pediatric

I've written extensively about 96110 usage among practicing pediatricians in the past and wanted to provide an update for 2008/9.

I have to make it brief because today is my pesto run day. [See below for explanation.]

For a few months, I have hinted from time-to-time about some changes that we're making at PCC related to this blog. Even though we expected to be done in June, we're only now broaching the unveiling of our new pediatric resource. What the heck am I talking about?

For years, pcc.com has been a challenge because we have mixed our business information with our "community" resources in a way that makes it difficult for folks who don't know us well to understand what we do and how we keep our meager company in business. Some of those resources - especially PedTalk - have made it very difficult to work on our WWW site (PedTalk has GIGAbytes of archives to maintain and attracts tens of thousands of people a month).

We realized that, for the better of both our business AND the pediatric community, we needed to split the two. Have pcc.com focus on our core business (pediatric software, consulting) and create a new site - with new and different tools - to create the best on-line pediatric community in the world. Like Winston says at the end of the first Ghostbusters, "We had the tools, we had the talent!"

More concretely, the plan is: move PedTalk, the various PCC resources (pediatric benchmarks, form letters, white papers, etc.), and this blog over to a new site and allow the community to contribute. Take advantage of the many new community building resources available that were not around when we started PedTalk. And see what happens.

Like I said, the door isn't open yet...but I'm allowing blog readers a SNEAK PEAK. That's right. If you want to see where we're headed in a week or two, check out PedSource! You can't sign up yet - in fact, please don't. And you'll see lots of little things that we're cleaning up - we're not open yet for a reason. And most of the goodies require you to log in, but you can't yet. But you'll be able to get a good sense of where this blog will be in a few weeks (don't worry, I'll make sure to minimize any changes you have to make). Yes, it's going to remain free - PCC is stupid that way. Check it out, get ready, and sometime in September, expect a big change!

What's pesto run day? My family belongs to a local community farm that raises, among other things, a lot of basil. Every year, I make a few giant pesto batches and freeze them. Frozen pesto is about 95% as good as super-fresh. At least it seems that way when it's -20F in January. Today, I figured I'd whip together lunch for the rest of PCC while doing so - in theory, all I have to do is cook some pasta and slap it on. Oh, here's my advice: most pestos call for pine nuts. They're good, but they're also $20+/#, often. My Vermont/Irish cheapskate kicks in and I have discovered that much-less-expensive CASHEWS not only work well, but are more interesting. You don't end up with a overpowering-cashew taste at all, just a sweetness like the pine nuts.

Now, exactly how many blogs do you know combine such high level pediatric practice management advice with cooking tips? Tell your friends!

Off to the farm. I'll have to fight mosquitoes, but it will be worth it.

Thanks to my new bf at the AAP (to whom I am significantly indebted), here is a copy of the AAP's response to the proposed RVU changes for 2009. I wrote about this a few weeks ago and would like to remind you all that you have one more day to get your comments in about the immunization admin disappointment. Copy the language in my previous post or here, it doesn't matter. Just get that letter in - pediatrics will continue to get the short end of the stick until we all stand up to be heard. I received some excellent examples of letters our clients sent...keep up the good work.

Some good data coming shortly about overdue physicals.

I just realized that today's post represents a milestone: 200 entries! Who knew? I started this blog as a lark and it's gotten to the point that if I don't write something every 3 days, I get backed up with too much important information. According to my blog stats, I get just under 2000 unique visitors every month (obviously many more visits than that, total, as most of you come quite often) with dozens of new people every day.

I really appreciate the comments and feedback I get - nearly everything I share comes at someone's request (see below). Please keep them coming. Enough about that.

At our Users' Conference a few weeks ago, Donelle Holle asked our audience about their 99239 usage. You know, the Hospital Discharge Day (>30 Minutes). And if Donelle Holle asks about it, we should listen. Apparently, most of you use the 99238 code when, in fact, you spend more than 30m related to that patient on the discharge day. So Igor dutifully checked and came back with some interesting data. Since 2003, our clients have performed approximately the same number of 99239s every year...given that our customer base has grown during that time, the implication is that the same small number of practices are using the code. Probably very little new adoption.

We learned that the 99239 pays about 20-30% more than the 99238 (which makes sense) and that the 99238 gets used about 10-20x more often than the 99239. Are your discharge days <30m 20x more often than they are over 30m? Perhaps so, but Donelle's hunch that providers may not be aware of the 99239 looks may be correct.

For some reading about the 99239 CPT, this provides a good summary (click through the license bit).

In my final installment from Bonnie regarding screening payment challenges, here is a sample Vision Screening Waiver used in a Real Live Pediatric Practiceâ„¢ with success. We have already reviewed an Audiogram Appeal Letter and a Typanometry Appeal Letter. Here is the document you can use to pre-empt all the trouble.

As before, the text is below, but you can also download it in OpenOffice, PDF, or Word format.

Your Practice Name

Address

City, State ZIP

Phone Number

VISION SCREENING

Patient Name: ________________________________________________

Every child needs a periodic vision examination, which something we provide here in our office. Your insurance company might pay part of the fee for an ophthalmologist or optometrist to check your child's eyesight, but you will likely have a co-payment. Insurance Companies often will not pay us for the vision screen but you have already paid your co-payment.

We care for you and your children, but just like the ophthalmologist and optometrist, we have expenses and cannot provide this service for free. We will provide this service for our standard fee or you may take your child to an optometrist or ophthalmologist instead. Our fee of $X0.00 compares to an average Optometrist fee of $X+0.00 or even an Ophthalmologist fee of $X+++ to $X++++ per visit. Even if you are covered, you will probably have a co-payment.

We are more convenient as you are already here and we do a good job but, we respect and support your choice. Please understand that if we provide this service and your insurance carrier elects not to pay us then you will be held responsible for the standard fee listed above.

Please select from the following choices:

_____ Please check my child's vision at today's visit. I understand I am responsible for the $30.00 fee if by chance my insurance carrier does not cover this service.

_____ I do not wish for my child's vision to be checked at today's visit. I will take my child to an Ophthalmologist or Optometrist soon.

Parent Signature: ___________________________ Date: __________

Enjoy - and thanks again to our friends in San Antonio! Obviously, if anyone else has appeal letters or waivers they'd like to share (with or without attribution/credit), send them along.

A little while ago, someone bravely asked to see 99174 usage data among pediatricians.

For those who aren't family, the 99174 is new in 2008. To quote the CPT book (but not enough to attract the ire of the AMA), the 99174 is "Ocular photoscreening with interpretation and report, bilateral."

So, waltzing into the massive PCC database, we find...no instances of the 99174 among our clients. None, zippo, nada. That doesn't help! Therefore, I turn to the new poll on the left. Anyone here using the 99174? Getting paid? Tell us more. The code itself is scheduled to get more/better RVUs in 2009, so perhaps it's time to pay attention.

Thanks.

As promised earlier, here is an excellent version of an appeal letter for bundling of the 92567 CPT code (Typanometry).

I will include the text of this one below, as well as PDF, OpenOffice, and M$ Word versions. Thanks, Bonnie! Great stuff!

Blue sky? Check.

Clear lake? Check.

Super slow Internet connection? Check.

New digital camera dumped in the above lake? Check.

As promised, and not threatened, I am on vacation this week. Was just in Seattle (had a blast) am now in McCall, ID for a few days. Will head to Sun Valley shortly and then back to Schenectady, NY for my Grandma-In-Law's 100th bday. Whew.

I have another appeal letter to post (Tue/Wed), but I thought I'd send these two items along before that. Dr. Stoller shared this first one with me (and if you were a SOAPM member, you'd already know about it). Apparently, there is some confusion related to FluMist distribution and here we have, from the proverbial horse's mouth, the scoop.

Hello Dr. Stoller,

I hope all is well. As you may have heard, MedImmune is very pleased to have begun shipping our initial lots of FluMist for the 08/09 season. Currently we have shipped 500K doses to our distributors for dissemination to pediatric offices. Unfortunately, some offices have logistical concerns with the early release of product. As a member of the SOAPM committee I wanted to provide you with the details of our replacement program should you receive questions or communications like the one below.

Because FluMist does not contain a preservative, two of the initial lots will be set to expire in mid-November. Offices with private doses that expire before January 31, 2009 will be able to replace unused FluMist doses through their distributor provided that they notify the distributor before January 30th 2009. This virtually eliminates the risk of wasted FluMist doses due to expiry before the replacement date. I say virtually because the distributors reserve the right to round down the replaced doses to the nearest tenth. For example, if an office were to take in a portion of their doses now but were unable to use 32 doses before expiration, they will be able to replace 30 doses with their distributor.

Fortunately, many pediatric offices see the value in being able to immunize their patients during the summer months and school physicals. This opportunity also allows NJ pediatricians to better address the State mandate for children entering licensed preschool and daycare facilities. The duration of protection demonstrated in FluMist clinical trials also makes dosing during August / September timeframe a safe and sensible option.

Please contact me directly if you have any questions about the replacement program or suggestions regarding how we can help improve the FluMist ordering process for physicians.

Best Regards, Tony

Tony Diorio

Area Business Manager

MedImmune Inc.

The second item of interest comes from AAP Presidential Candidate, Dr. Kraft:

Vaccinate Your Baby PSA Videos

Two things to note here:

• These are the Amanda Peet videos and can be linked to on your practice WWW page as well as easily distributed to your patients. For those of you who have attended my Patient Education Materials talks, this is exactly the kind of tool I find has a lot of success.
• For the same reason I supported Dr. Tayloe, I support Dr. Kraft now: she is a real, practicing pediatrician who takes time out of her day to get the word out to anyone who might benefit - in a practical manner. Thanks, Dr. Kraft.

Over the next 2.5 weeks, I am on vacation. Sadly, in my pathetic world, that means I will be still reading email and even, perhaps, posting to the blog. In order to stretch out my effort, I am going to run a series of quick appeal letters and a patient waiver related to the recent data I shared about pediatric usage of hearing and vision screens.

The first letter is straightforward, effective, and, in the words of the generous practice who sent it along to be shared (thanks, Bonnie!):

I keep quiet most of the time, but I thought I would respond to your question regarding reimbursement for vision and hearing.

We have been charging for the vision for many years and at one time were being paid something over $10 by a few companies. So many of the ins.cos. bundled it to the office visit. Now we have every parent sign a waiver giving them the option of having their vision tested by us or seeing an eye doctor. If they opt to have it done here and their ins.

does not pay, then they agree to pay $30.

For code 92552 and 92567 we are reimbursed between $18 and $23. There are some ins. plans that show these as "non covered" services and the charge is passed on to the parent. Some ins plans try to bundle the code to the office visit. I have two great appeal letters that work very well for getting them to change their minds. UHC has only certain Dx codes you can use and be paid for the hearing screens.

First - thanks, Bonnie! Awesome. Here is her first letter, in OpenOffice, Word, and PDF formats. A complete Audiogram 92552 Appeal Letter.

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.