CPT Coding and Reimbursement Update 2006 NATIONAL VACCINE ADVISORY COMMITTEE

1. CPT Coding and Reimbursement Update 2006 NATIONAL VACCINE ADVISORY COMMITTEE Joel F. Bradley M.D. FAAP June 6, 2006

2. OUR GOALS To Learn About the Reimbursement Systems that Support Vaccine Delivery in the Physician’s Office Explore Strategies and Progress To Improve the System by Removing/Improving Existing Barriers

3. THE PLAN The Reimbursement System-Simplified Vaccine Coding and Reimbursemen Future Needs/Programs-P4P,CDHP

4. THE POST PRANDIAL STUPOR + A TALK ON CODING = ? NAP

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

7. 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

8. The Problems and Opportunities Vaccine Administration Fees Private Payers VFC Vaccine Costs Vaccine Payment Systems

9. 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

10. 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

11. Vaccine Financing in the Office The Infrastructure

12. HOW PHYSICIANS ARE PAID(KEY TO SOLVING REIMBURSEMENT PROBLEMS)

13. SERVICE ? CODE ?VALUE ? RBRVS ? FEE SCHEDULE ?EMPLOYER ? CONTRACT ? PAYMENT

14. 1. THE CODE First…DEFINE THE SERVICE Then…FIND A CODE! (AMA CPT)

15. 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

16. CPT CODES-”What We Do”Current Procedural Terminology OWNED/MAINTAINED BY AMERICAN MEDICAL ASSOCIATION (AMA) BEGAN IN 1966 OFFICIAL CODE SET FOR HIPAA REVISED YEARLY –FALL

17. AMA CPT E/M SERVICES >100 Codes Evaluation and Management Services Generally more “cognitive” PROCEDURES >8000 Codes Procedures, Surgery,Labs, X-rays etc

18. 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

19. The CPT Process  The genesis of a code

20. CPT – THE EDITORIAL PANEL 17 VOTING MEMBERS NOMINATED BY SPECIALITY SOCIETY APPOINTED BY AMA BOARD 4 AND 8 YEAR TERMS

21. CPT – THE EDITORIAL PANEL CPT ADVISORY COMMITTEE 100 SPECIALTY SOCIETIES EACH HAS ONE ADVISOR ADVISOR PRESENTS CODE PROPOSAL PANEL VOTES “yes” or “no”

22. 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

23. 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)

24. 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

25. 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)

26. 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:

27. 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 90669 Pneumo conjugate vaccine V03.82 90466* Administration of pneumo conjugate vaccine V03.82 *Claim would show 90466 as 2 units of service

28. RBRVS Update 2006   Medicare Celebrated 40th Birthday on July 30 2005 Next Get a Value- 2005 values should result in a 2% increase for pediatriciansNext Get a Value- 2005 values should result in a 2% increase for pediatricians

29. 2. THE VALUE SECOND…CPT CODES FIND VALUE AMA- RBRVS UPDATE COMMITTEE or “RUC”

30. The RUC Process  Genesis of Relative Value for Physicians

31. 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

32. 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

33. 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)

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

35. RBRVS AND VACCINES Resource Based Relative Value Scale Real Bad Reimbursement Very SoonReal Bad Reimbursement Very Soon

36. RBRVS-Resource Based Relative Value Scale Fee Schedule of CMS-Medicare Used by most ALL Payers Most CPT codes have a “Relative Value”

37. RBRVS AND PEDIATRICIANS RELEVANCE TO PRACTICE IT IS THE BASIS OF HOW Most Pysicians GET PAID!

38. RBRVS by PAYER% WHO USE

39. 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

40. 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.

41. RBRVS-3 MAJOR COMPONENTS PHYSICIAN WORK PRACTICE EXPENSE MALPRACTICE EXPENSE

42. RBRVS AND PEDIATRICIANSMAJOR COMPONENTS

43. PHYSICIAN WORK PHYSICAN TIME TECHNICAL SKILL/PHYSICAL EFFORT MENTAL EFFORT/JUDGEMENT STRESS-IATROGENIC RISK

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

45. 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

46. 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)

47. So…. can you take an RVU to the Bank? Total RVU (in units) x Conversion Factor (CF) in $ per rvu = The payment in “$”

48. RBRVS-CONVERSION FACTOR CMS for 2006- $37.8975 Formula is Legislated

49. CONVERSION FACTOR$ BY PAYER

50. 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

51. 4. THE PAYERS THEN… PAYERS ADOPT RBRVS AS THEIR PHYSICIAN FEE SCHEDULE PAYERS SELECT MANY CODES/VALUES- OMIT OTHERS! PAYMENT POLICY

52. 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

53. 5. THE PATIENTS EMPLOYER PURCHASES PLAN = COVERED BENEFITS PLAN May not include preventive care/vaccines!

54. 6. PHYSICIAN REIMBURSED PROVIDER - PAYER CONTRACT PROVIDER PERFORMS THE SERVICE SUBMITS THE CLAIM (CPT CODE) PAYER PAYS THE CLEAN CLAIM

55. PAYMENT PROBLEMS PROBLEMS AND THE BEST SOLUTIONS ARE FOUND AT DIFFERENT LEVELS !

56. 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

57. WHAT’S NEW IN CPT AND ICD? New CPT Panel Process for Vaccine Codes New and Revised Codes

58. NEW and Revised Vaccine CPT Product Codes Timing Is Everything! Codes should be active when new vaccines come to market

59. CPT Vaccine Product Codes“Early 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

60. 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

61. 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

62. 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

63. 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!

64. 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

65. 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)?

66. 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)?

67. 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.?

68. Pediatric Immunization Administration90465-8 Reflects Vaccine Risk Benefit Counseling by physician -VIS ( In CPT Physician = NP = PA ) Use for patients < 8 y.o. Different Codes for – -First vs Subsequent -Route- injected vs Oral/IN

69. 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)

70. 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)

71. Immunization AdministrationExisting Codes Revised Use (90471-4) for all encounters when- Patient is 8 yrs of age or > Physician Counseling does not occur

72. ICD-9 PEDIATRICS 2006 New and revised ICD vaccine codes V06.1 Diphtheria-tetanus-pertussis, combined [DTP] [DtaP] V06.5 Tetanus-diphtheria [Td][DT] 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

73. ICD-9 UPDATEVACCINE CODING CHANGES 2006 New and revised ICD vaccine codes Released in the Federal Register in the Summer- Active 1 October

74. 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

75. 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

76. Reimbursement Update CMS and the

77. Vaccine Administration-What’s 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

78. Vaccine Administration-What’s all the fuss? CMS omits RVU’s 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

79. Vaccine Administration- Private and state Medicaid Payers Select Variable Payments “carrier priced”- $0-20 AAP, AAFP, ACP Comment

80. 2000VACCINE ADMINISTRATION-BETWEEN A RUC and a Hard PLACE

81. Vaccine Administration-What’s all the fuss? 2001- NO RESPONSE 2002- CMS PUBLISHES Relative Values–But…. -value omits work rvu! - pe value cross walked from simple injection code ($3.98) AAP, AAFP, ACP COMMENT

82. 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

83. 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

84. 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

85. SO, NEW FOR 2005 VACCINE ADMINISTRATION CODES for CHILDREN MEDICARE MODERNIZATION ACT

86.  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

87.  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

88. All IA Codes Now Fully Valued!

89.  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!!

90. 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

91. 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

92. A CHALLENGE-COMBINATION VACCINES THE PARADOX- AS NUMBER OF COMPONENTS in 1 vaccine INCREASE- -physician work of counseling increases, but…….. -practice expenses decreases

93. Immunization Coding for Future AAP Working on- CPT Code for Immunization Administration of Combination Vaccines Increasing the Age

94. 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

95. The “New World” Pay For Performance“P4P” 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

96. 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.

97. 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

98. The “New World” –P 4 PCPT Category II Codes -Proposed By the AMA Performance Improvement Advisory Group -Will Be Used by CMS for PVRP

99. 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

100. 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)

101. 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?

102. 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 CDHP’s

103. Whew!....Thank You