rvu

Long overdue, but I did try to get them right. Thanks go out to Donelle Holle as well as Igor and Q who helped check them out before posting.

If you'd like a nice, neat copy, you can download the PDF. I was going to post the entire thing here, but it is much too long. Here is a sample Q/A:

1. What RVU is associated with 99058 (emergency)? Do insurers pay?

The 99058 CPT code has no RVUs. There are, indeed, many insurers that pay the office emergency code however. Of course, payment will vary from one carrier to another – payments are usually between $20 and $75. When using this code, remember to document the fact that the service was indeed an emergency, as we all know that not all walk-ins are emergencies.

Don't forget that we have another AAP-endorsed event scheduled for September!

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.

I don't know how I missed this announcement (thanks, Bob @ PhysAll), but the AMA has embarked on an advocacy campaign specifically targeting the baloney that goes on during the insurance claim submission process. Now this is the kind of work I want to see the AMA doing (instead of restricting the rights of its members and public to use CPT codes and RVUs).

First, check out the home site here. People who like to skip the instruction manual and jump right in, should read the amazing payor report card! I have only two gripes (limited list of payors, small sample size), but their chosen metrics really look great. Did you know that in the 134K payments from UHC analyzed in Feb/Mar in this report, UHC only allowed the proper amount...61.55% of the time? Amazing data.

The AMA also includes an appeal toolkit and pretty good "interactive document" (my favorite part) designed to help you appeal your claims. Though I'm not usually the AMA's biggest fan, this is an excellent start. Good work by them. Between this report card and the one from the Verden Group, you should have plenty of fun at your next insurance sit-down.

As promised, here's a followup to my 96110 data from the other day. It's interesting to see how 96110 usage has increased in pediatricians over the years, but what are folks getting paid? Here's the data:

I know it's hard to read, so click here or on the image to see the entire thing.

So, what do we learn? Back when the 96110 was rarely used by pediatricians, it was paid pretty well ($50+). However, in 2004, CMS first published RVUs for the code and the average reimbursement plummeted. Today (and 2008 projects the same), the average payment is often between $14 and $15...or right about 100% of Medicare for most folks. Given that this is a service many of you already perform - and all of you should! - it's nice to get reimbursed at all in today's climate. Frankly, 100% of Medicare is right in line with average pediatric reimbursement in general - sad, but true - so this looks like it should slip right into the daily expectation of your well visits, etc.

In order to see the total effect of 96110 income on a pediatric practice, compare this with the previous graph...if the average PCC client (who uses this code) recorded 1800+ of them in 2007, that's almost $30,000. Add to this Dr. Stoller's message (and, yes, you too, Dr. Cain!), and you're talking about lots of potential income. Enough to make the effort. What are you waiting for, agian?

Now here's a combination of topics that no one will ever look for. I don't know, for "search engine optimization purposes" whether mixing two items like this is better or worse than writing two quick blog pieces (and pushing content further down the page or into the archives), but I won't worry about it.

First, many of you have noticed that the traffic on PedTalk and the SOAPM lists had died off for about two weeks. You can see why here:

http://web.mac.com/jsstoller/iWeb/Site/2008%20OCI%20Mission.html
http://web.mac.com/jsstoller/iWeb/Site/End%20of%20mission%20fun.html

...this what Drs. Stoller and Lessin were up to from Mar 6 to Mar 19 - their medical mission to Ghana.

Second, some of you are aware of the fight we have had with the AMA over our RVU calculators. You'll notice that this one only contains a subset of the codes (the most important pediatric ones) and this one requires you download the codes yourself. Their argument was that, due to their copyright of the CPT codes, no one is allowed to publish any more than 30 CPT codes (and the accompanying RVU values). We didn't have the $$ to fight them, so no more free RVU calculator that doesn't require you to download the codes yourself. Anyway, I have enjoyed making a collection of WWW sites that publish full RVU/CPT values. The problem is that I keep finding them everywhere. There are literally dozens, if not hundreds, more. I wonder why the AMA has time to threaten PCC with a lawsuit and not all these folks? [Hint: it has to do with Ingenix losing money.]

Those of you who have the misfortune of having spent time with me know that I tell a lot of stories, often more than once. I also use the same punchlines a lot.
One little routine I've inserted into seminars, phone calls, and lunches a thousand times over the last decade is the UHC/Ingenix piece. "Sure, there is another place where you can get some of the data I'm talking about - Ingenix. You know who owns them, though, right?" Very few people have ever known before I told them.

Whew.  They are up.  Want to know what the RVU values for the top 30 codes in pediatrics will be in 2008? Want to check any code?  I finished the Build-Your-Own RVU Calculator for 2008 and the Online Pediatric RVU Calculator for 2008.  Please check my work.

I hope to have time to post a good RVU calculation message this afternoon but, before I do, I wanted to share an excerpt from a PedTalk message this AM.  It comes from Dr. Lessin, with whom I often enjoy disagreeing particularly because we often actually share similar viewpoints.

I think the message below captures a growing vision of pediatrics-to-come, the dismay at the direction of the practice of medicine.  It's like [censored]ens' Christmas Story: this is the Ghost of Pediatrics Future.  Everyone whines about the "good ol' days" in just about any context ("When I was in school..." or "In 1956, the New York Yankees..." or "They call that music?"), but I really think we are heading towards a nadir of satisfaction in this profession unless there are some significant changes.
Anyway, here it is.

Unfortunately, with the emphasis on consumer driven health care, we are  becoming even more focused on what people want as opposed to what they  need.  Hospitals design their systems to appeal to the customer.  That is  good, except when it impedes the doctor's work flow and ability to provide  good care.  Patients come in demanding things that they have read about on the internet.  Sometimes, they are right.  Often they are wrong.  But since we are now a volume dependent business, we are terrified that they will go to someone who will give them what they want.  It is coming down to the fact that we might prescribe that useless antibiotic because the guy down  the street will do it and the patient will flame us on the net if we do not., and complain to the insurer about what an awful doctor we are.  It is a sad state of affairs.  I never thought that this profession would devolve  to the decision between paper or plastic.

Herschel Lessin MD

I don't agree with him 100%, but boy that's an excellent summary of the corner into which pediatricians have painted themselves.  Sure, it's easy to pick on the position he takes here (I think of that awesome scene from Malice with Alec Baldwin), but that would miss the point.

Over the last month, I have had three practices ask me about multi-year contracts.  What do I think of them?

Multi-year contracts can be great.  Why not?  It's one less contract to worry about for 2-3 years.  Presuming you do it properly, of course.  Sometimes, the payors are willing to give price increases over time that you could never get going year-to-year.  In addition to all of the normal contracting issues to consider, here is my general advice when a multi-year contract is on the table:

• Whatever rate you are paid for your multi-year contract should increase each year.  100% -> 110% -> 120% of Medicare, etc.  Obviously, it's more money.  And, obviously, it reflects an expected cost-of-living increase.  But it also means that the starting point in your negotiations 3y from now is higher.  And it's a matter of principle.
• Lock in your RVU year.  In the past quarter I have seen more contracts that talk about the "prevailing CMS rates" than in the previous two years.  Why?  Because all the payors know that Medicare rates are going to get cut.  In fact, as I've pointed out here, depending on your "gypsy," you may already be getting a sizable cut.  So, the smart payors tie you the most recent year because they expect that it will cut their reimbursement 10-20% in the years to come.  So, lock your contract to, say, 2006 or 2007.
• Finally, take this chance to make sure the payor refers to RVUs, etc., and not the "Medicare rates" - the latter language gives them freedom to use the Budget Neutrality adjusters, which are an additional ~5% cut.