pediatrician

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

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.

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.

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.

The blog is going to be thin this week because I'm dawn to dusk at the Users' Conference. Today is our official Practice Management Conference and I still have to get my "keynote" speech together within the hour! Time to get out of my bathrobe.

It has been a pleasure seeing all the familiar faces, many of whom have posted here. One insight that I am brooding on is the growing focus on Medical Home/Chronic Disease Management/etc. I think there is a opportunity for a consultant to help practices develop effective Chronic Disease Management plans and connect them to the money in a way that benefits practices and the patients. Of course, the practices can do this themselves and it would be great if the AAP could map out a few examples (we did a good obesity/BMI one in class yesterday).

I also heard from an old friend yesterday who happens to be nominated for AAP President. I really like her ideas related to improving the media-savvy of the AAP, a concept that is loooong overdue. Anyway, check out Dr. Kraft's WWW site and consider voting for her! I am a strong proponent of having real, practicing pediatricians in key positions like this and it's nice to see we might have a chance to extend that streak.

If you missed it (and I suspect many pediatricians did), Congress surprised many and actually overrode Bush's veto of the Medicare fix. Without launching into a never-ending note about how things really should be done here, at least, is a good summary of what the effects will be on the pediatric world:

Yesterday, both the House and the Senate voted to override President Bush's veto (please see his message attached) of the Medicare Improvements for Patients and Providers Act of 2008.

It's not too soon to look ahead to 2009 to see what's in store for pediatricians as a result of the CMS machinations. I've ignored, as you can see, the drama over the last few weeks related to the scheduled Medicare fee cuts - there are plenty of places you can find that news. However, I have the opportunity to share some notes to the AAP's Coding and Nomenclature Committee about what they are seeing. I've edited or reduced the information and highlighted some important (to me) points, so please blame just me for any miscommunication, etc.

• "...CMS is proposing to exclude the clinical staff times when calculating the 2009 PE RVUs for the immunization administration codes...the potential increase in PE RVUs that we had been expecting will be negligible, if anything."

  The clinical staff time in question includes time spent entering data into an immunization registry, logging temps, etc. Given that this time demand has exploded for some offices, it's pathetic that CMS doesn't understand what these practices are going through.

• CPT 99174 (Ocular Photoscreening) should get PE and PLI RVUs.
• There is a scheduled 5.4% fee cut. My bet is that is sticks - things are going to get worse before they get better.
• The 1.000 GPCI floor will be removed. It's been threatened before, but I also think it will stick. This is a big deal that will add up to an additional 5-10% cut, iirc, for some places.
• "Per CPT copyright release restrictions, new codes are not able to be included in the proposed rule (since its publication pre-dates the AMA's release of new codes via its CPT manual). Therefore, we will not know how CMS proposes to value the new expanded age PICU codes or the ESRD codes until the final rule comes out in November."

  I want to see if I have this right: because the AMA wants to protect its ridiculous CPT copyright (including the non-copyrightable RVU values), its own members - and the affected public - cannot actually learn what our government is going to do with some federally mandated codes until the AMA has time to publish its book. I can't believe that this was in the spirit of the copyright law when it was written and I have a hard time believing it's actually in the letter of the law, either. Someone lend my the $500K+ it would take to fight that lawsuit and I'll get right on it. The money the AMA receives from their licenses ($70m/annually, when they last told me) is worth more to them than doing the right thing.

Enough of my ranting. I have to go prep for CCHIT. What can a lowly pediatrician do? Make sure your contracts are locked into a specific year of the RVUs. I prefer 2005->2007, myself.

As promised, here's a glimpse into the Care Plan Oversight usage among PCC clients from 2006 through April 2008.

They used the code twelve times.

No, not per month, per client, or even per year. Twelve times, total, among all our pediatricians.

Now, this isn't an enormous surprise. It's a largely unknown and misunderstood pair of CPT codes which gained RVU values, finally, in 2007 (1.89 and 2.64, respectively, compared to a 213's 1.68). But what folks don't realize is that it pays, at least in my small sample, and pretty well at that - between $65 and $85. That's money that you don't get now for doing work that you are often stuck doing.

How about some links that explain how to use these codes properly? Here's a nice list:

• What the AAFP says
• What the ACP says (at the bottom)
• Perhaps my favorite, a piece from the AAP/Medical Home/CSCHN folks (includes good forms)

The tricky part, with this code, is tracking the time. Once you cross 15 minutes, per month, you have the 99339. Over 30 and it's a 99340. So, you don't want to pull the trigger too early each month because you never know when you're going to have to get back on the phone. Perhaps the best thing to do is have an end-of-month run through of your patients who need "oversight services of children with special health care needs and chronic medical conditions."

Time for a new poll.

After the third request for these this week, I figured I'd post them to the blog. They're text instead of PDF for easy cut-n-paste action, imagine that. The supposition here is that this is to an insurance company you really don't want to get rid of if they'd only treat you properly. And these are sent as far in advance of your termination as possible.

Letter #1 - To the Patients

Fred and Wilma Flintstone

1 Main Street

Bedrock, NJ 05696

Our files indicate that your family has health insurance coverage through Bedrock Health Insurance. Regretfully, we have terminated our contract with this insurance company effective July 1, 2008. We will continue to be contracted with HealthCare Insurance, BCBS, and Tourists HMOs.

[If you want to explain why, it goes here.]

We have chosen to notify our patients' families to ensure that you are able to effect necessary changes. Notices from your insurance company can often be difficult to understand, so please call our billing department at 802-846-8177 us if you need assistance. We will be happy to answer any questions you may have. You may also wish to contact Bedrock direct at 800-456-789 or customerservice@americare.com. [Insert other direct contact information here.]

Of course, we will gladly continue to be your family's pediatricians unless you choose to transfer to another provider. However we will no longer be able to submit claims to Bedrock on your behalf. There may be options for you to change plans as some employers have several plans for you to choose from. Another option may be to submit your paid receipt for for reimbursement by Bedrock; we will be happy to help

We hope to continue as your children's pediatricians and we will endeavor to make all efforts to assist you in receiving uninterrupted care. Please do not hesitate to call us with any questions or concerns.

Pediatric Associates

[use the names of the docs, not just the practice name]

Letter #2 - To the Employers

Betty Rubble

Human Resources

Acme Gravel

Bedrock, NJ

Dear Ms. Rubble:

During the past 2 months, our practice has been in negotiation with Bedrock Health Insurance over matters related to their lack of appropriate reimbursement and high administrative costs. Unfortunately, these negotiations appear to be at an impasse and we have terminated our contract effective June 1, 2008.

Our records indicate that we provide important pediatric care for over 60 children whose parents are employed or otherwise contract their insurance through your company.

We are contacting Acme Gravel for two reasons. First, we would like you to be aware that Bedrock does not represent a wise partner, at least for a practice such as ours, and we believe that feedback is important to organizations choosing health insurance solutions for their employees. Second, should our negotiations fail, we do not wish to surprise you or your employees whose children we see with the news that we are dropping Bedrock.

Although we will make every reasonable effort to transition those families who would switch pediatric coverage to another practice, be assured that the disruption to you and your employees may be significant.

Please contact us at any time if you have any questions or concerns.

[this should definitely be signed by the physician who treats the most kids for this company]

Share and Enjoy.

We all knew this already. Here's another study showing Pediatricians a distant last in the income category. It's Fierce HealthCare's take on a WSJ Blog.

If you really want to make the bucks, primary care isn't the way to go. That fact was underscored this week by a study from staffing firm Merritt Hawkins & Associates, which noted that while internist pay topped out at $176,000 annually, and family practice doctors at $172,000, nurse anesthetists recruited by the firm were making average salaries of $185,000. (Anesthesiologists averaged $336,000 per year.) Other Merritt Hawkins high earners included cardiologists, averaging $392,000 per year, radiologists, at $401,000 and gastroenterologists, at $379,000. Pediatricians, in contrast, were pulling down a relatively modest $159,000.

I suspect that if you were to find the median salary for pediatricians, it would be even lower. Queue deep sigh, now.