization buying groups. Pediafed, Main Street Vaccines, and, in particular, Physician's Alliance (I'm sure there are others and I know of at least one that should be starting soon). I think I'll do a little detailed piece on them soon! Physician's Alliance has been particularly helpful to us and our clients over the last year and they do a lot more than just vaccines. Go, Bob!

Meanwhile, I will attempt to "live blog" from the NCE over the next few days with my pithy comments and observations. I'm sure you'll be riveted.

Oh, here's a fun email I received:

When I told my billing staff yesterday that we probably would be sealing a deal with OXP/UHC shortly, they said many of our patients had already switched to other plans, "just in case." Our letter was like a last straw for them because so many of their other doctors had already dropped Oxford/UHC (or were about to).

Yes, you can blog that .

This month's AAP News has some great news and some congratulations are in order to some PCC friends and family.

First, Dr. Richard Tuck won the District V Vice Chairperson position. Wow! I can't think of a better person to lead a district.

Second, Dr. Phyllis Cavens won the 2007 AAP Local Heroes award. To quote: "Dr. Cavens leads the Child and Adolescent Clinic, a private practice of nine pediatricians, four pediatric nurse practitioners and 55 employees that cares for 20,000 children in southwest Washington. The group provides access to all children regardless of their insurance status. Besides her work on behalf of children in her community, Dr. Cavens has led medical teams to treat victims disasters in Cambodia, Ethiopia, Somalia, Mexico, Uzbekistan, Moldova, and Honduras." Awesome work.

She also does a killer talk about chronic disease management. Er, not a killer talk, you know what I mean.

Third, Dr. Anne Francis was recognized with the 2007 Charles "Buzzy" Vanchiere Award (sponsored by PCC, of course). "Dr. Francis is the managing partner of the Elmwood Pediatric Group in Rochester, NY...Past chair of the AAP Section on Administration and Practice Management executive committee, Dr. Francis chairs the AAP Private Payer Advocacy Advisory Committee. She played a key role in the launch of the Practice Management Online and continues to provide information on best business practices for pediatricians." Well deserved and rewarded even for PCC to see her win.

I'm also personally delighted to see Dr. Tayloe win the Presidency position after witnessing his behind-the-scenes effort to help someone over on PedTalk. The details aren't important, but I was blown away by the time he took to help a practice manager and an ill child from another state.

Congratulations to all.

At the annual AAP NCE meeting in SF next week, we'll be eating and drinking a lot as usual. We'd - and I! - would be delighted to see you if you're there. Even better, if you're a SOAPM member, make sure to come to the (now) annual SOAPM "informal" gathering. Below, please find two invites to food in San Francisco - how bad can it be?

Invitation 1:
* Join Us For Dinner on 10/28*

Will you be in San Francisco for the AAP National Conference and
Exhibition October 27-30? If so, what are your dinner plans for Sunday,
Oct. 28?

PCC will be hosting a PCC client, friend, and PedTalk member dinner on
Sunday, and we would love to see you there! We plan to make a dinner
reservation for 8 p.m. that evening.

If you would like to join us for dinner on Sunday, (or on another night
if Sunday does not work for you), please RSVP online:

http://survey.pcc.com/aapdinner.html

If you have questions, please contact Scott Child or Sarah Bunning at
1-800-722-7708, option 2. If you can't join us for dinner during your
stay in San Francisco, please stop by our booth (#1519) in the AAP
exhibit hall to say hello.
Invitation 2:
Join your fellow SOAPM members at the National Conference Exhibition
(NCE) in San Francisco for what is becoming the annual SOAPM informal
gathering. The information for this great social event is as follows:

What: SOAPM social gathering
When: Monday, October 29th
Time: 6:30 pm - 8:30 pm
Where: TWO, 22 Hawthorne Street, San Francisco, CA

This event has been generously sponsored by the Physician's Computer
Company (PCC).

Please RSVP to me (Heather Fitzpatrick) off-line at hidden@email-address
NO LATER THAN SUNDAY, OCTOBER 21ST. This will help give us a rough idea
of the numbers to expect.

I don't think this is archived on the AAP WWW site, yet, but the Private Payor Advocacy group just released the following:

1. Clarification on UnitedHealthcare (UHC) audiological and vestibular function testing policy

As reported in its September Network Bulletin, UHC is dropping CPT code 92587 (Evoked otoacoustic emissions; limited (single stimulus level, either transient or distortion products)and previously had dropped CPT code 92586 (Auditory evoked potentials for evoked response audiometry and/or testing of the central nervous system, limited) from this policy. Removing the codes from the review means that the claims for newborn hearing screening will be paid with either of those two CPT codes (92586 and 92587). Claims for these two codes will not be denied payment subject to the UHC policy. The policy lists certain CPT codes that will be paid if they are linked with certain diagnoses. However, CPT codes 92586 and 92587 are removed from the UHC policy meaning that for purposes of claims payment, they do not need to be linked to the certain diagnostic codes listed in the in UHC policy. The AAP coordinated pediatric input to UHC to revise this policy and UHC made the change given the prevalent use for screening purposes in the pediatric population.

The important part reads:

...claims for newborn hearing screening will be paid with either of those two CPT codes (92586 and 92587)...they do not need to be linked to the certain diagnostic codes listed in the in UHC policy.

Good news! And good work, PPAC!