cms

Many of you are familiar with the 96110 RVU snafu at the beginning of 2012.  CMS removed all the RVUs for the 96110 and then, with the help of the AAP making noise, replaced the values.

Apparently, a number of  payers took this as an opportunity to stop paying on the 96110 altogether. Sigh.

It looks like your hard work paid off!  From a CMS bulletin dated 12/29/2011:

After today's post, I am going to return with some really cool benchmark data (the sort of topic I prefer), but the news about EHRs is coming fast and furiously. My apologies for the length of the post.

First, from the AAP:

Just yesterday, we had an update from the AAP about how healthcare reform items are taking shape in Washington.  Now, we have a new one, a little more fresh.  The most important part is the "ACADEMY PERSPECTIVE" I think.

Today, I share a memo from the Federal Affairs desk of the AAP that pediatricians and their staff should consider.   Normally, I gloss over stuff like this (admit it, you do, too), but the comments Obama has made about child health are important and I think this is the time to make your voices heard.  We saw CMS make some changes as the result of private pediatric feedback promoted on this blog, so we know that input is valuable.

I’ve said more than once that the AAP is the first place pediatricians should go to learn about RVUs.  They have updated it and you can now find their 2009 RBRVS Conversion Spreadsheet on-line.  I got to help out by making a little change to the sheet (now the GPCI piece is just a pull down and not something you need to do manually).  Cool.  After reading through the

Yesterday, I asked if anyone knows how the awkward RBRVS GPCI system is developed.  Siouxsie, of course, had the answer.  In fact, more than answer.  Those of you who are dinged by the GPCI breakdown should head Reed Tinsley’s quick review of it and then check out CMS’s PDF…and get in touch with CMS! Remember, it worked with the imms admin for 2009, why not for GPCIs

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.

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:

Acting Administrator Kerry Weems

Centers for Medicare and Medicaid Services

Department of Health and Human Services

Room 443-G

Hubert H. Humphrey Building

200 Independence Avenue, SW

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.

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.