CPT Coding and Reimbursement Update 2006 NATIONAL VACCINE ADVISORY COMMITTEE

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CPT Coding and Reimbursement Update 2006
NATIONAL VACCINE ADVISORY COMMITTEE

• Joel F. Bradley M.D. FAAP
• June 6, 2006

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OUR GOALS

• To Learn About the Reimbursement Systems that
  Support Vaccine Delivery in the Physicians
  Office
• Explore Strategies and Progress To Improve the
  System by Removing/Improving Existing Barriers

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THE PLAN

• The Reimbursement System-Simplified
• Vaccine Coding and Reimbursemen
• Future Needs/Programs-P4P,CDHP

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• THE POST PRANDIAL STUPOR
• A TALK ON CODING ? NAP

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• Stay Awake- Otherwise You Might Slide Right Out
  of Your Seat!

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(No Transcript)
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No Margin-No Mission

• Physicians Choose the Best Practices for Quality
  Care for Children
• Then Must Use the Coding and Contracting Systems
  to Fund the Services
• Those Services that are Undervalued May End

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The Problems and Opportunities

• Vaccine Administration Fees
• Private Payers
• VFC
• Vaccine Costs
• Vaccine Payment Systems

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The PROBLEMSVaccine Administration

• Vaccine Administration is Undervalued in Many
  Physician Payment Schedules
• Most Vaccines Are Given to Children in the
  Private Setting
• Payment for Vaccine Administration is the Sole
  Payment for Vaccine Delivery in the VFC Program

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The PROBLEMSPayment for Vaccine Products

• Reimbursement Methodology Has Changed Average
  Sales Price
• Delays Exist in New Vaccine Coverage by Private
  Payers
• The Number of New Vaccines Has Increased These
  Problems

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Vaccine Financing in the Office The
Infrastructure
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HOW PHYSICIANS ARE PAID(KEY TO SOLVING
REIMBURSEMENT PROBLEMS)
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SERVICE ? CODE ?VALUE ? RBRVS ? FEE SCHEDULE
?EMPLOYER ? CONTRACT ? PAYMENT
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1. THE CODE

• FirstDEFINE THE SERVICE
• ThenFIND A CODE!
• (AMA CPT)

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CODES

• CPT CODES
• Describes the Service Performed
• What We Have Done
• DIAGNOSIS CODES
• Describes the Patient, Condition, or
  Circumstances
• Who, Why, and the Reason (Medical Necessity) for
  doing it

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CPT CODES-What We DoCurrent Procedural
Terminology

• OWNED/MAINTAINED BY AMERICAN MEDICAL ASSOCIATION
  (AMA)
• BEGAN IN 1966
• OFFICIAL CODE SET FOR HIPAA
• REVISED YEARLY FALL

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AMA CPT

• E/M SERVICES gt100 Codes
• Evaluation and Management Services
• Generally more cognitive
• PROCEDURES gt8000 Codes
• Procedures, Surgery,Labs, X-rays etc

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AMA CPT

• LEVEL One-3 Categories
• Category I- Billing Codes
• Category II- Performance Improvement
• Category III- New Technology
• LEVEL Two- HCPCS
• Non Physician Services
• CMS G Codes
• Drugs/Medications J Codes

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The CPT Process The genesis of a code
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CPT THE EDITORIAL PANEL

• 17 VOTING MEMBERS
• NOMINATED BY SPECIALITY SOCIETY
• APPOINTED BY AMA BOARD
• 4 AND 8 YEAR TERMS

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CPT THE EDITORIAL PANEL

• CPT ADVISORY COMMITTEE
• 100 SPECIALTY SOCIETIES
• EACH HAS ONE ADVISOR
• ADVISOR PRESENTS CODE PROPOSAL
• PANEL VOTES yes or no

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DIAGNOSIS CODESInternational Classification Of
Disease

• Published by the World Health Organization for
  epidemiological tracking of illness and injury
• The clinical modification (CM) for Billing in the
  US is maintained by
• CMS
• National Center for Health Statistics/CDC
• American Hospital Association
• American Health Information Management
  Association
• Has Its Own Editorial Board

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What are the ICD-9-CM Codes?

• Numeric codes 3-5 numeric characters
  representing illnesses and conditions
• (314.01 - ADHD)
• E codes alpha-numeric describing (external
  causes of injuries, poisonings, and adverse
  effects (E 906.0 dog bite)
• V codes alpha-numeric describing factors
  influencing health status and encounters with
  health services
• (V20.2- well exam in a child)

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ICD-9 PEDIATRICS 2006

• ICD vaccine codes-
• -Describe the reason for the vaccine (medical
  necessity), or
• -Describe the circumstances surrounding the
  vaccine visit
• Link to the CPT vaccine product and IA code

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Correct Vaccine Coding

• 1. Select the Correct CPT Code for the Product
  be specific!
• 2. Correctly link an ICD 9 Code (diagnosis) to
  the CPT code for the Vaccine
• 3. Always add the appropriate vaccine
  administration CPT code considering age, MD
  counseling, and route/order of administration
  (and link the same Diagnosis code to this CPT
  code)

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Coding Examples

• 2 month old patient goes to physician office
• for a well visit, patient receives 1 dose of
• HIB ( ActHIB) vaccine, DTaP-Hep B-IPV, PCV 7
  with physician counseling.
• You Report

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Coding Examples

• CPT                                           
      ICD-9-CM
• 99391 Preventive visit, established patient
  V20.2
• 90648 ActHIB vaccine
  V03.81
• 90465 Administration of ActHIB vaccine
  V03.81
• 90723 DTaP -Hep B- IPV vaccine
  V06.3, V05.3
• 90466 Administration of DTaP-Hep B-IPV vaccine
  V06.3, V05.3

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RBRVS Update 2006 Medicare Celebrated 40th
Birthday on July 30 2005
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2. THE VALUE

• SECONDCPT CODES FIND VALUE
• AMA- RBRVS UPDATE
• COMMITTEE
• or
• RUC

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The RUC Process Genesis of Relative Value
for Physicians
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RUC THE RBRVS UPDATE COMMITTEE

• 29 MEMBERS
• 23 SEATS ASSIGNED TO SPECIALTIES
• ALSO AMA, AOA, HCPAC, PEAC, CPT PANEL
• NOMINATED BY SPECIALITY SOCIETY
• APPOINTED BY AMA BOARD
• NO TERMS

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RUC THE RBRVS UPDATE COMMITTEE

• CMS ATTENDS/COMMENTS
• RUC ADVISORY COMMITTEE
• ADVISORS PRESENT SOCIETY RVU RECOMMENDATIONS ON
  WORK AND PE
• PRESENTATION DATA BASED ON MEMBER SURVEYS or
  EXPERT PANELS

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RUC THE RBRVS UPDATE COMMITTEE

• RUC VOTES ON RELATIVE VALUE
• RECOMMENDATIONS TO CMS
• Physician work rvu
• Direct Practice Expense inputs (CMS calculates
  final PE rvu)

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3. THE FEE SCHEDULE (RBRVS)

• NEXT.CMS AGREES (90!), OR
• CAN ? OR ?
• PUBLISHES THE VALUE (FEDERAL
• REGISTER)-MEDICARE FEE
• SCHEDULE OR RBRVS

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RBRVS AND VACCINES

• Resource Based Relative
• Value Scale

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RBRVS-Resource Based Relative Value Scale

• Fee Schedule of CMS-Medicare
• Used by most ALL Payers
• Most CPT codes have a Relative Value

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RBRVS AND PEDIATRICIANS

• RELEVANCE TO PRACTICE
• IT IS THE BASIS OF HOW Most Pysicians GET PAID!

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RBRVS by PAYER WHO USE
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RBRVS AND PEDIATRICIANS

• RBRVS
• Began January 1, 1992 ( CPT EM codes)
• Authorized by Congress 1989- OBRA 89
• Revised the Medicare Fee Schedule (1965)
• A CPR system(customary, prevalent, reasonable)
• Maintains budget neutrality

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RBRVS AND PEDIATRICIANS

• CONCEPT- Services are ranked relative to the
  costs of the resources used to perform them.
• If service A is harder and takes longer, uses
  more overhead expense of service B, then A will
  have a proportionately higher value than B.

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RBRVS-3 MAJOR COMPONENTS

• PHYSICIAN WORK
• PRACTICE EXPENSE
• MALPRACTICE EXPENSE

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RBRVS AND PEDIATRICIANSMAJOR COMPONENTS
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PHYSICIAN WORK

• PHYSICAN TIME
• TECHNICAL SKILL/PHYSICAL EFFORT
• MENTAL EFFORT/JUDGEMENT
• STRESS-IATROGENIC RISK

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PRACTICE EXPENSE

• 1. DIRECT COSTS
• CLINICAL LABOR,MEDICAL SUPPLIES, AND MEDICAL
  EQUIPMENT
• 2. INDIRECT COSTS
• ADMIN. LABOR,OFFICE EXPENSE,
  AND OTHER COSTS

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PLI- PROFESSIONAL LIABILITY INSURANCE

• 1-3 of the total rvu
• ORIGINALLY CHARGE BASED
• RESOURCE BASED SINCE 2000
• BASED ON SPECIALTY SPECIFIC PREMIUM DATA, RISK,
  AND UTILIZATION

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OTHER MEDICARE ADJUSTMENTS

• GPCI
• GEOGRAPHIC PRACTICE COST INDEX
• ACCOUNTS FOR GEOGRAPHIC DIFFERENCE IN COST OF
  RESOURCES
• 1.0 AVERAGE.
• DIFFER BY AREA (STATE), AND TYPE OF RESOURCE
  (WORK,PE,PLI)

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So. can you take an RVU to the Bank?

• Total RVU (in units)
• x Conversion Factor (CF) in per rvu
• The payment in

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RBRVS-CONVERSION FACTOR

• CMS for 2006- 37.8975
• Formula is Legislated

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CONVERSION FACTOR BY PAYER
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RBRVS-Relative Value-RVU

• TOTAL RVU Work rvu Practice Expense (pe) rvu
  Professional Liability Insurance (pli) rvu
• 99213 reference 0.67 rvu (work) 0.69 (pe)
  0.03 rvu (pli) 1.39 total rvu (FOR 2006
  non-facility)
• Payment- 1.39 x 37.89 52.68

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4. THE PAYERS

• THEN PAYERS ADOPT RBRVS AS THEIR PHYSICIAN FEE
  SCHEDULE
• PAYERS SELECT MANY CODES/VALUES- OMIT OTHERS!
• PAYMENT POLICY

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CMS OPTIONS-PAYMENT POLICY

• PUBLISHES
• RUC RECOMMENDED VALUE
• AMENDED VALUE-OMIT WORK
• MAKE NON-ACTIVE (not paid)
• DOES NOT PUBLISH VALUES
• OTHER PAYERS ASSIGN OWN VALUES (Carrier Priced)
• OFTEN NOT PAID

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5. THE PATIENTS

• EMPLOYER PURCHASES PLAN
• COVERED BENEFITS PLAN
• May not include preventive care/vaccines!

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6. PHYSICIAN REIMBURSED

• PROVIDER - PAYER CONTRACT
• PROVIDER PERFORMS THE SERVICE
• SUBMITS THE CLAIM (CPT CODE)
• PAYER PAYS THE CLEAN CLAIM

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PAYMENT PROBLEMS

• PROBLEMS AND THE BEST
• SOLUTIONS
• ARE FOUND AT
• DIFFERENT LEVELS !

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POTENTIAL SOLUTIONS

• AAP Looks for Opportunities To Support Vaccine
  Delivery
• CPT Codes-new or revised
• RBRVS /CMS (Im)Prove Value
• Payers/Employers- Education and Discussion
• Providers- Practice Management Support

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WHATS NEW IN CPT AND ICD?

• New CPT Panel Process for Vaccine Codes
• New and Revised Codes

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NEW and Revised Vaccine CPT Product Codes

• Timing Is Everything!
• Codes should be active when new vaccines come to
  market

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CPT Vaccine Product CodesEarly Release on
the Website

• Published in CPT each October- Active 1 January
• But Appear Twice a Year on the AMA website
  early Release
• -1 Jan.
• -1 July
• Codes Become Active for use 6 months after
  appearing
• www.ama-assn.org/ama/pub/category/
• 10902.html

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CPT Vaccine Product CodesNew 2006

• New appendix K in CPT 2006-list all vaccine codes
  for products without FDA approval
• New Symbol ? to indicate FDA approval is
  pending
• CPT Panel requests for new code applications
• Evidence from Phase 3 Trials of Efficacy/Safety
• Timing of FDA Filing of the BLA

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NEW FOR 2005Vaccine Coding Caucus

• Established to Improve Timing of New CPT Vaccine
  Codes
• Advisory to the Panel and Maintained by AMA/AAP
• Members- AAP,AAFP, ACIP, ACOG,ANA, FDA, CDC, CMS,
  Vaccine Maufacturers

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New Vaccine Codes 2006website 1 Jan 05 -Active 1
July 05

• ? 90649 Human Papilloma virus (HPV) vaccine,
  types 6, 11, 16, 18 (quadrivalent), 3 dose
  schedule, for intramuscular use
• ? 90680 Rotavirus vaccine, pentavalent, 3 dose
  schedule, live, for oral use
• ?90713 Poliovirus vaccine, inactivated, (IPV),
  for subcutaneous or intramuscular use
• ?90714 Tetanus and diphtheria toxoids (Td)
  adsorbed, preservative free, for use in
  individuals seven years or older, for
  intramuscular use
• ?90715 Tetanus, diphtheria toxoids and
  acellular pertussis vaccine (Tdap), for use in
  individuals 7 years or older, for im use

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NEW FOR 2005

• Influenza Vaccine Coding Changes-
• 90655-preservative free 6-35 mos
• 90656-preservative free age 3 yr-over
• 90657-split virus, age 6-35 mos
• 90658-split virus, age 3 yr-over (90659 deleted)
• Note cost differentials above! Check Payers!

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NEW for 2005 Pediatric Immunization
Administration Codes

• Why created- because CMS (and other payers
  undervalued the codes for vaccine administration
  by omitting the work value (50 of total value)
• CPT approved Pediatric specific codes-CMS
  agreed to publish the relative work value in the
  Medicare Fee Schedule

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Pediatric Immunization Administration

• ?90465 Immunization administration under 8 years
  of age (includes percutaneous, intradermal,
  subcutaneous, or intramuscular injections) when
  the physician counsels the patient/family first
  injection (single or combination vaccine/toxoid),
  per day
• ?(Do not report 90465 in conjunction with
  90467)?
• ?90466 each additional injection (single or
  combination vaccine/toxoid), per day (List
  separately in addition to code for primary
  procedure)
• ?(Use 90466 in conjunction with 90465 or 90467)?

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Pediatric Immunization Administration

• ?90467 Immunization administration under age 8
  years (includes intranasal or oral routes of
  administration) when the physician counsels the
  patient/family first administration (single or
  combination vaccine/toxoid), per day
• ?(Do not report 90467 in conjunction with
  90465)?
• ?90468 each additional administration (single or
  combination vaccine/toxoid), per day (List
  separately in addition to code for primary
  procedure)
• ?(Use 90468 in conjunction with 90465 or 90467)?

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Pediatric Immunization Administration

• ?Report codes 90465-90468 only when the physician
  provides face-to-face counseling of the patient
  and family during the administration of a
  vaccine.
• For immunization administration of any vaccine
  that is not accompanied by face-to- face
  physician counseling to the patient/family,
  report codes 90471-90474.?

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Pediatric Immunization Administration90465-8

• Reflects Vaccine Risk Benefit Counseling by
  physician -VIS
• ( In CPT Physician NP PA )
• Use for patients lt 8 y.o.
• Different Codes for
• -First vs Subsequent
• -Route- injected vs Oral/IN

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Existing Immunization Administration

• 90471 Immunization administration (includes
  percutaneous, intradermal, subcutaneous, or
  intramuscular injections) one vaccine (single or
  combination vaccine/toxoid)
• 90472 each additional vaccine (single or
  combination vaccine/toxoid)

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Existing Immunization Administration

• 90473 Immunization administration by intranasal
  or oral route one vaccine (single or combination
  vaccine/toxoid)
• 90474 Each additional vaccine
• (single or combination vaccine/toxoid)

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Immunization AdministrationExisting Codes
Revised

• Use (90471-4) for all encounters when-
• Patient is 8 yrs of age or gt
• Physician Counseling does not occur

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ICD-9 PEDIATRICS 2006

• New and revised ICD vaccine codes
• V06.1 Diphtheria-tetanus-pertussis, combined
  DTP DtaP
• V06.5 Tetanus-diphtheria TdDT
• V04.81 Need for prophylactic vaccination and
  inoculation, Influenza
• V04.82 Need for prophylactic vaccination and
  inoculation, Respiratory synctial virus (RSV).
• V04.89 Need for prophylactic vaccination and
  inoculation, Other viral diseases

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ICD-9 UPDATEVACCINE CODING CHANGES 2006

• New and revised ICD vaccine codes
• Released in the Federal Register in the
• Summer- Active 1 October

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ICD-9 PEDIATRICS 2006

• New and revised ICD vaccine codes
• V64.00 ..... Vaccination not carried out,
  unspecified reason
• V64.01 ..... Vaccination not carried out because
  of acute illness
• V64.02 ..... Vaccination not carried out because
  of chronic illness or condition
• V64.03 ..... Vaccination not carried out because
  of immune compromised state

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ICD-9 PEDIATRICS 2006

• New and revised ICD vaccine codes for -cont.
• V64.04 ..... Vaccination not carried out because
  of allergy to vaccine or component
• V64.05 ..... Vaccination not carried out because
  of caregiver refusal
• V64.06 ..... Vaccination not carried out because
  of patient refusal
• V64.07 ..... Vaccination not carried out for
  religious reasons

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Reimbursement Update CMS and the
Relative Value Roller Coaster
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Vaccine Administration-Whats all the fuss?

• 2000- AMA CREATES CPT CODE
• 2000- AMA RUC RECOMMENDS VALUE
• 90471- work rvu 0.20 (est 15 total fee)
• 90472- work rvu 0.17 (est 13 total fee)
• RUC forwards to CMS

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Vaccine Administration-Whats all the fuss?

• CMS omits RVUs for all Vaccine Administration
  Codes!
• In the Medicare program- Physician Counseling Is
  Not Typical and Payments Are Bundled Into Other
  Services
• CMS Creates Its Own G Codes (HCPCS) for Payment

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Vaccine Administration-

• Private and state Medicaid Payers Select Variable
  Payments
• carrier priced- 0-20
• AAP, AAFP, ACP Comment

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2000VACCINE ADMINISTRATION-BETWEEN A RUC and
a Hard PLACE
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Vaccine Administration-Whats all the fuss?

• 2001- NO RESPONSE
• 2002- CMS PUBLISHES Relative ValuesBut.
• -value omits work rvu!
• - pe value cross walked from simple injection
  code (3.98)
• AAP, AAFP, ACP COMMENT

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Vaccine Administration-

• 2003- CMS REVISES VALUE
• PE value now based on resources used
• Values increase
• 90471 3.98 to 7.75
• 90472 3.98 to 5.25
• BETTER- BUT STILL NO WORK VALUE
• CMS suggests (Federal Register) a coding change
  might allow physician work recognition in
  children

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Vaccine Administration-

• 2003- AAP Begins Work with AAFP, ACP, and CMS for
  a Coding Change
• CPT Codes for Vaccine Delivery in Children
• Would Distinguish Codes that Recognize Physician
  Counseling
• Would Allow CMS to Publish Physician Work Value
• CDC , NVAC, and CMS Support to AMA

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Vaccine Administration-

• 2004- CMS UPDATES VALUE
• PE value based on resources used
• Values increase under MMA 1.5
• 90471 7.75 to 8.21
• 90472 5.25 to 5.60
• STILL NO WORK VALUE

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SO, NEW FOR 2005

• VACCINE ADMINISTRATION CODES for CHILDREN
• MEDICARE MODERNIZATION ACT

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RBRVS FOR 2005 Good News!Medicare Fee
Schedule RBRVS

• CPT CODE RVU 20 04 ? 2006
• 90471- .21 ? .49 8.21 ? 17.73
• 90472- .15 ? .31 5.60 ? 10.49
• 90465- .49 8.21 ? 17.73
• 90466- .31 5.60 ?
  10.99
• 99213- 1.39 52.68
• 2006 Conversion factor 37.89

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RBRVS FOR 2006Now Good News for Oral/
Intranasal!

• CPT CODE RVU -2006
• 90473- .0 ? .37 0 ? 13.39
• 90474- .0 ? .26 0 ? 9.41
• 90467- .35 12.66
• 90468- .27 9.77
• 99213- 1.39 52.68
• 2006 conversion factor 37.89

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All IA Codes Now Fully Valued!
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RBRVS FOR 2005 Good News!

• POTENTIAL IMPACT-
• 4,000,000 births a year in the US
• 25 Vaccines birth to five
• 100,000,000 vaccine admin. (Possible)
• 1,000,000,000 potential to support vaccine
  delivery!!

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Immunization Administration 2006 Relative
ValuesContracting

• These Relative Values Are Resource Based and
  Validated Through a Rigorous Process (RUC/CMS
  Review)
• They Should Serve as the Basis (the FLOOR) for
  Valuing the Service by Payers and ?State Medicaid
  Programs

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Vaccine Product ReimbursementChanges in Payer
Methodology

• CMS now using Average Sales Price (ASP) for
  medications
• Private Payers Adopting
• Lower Than AWP by 10-25
• May Push Reimbursement of Vaccine Products to
  Providers Lower/Below Actual Cost to Purchase,
  Store, and Maintain Inventory

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A CHALLENGE-COMBINATION VACCINES

• THE PARADOX-
• AS NUMBER OF COMPONENTS in 1 vaccine INCREASE-
• -physician work of counseling increases,
  but..
• -practice expenses decreases

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Immunization Coding for Future

• AAP Working on-
• CPT Code for Immunization Administration of
  Combination Vaccines
• Increasing the Age

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AAP REIMBURSEMENT INITIATIVES 2006

• Private Payer Advocacy Program
• Meeting with National Payers
• State Managed Care Councils meet with
  Local/regional payers
• Vaccines Are a Top Priority
• Immunization Task Force

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The New World Pay For PerformanceP4P

• Programs that Payers Use to Provide Incentives
  for Physicans to Improve Performance on Selected
  Measures
• CMS- 2006- Physician Voluntary Reporting Program
• Private Payers Watching- Some Implementing

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The New World Pay For Performance

• Pediatric Programs Will Likely Use Immunization
  Rates As a Measure
• 1. Process- of children offered vaccines at a
  preventive medicine visit
• 2. Outcome- Number of children completely
  vaccinated by age 2.

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The New World P 4 P

• Correct Coding both CPT and ICD will become even
  more important as pediatric pay for quality
  programs increase.
• New Codes (CPT Category II) will allow data
  reporting using claims data

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The New World P 4 PCPT Category II Codes

• -Proposed By the AMA Performance Improvement
  Advisory Group
• -Will Be Used by CMS for PVRP

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The New World P 4 P

• Potential Strength- Allows Finances to Follow
  Vaccine Delivery
• Potential Threat- the Administrative Burden of
  Reporting/Collecting Data May Be Overwhelming To
  Physicians

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The New World Consumer Directed Health Plans

• Insurance Plans that Combine
• High Deductible Policy
• Health Savings Account
• Provide a Fixed Cost for Employers
• Transfers Risk to Patient (Member)

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The New World Consumer Directed Health Plans

• Potential Strength- Insurance Becomes More
  Affordible for Some Populations
• Potential Threat- First Dollar Coverage for
  Preventive Services (Well Care and Vaccines)
• Will Patients Use Their for Vaccines?

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Future- Keep The Mission!

• Develop a Solution for Reporting Combination
  Vaccine Administration
• Private and State Medicaid Payer Education
  About New Codes/Values
• Involvement by Those Who Understand Vaccines in
  the P4P Process and CDHPs

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Whew!....Thank You