CPT Coding and Reimbursement Update 2006

NATIONAL VACCINE ADVISORY COMMITTEE

Joel F. Bradley M.D. FAAPJoel F. Bradley M.D. FAAPJune 6, 2006June 6, 2006

OUR GOALS

1.1. To Learn About the To Learn About the Reimbursement Systems that Reimbursement Systems that Support Vaccine Delivery in the Support Vaccine Delivery in the Physician’s OfficePhysician’s Office

2.2. Explore Strategies and Progress Explore Strategies and Progress To Improve the System by To Improve the System by Removing/Improving Existing Removing/Improving Existing Barriers Barriers

THE PLAN

1.1. The Reimbursement System-The Reimbursement System-SimplifiedSimplified

2.2. Vaccine Coding and Vaccine Coding and ReimbursemenReimbursemen

3.3. Future Needs/Programs-Future Needs/Programs-P4P,CDHPP4P,CDHP

THE POST PRANDIAL STUPORTHE POST PRANDIAL STUPOR++

A TALK ON CODING = ? NAPA TALK ON CODING = ? NAP

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

No Margin-No Mission

Physicians Choose the Best Practices Physicians Choose the Best Practices for Quality Care for Childrenfor Quality Care for Children

Then Must Use the Coding and Then Must Use the Coding and Contracting Systems to Fund the Contracting Systems to Fund the ServicesServices

Those Services that are Undervalued Those Services that are Undervalued May EndMay End

The Problems and Opportunities

Vaccine Administration FeesVaccine Administration Fees– Private PayersPrivate Payers– VFCVFC

Vaccine Costs Vaccine Costs

Vaccine Payment Systems Vaccine Payment Systems

The PROBLEMSVaccine Administration

Vaccine Administration is Vaccine Administration is Undervalued in Many Physician Undervalued in Many Physician Payment SchedulesPayment Schedules– Most Vaccines Are Given to Children Most Vaccines Are Given to Children

in the Private Settingin the Private Setting– Payment for Vaccine Administration is Payment for Vaccine Administration is

the the Sole PaymentSole Payment for Vaccine for Vaccine Delivery in the VFC ProgramDelivery in the VFC Program

The PROBLEMSPayment for Vaccine

Products1.1. Reimbursement Methodology Has Reimbursement Methodology Has

Changed –Average Sales PriceChanged –Average Sales Price2.2. Delays Exist in New Vaccine Delays Exist in New Vaccine

Coverage by Private Payers Coverage by Private Payers 3.3. The Number of New Vaccines Has The Number of New Vaccines Has

Increased These Problems Increased These Problems

Vaccine Financing in the Office

The Infrastructure

HOW PHYSICIANS ARE PAID

(KEY TO SOLVING REIMBURSEMENT

PROBLEMS)

SERVICE CODE

VALUE RBRVS

FEE SCHEDULE

EMPLOYER CONTRACT

PAYMENT

1. THE CODEFirst…DEFINE THE SERVICEFirst…DEFINE THE SERVICE

Then…FIND A CODE! Then…FIND A CODE! (AMA CPT)(AMA CPT)

CODES CPT CODESCPT CODES

– Describes the Service PerformedDescribes the Service Performed– ““What We Have Done”What We Have Done”

DIAGNOSIS CODESDIAGNOSIS CODES– Describes the Patient, Condition, or Describes the Patient, Condition, or

CircumstancesCircumstances– ““Who, Why, and the Reason (Medical Who, Why, and the Reason (Medical

Necessity) for doing itNecessity) for doing it

CPT CODES-”What We Do”

Current Procedural Terminology

OWNED/MAINTAINED BY OWNED/MAINTAINED BY AMERICAN MEDICAL ASSOCIATION AMERICAN MEDICAL ASSOCIATION (AMA)(AMA)

BEGAN IN 1966BEGAN IN 1966 OFFICIAL CODE SET FOR HIPAAOFFICIAL CODE SET FOR HIPAA REVISED YEARLY –FALLREVISED YEARLY –FALL

AMA CPT

E/M SERVICES >100 CodesE/M SERVICES >100 Codes– Evaluation and Management ServicesEvaluation and Management Services– Generally more “cognitive” Generally more “cognitive”

PROCEDURES >8000 CodesPROCEDURES >8000 Codes– Procedures, Surgery,Labs, X-rays etcProcedures, Surgery,Labs, X-rays etc

AMA CPT

LEVEL One-3 CategoriesLEVEL One-3 Categories– Category I- Billing CodesCategory I- Billing Codes– Category II- Performance Improvement Category II- Performance Improvement – Category III- New TechnologyCategory III- New Technology

LEVEL Two- HCPCSLEVEL Two- HCPCS– Non Physician ServicesNon Physician Services– CMS “G” CodesCMS “G” Codes– Drugs/Medications “J” CodesDrugs/Medications “J” Codes

The CPT Process The genesis of a code

Table P roposal C P T C ode C han ge

R eject P roposal

CPT Panel

C P T Spec ialty Advisors

AM A S taf f R eview

Specia lty SocietyW e 've go t a n id e a ...

CPT – THE EDITORIAL PANEL

1717 VOTING MEMBERS VOTING MEMBERS NOMINATED BY SPECIALITY NOMINATED BY SPECIALITY

SOCIETYSOCIETY APPOINTEDAPPOINTED BY AMA BOARD BY AMA BOARD 4 AND 8 YEAR TERMS4 AND 8 YEAR TERMS

CPT – THE EDITORIAL PANEL

CPT ADVISORY COMMITTEECPT ADVISORY COMMITTEE– 100 SPECIALTY SOCIETIES100 SPECIALTY SOCIETIES– EACH HAS ONE ADVISOREACH HAS ONE ADVISOR

ADVISOR PRESENTS CODE ADVISOR PRESENTS CODE PROPOSALPROPOSAL

PANEL VOTES “yes” or “no”PANEL VOTES “yes” or “no”

DIAGNOSIS CODESInternational Classification

Of Disease Published by the World Health Published by the World Health

Organization for epidemiological tracking Organization for epidemiological tracking of illness and injuryof illness and injury

The clinical modification (CM) for Billing in The clinical modification (CM) for Billing in the US is maintained bythe US is maintained by– CMSCMS– National Center for Health Statistics/CDCNational Center for Health Statistics/CDC– American Hospital AssociationAmerican Hospital Association– American Health Information Management American Health Information Management

AssociationAssociation Has Its Own Editorial BoardHas Its Own Editorial Board

What are the ICD-9-CM Codes?

Numeric codes: 3-5 numeric characters Numeric codes: 3-5 numeric characters representing illnesses and conditionsrepresenting illnesses and conditions

(314.01 - ADHD)(314.01 - ADHD) E codes: alpha-numeric describing E codes: alpha-numeric describing

(external causes of injuries, poisonings, (external causes of injuries, poisonings, and adverse effects (E 906.0 –dog bite)and adverse effects (E 906.0 –dog bite)

V codes: alpha-numeric describing factors V codes: alpha-numeric describing factors influencing health status and encounters influencing health status and encounters with health serviceswith health services

(V20.2- well exam in a child)(V20.2- well exam in a child)

ICD-9 PEDIATRICS 2006 ICD vaccine codes-ICD vaccine codes-

-Describe the reason for the vaccine (medical -Describe the reason for the vaccine (medical necessity), ornecessity), or

-Describe the circumstances surrounding the -Describe the circumstances surrounding the vaccine visitvaccine visit

** ** Link to the CPT vaccine product and IA Link to the CPT vaccine product and IA codecode

Correct Vaccine Coding1. 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)

Coding Examples

2 month old patient goes to physician office2 month old patient goes to physician office for a well visit, patient receives 1 dose offor a well visit, patient receives 1 dose of

HIB ( ActHIB) vaccine, DTaP-Hep B-IPV, PCV HIB ( ActHIB) vaccine, DTaP-Hep B-IPV, PCV 77 – with physician counseling. – with physician counseling.

You You Report:Report:

Coding ExamplesCPT                                                ICD-9-CMCPT                                                ICD-9-CM

99391 99391 Preventive visit, established patient Preventive visit, established patient V20.2V20.2

90648 90648 ActHIB vaccine ActHIB vaccine V03.81V03.81

9046590465 Administration of ActHIB vaccine Administration of ActHIB vaccine V03.81V03.81

90723 90723 DTaP -Hep B- IPV vaccine DTaP -Hep B- IPV vaccine V06.3, V06.3, V05.3V05.3

90466*90466* AAdministration of DTaP-Hep B-IPV vaccinedministration of DTaP-Hep B-IPV vaccine V06.3, V05.3V06.3, V05.3

9066990669 Pneumo conjugate vaccine Pneumo conjugate vaccine V03.82V03.82

90466* A90466* Administration of pneumo conjugate vaccine dministration of pneumo conjugate vaccine V03.82V03.82

*Claim would show 90466 as 2 units of service*Claim would show 90466 as 2 units of service

RBRVS Update 2006

Medicare Celebrated 40th Birthday on July 30 2005

2. THE VALUE SECOND…CPT CODES FIND SECOND…CPT CODES FIND VALUEVALUE

AMA- RBRVS UPDATE AMA- RBRVS UPDATE COMMITTEE COMMITTEE

oror““RUC”RUC”

The RUC Process Genesis of Relative Value for

Physicians

F ederal R egis ter

C M S &C arrier M edical D irectors

RVS Update Com m ittee

R U C S urvey

R eview by S pec ialty S ociety A dvisors

RUC – THE RBRVS UPDATE COMMITTEE

2929 MEMBERS MEMBERS– 23 SEATS ASSIGNED TO SPECIALTIES23 SEATS ASSIGNED TO SPECIALTIES– ALSO AMA, AOA, HCPAC, PEAC, CPT ALSO AMA, AOA, HCPAC, PEAC, CPT

PANELPANEL NOMINATED BY SPECIALITY SOCIETYNOMINATED BY SPECIALITY SOCIETY APPOINTED BY AMA BOARDAPPOINTED BY AMA BOARD NO TERMSNO TERMS

RUC – THE RBRVS UPDATE COMMITTEE

CMS ATTENDS/COMMENTSCMS ATTENDS/COMMENTS RUC ADVISORY COMMITTEERUC ADVISORY COMMITTEE

– ADVISORS PRESENT SOCIETY RVU ADVISORS PRESENT SOCIETY RVU RECOMMENDATIONS ON WORK AND PERECOMMENDATIONS ON WORK AND PE

PRESENTATION DATA BASED ON MEMBER PRESENTATION DATA BASED ON MEMBER SURVEYS or EXPERT PANELSSURVEYS or EXPERT PANELS

RUC – THE RBRVS UPDATE COMMITTEE

RUC VOTES ON RELATIVE VALUERUC VOTES ON RELATIVE VALUE RECOMMENDATIONS TO CMSRECOMMENDATIONS TO CMS

– Physician work rvuPhysician work rvu– Direct Practice Expense inputs (CMS Direct Practice Expense inputs (CMS

calculates final PE rvu)calculates final PE rvu)

3. THE FEE SCHEDULE (RBRVS)

NEXT….CMS AGREES (90%!), OR…NEXT….CMS AGREES (90%!), OR… CAN CAN OR OR PUBLISHES THE VALUE (FEDERALPUBLISHES THE VALUE (FEDERAL REGISTER)-MEDICARE FEEREGISTER)-MEDICARE FEE SCHEDULE OR RBRVSSCHEDULE OR RBRVS

RBRVS AND VACCINES

RResource esource BBased ased RRelative elative

VValue alue SScalecale

RBRVS-Resource Based Relative Value Scale

Fee Schedule of CMS-MedicareFee Schedule of CMS-Medicare Used by most Used by most ALL PayersALL Payers Most CPT codes have a “Relative Most CPT codes have a “Relative

Value”Value”

RBRVS AND PEDIATRICIANS

RELEVANCE TO PRACTICERELEVANCE TO PRACTICE

– IT IS THE BASIS OF HOW Most IT IS THE BASIS OF HOW Most Pysicians GET PAID!Pysicians GET PAID!

RBRVS by PAYER% WHO USE

0102030405060708090

BC/BS MCO-pvt MCAID OTHER

RBRVS

RBRVS AND PEDIATRICIANS

RBRVSRBRVS– Began January 1, 1992 ( CPT EM Began January 1, 1992 ( CPT EM

codes)codes)– Authorized by Congress 1989- OBRA Authorized by Congress 1989- OBRA

’89’89– Revised the Medicare Fee Schedule Revised the Medicare Fee Schedule

(1965)(1965) A CPR system(customary, prevalent, A CPR system(customary, prevalent,

reasonable)reasonable) Maintains budget neutrality Maintains budget neutrality

RBRVS AND PEDIATRICIANS

– CONCEPT- Services are ranked CONCEPT- Services are ranked relative to the costs of the resources relative to the costs of the resources used to perform them.used to perform them.

– If service A is harder and takes If service A is harder and takes longer, uses more overhead expense longer, uses more overhead expense of service B, then A will have a of service B, then A will have a proportionately higher value than B.proportionately higher value than B.

RBRVS-3 MAJOR COMPONENTS

1.1.PHYSICIAN WORKPHYSICIAN WORK2.2.PRACTICE EXPENSEPRACTICE EXPENSE3.3.MALPRACTICE EXPENSEMALPRACTICE EXPENSE

RBRVS AND PEDIATRICIANSMAJOR COMPONENTS

WORK53%

PE44%

PLI3%

PHYSICIAN WORK

PHYSICAN TIMEPHYSICAN TIME TECHNICAL SKILL/PHYSICAL TECHNICAL SKILL/PHYSICAL

EFFORTEFFORT MENTAL EFFORT/JUDGEMENTMENTAL EFFORT/JUDGEMENT STRESS-IATROGENIC RISKSTRESS-IATROGENIC RISK

PRACTICE EXPENSE

1. 1. DIRECT COSTSDIRECT COSTSCLINICAL LABOR,MEDICAL SUPPLIES, CLINICAL LABOR,MEDICAL SUPPLIES, AND MEDICAL EQUIPMENTAND MEDICAL EQUIPMENT2. 2. INDIRECT COSTSINDIRECT COSTSADMIN. LABOR,OFFICE EXPENSE, ADMIN. LABOR,OFFICE EXPENSE, AND OTHER COSTSAND OTHER COSTS

PLI- PROFESSIONAL LIABILITY INSURANCE

– 1-3%1-3% of the total rvu of the total rvu– ORIGINALLY CHARGE BASEDORIGINALLY CHARGE BASED– RESOURCE BASED SINCE 2000RESOURCE BASED SINCE 2000– BASED ON SPECIALTY SPECIFIC BASED ON SPECIALTY SPECIFIC

PREMIUM DATA, RISK, AND PREMIUM DATA, RISK, AND UTILIZATIONUTILIZATION

OTHER MEDICARE “ADJUSTMENTS”

GPCIGPCI– GEOGRAPHIC PRACTICE COST INDEXGEOGRAPHIC PRACTICE COST INDEX– ACCOUNTS FOR GEOGRAPHIC ACCOUNTS FOR GEOGRAPHIC

DIFFERENCE IN COST OF RESOURCESDIFFERENCE IN COST OF RESOURCES– 1.0 = AVERAGE.1.0 = AVERAGE.– DIFFER BY AREA (STATE), AND TYPE DIFFER BY AREA (STATE), AND TYPE

OF RESOURCE (WORK,PE,PLI)OF RESOURCE (WORK,PE,PLI)

So…. can you take an RVU to

the Bank?

Total RVU (in units) Total RVU (in units) x Conversion Factor (CF) in $ per x Conversion Factor (CF) in $ per

rvurvu = = The payment in “$” The payment in “$”

RBRVS-CONVERSION FACTOR

CMS for 2006- $37.8975CMS for 2006- $37.8975

Formula is LegislatedFormula is Legislated

CONVERSION FACTOR$ BY PAYER

05101520253035404550

BC/BS MCO-pvt MCAID OTHER

CF

RBRVS-Relative Value-RVU

TOTAL RVU= Work rvu + Practice TOTAL RVU= Work rvu + Practice Expense (pe) rvu + Professional Expense (pe) rvu + Professional Liability Insurance (pli) rvuLiability Insurance (pli) rvu

– 99213 99213 reference = 0.67 rvu (work) + reference = 0.67 rvu (work) + 0.69 (pe) + 0.03 rvu (pli) = 0.69 (pe) + 0.03 rvu (pli) = 1.391.39 total total rvu (FOR 2006 non-facility)rvu (FOR 2006 non-facility)

– Payment- 1.39 x $37.89 = $ 52.68Payment- 1.39 x $37.89 = $ 52.68

4. THE PAYERS

THEN… PAYERS ADOPT RBRVS AS THEN… PAYERS ADOPT RBRVS AS THEIR PHYSICIAN FEE SCHEDULETHEIR PHYSICIAN FEE SCHEDULE

PAYERS SELECT MANY PAYERS SELECT MANY CODES/VALUES- OMIT OTHERS! CODES/VALUES- OMIT OTHERS!

PAYMENT POLICY PAYMENT POLICY

CMS OPTIONS-PAYMENT POLICY

PUBLISHESPUBLISHESRUC RECOMMENDED VALUERUC RECOMMENDED VALUEAMENDED VALUE-OMIT WORKAMENDED VALUE-OMIT WORKMAKE NON-ACTIVE (not paid)MAKE NON-ACTIVE (not paid)

DOES NOT PUBLISH VALUESDOES NOT PUBLISH VALUES

– OTHER PAYERS ASSIGN OWN VALUES OTHER PAYERS ASSIGN OWN VALUES (Carrier Priced)(Carrier Priced)

– OFTEN NOT PAIDOFTEN NOT PAID

5. THE PATIENTS

EMPLOYER PURCHASES PLAN =EMPLOYER PURCHASES PLAN =

COVERED BENEFITS PLANCOVERED BENEFITS PLAN

May not include preventive care/vaccines!

6. PHYSICIAN REIMBURSED

PROVIDER - PAYER CONTRACTPROVIDER - PAYER CONTRACT

PROVIDER PERFORMS THE SERVICEPROVIDER PERFORMS THE SERVICE SUBMITS THE CLAIM (CPT CODE)SUBMITS THE CLAIM (CPT CODE) PAYER PAYS THE CLEAN CLAIMPAYER PAYS THE CLEAN CLAIM

PAYMENT PROBLEMS

PROBLEMS PROBLEMS ANDAND THE BEST THE BEST

SOLUTIONSSOLUTIONS

ARE FOUND AT ARE FOUND AT

DIFFERENT LEVELS !DIFFERENT LEVELS !

POTENTIAL SOLUTIONS AAP Looks for Opportunities To AAP Looks for Opportunities To

Support Vaccine DeliverySupport Vaccine Delivery– CPT Codes-new or revisedCPT Codes-new or revised– RBRVS /CMS – (Im)Prove ValueRBRVS /CMS – (Im)Prove Value– Payers/Employers- Education and Payers/Employers- Education and

DiscussionDiscussion– Providers- Practice Management Providers- Practice Management

SupportSupport

WHAT’S NEW IN CPT AND ICD?

1.1. New CPT Panel Process New CPT Panel Process for Vaccine Codesfor Vaccine Codes

2.2. New and Revised CodesNew and Revised Codes

NEW and Revised Vaccine CPT Product Codes

Timing Is Everything!Timing Is Everything!

Codes should be active when Codes should be active when new vaccines come to new vaccines come to marketmarket

CPT Vaccine Product Codes“Early Release” on the

Website Published in CPT each October- Active 1 Published in CPT each October- Active 1

JanuaryJanuary But Appear Twice a Year on the AMA website But Appear Twice a Year on the AMA website

“early Release”“early Release”-1 Jan.-1 Jan.-1 July-1 JulyCodes Become “Active” for use 6 months after Codes Become “Active” for use 6 months after appearingappearing

www.ama-assn.org/ama/pub/categorywww.ama-assn.org/ama/pub/category//10902.html10902.html

CPT Vaccine Product Codes

New 2006

New appendix K in CPT 2006-list all vaccine New appendix K in CPT 2006-list all vaccine codes for products without FDA approvalcodes for products without FDA approval

New Symbol “New Symbol “ “to indicate FDA approval is “to indicate FDA approval is pending pending

CPT Panel requests for new code CPT Panel requests for new code applicationsapplications– Evidence from Phase 3 Trials of Efficacy/SafetyEvidence from Phase 3 Trials of Efficacy/Safety– Timing of FDA Filing of the BLATiming of FDA Filing of the BLA

NEW FOR 2005Vaccine Coding Caucus

Established to Improve Timing of New Established to Improve Timing of New CPT Vaccine CodesCPT Vaccine Codes

Advisory to the Panel and Maintained by Advisory to the Panel and Maintained by AMA/AAPAMA/AAP

Members- AAP,AAFP, ACIP, ACOG,ANA, Members- AAP,AAFP, ACIP, ACOG,ANA, FDA, CDC, CMS, Vaccine MaufacturersFDA, CDC, CMS, Vaccine Maufacturers

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

9064990649Human Papilloma virus (HPV) vaccine, types 6, 11, Human Papilloma virus (HPV) vaccine, types 6, 11, 16, 18 (quadrivalent), 3 dose schedule, for intramuscular 16, 18 (quadrivalent), 3 dose schedule, for intramuscular useuse

9068090680Rotavirus vaccine, pentavalent, 3 dose schedule, Rotavirus vaccine, pentavalent, 3 dose schedule, live, for oral uselive, for oral use

9071390713 Poliovirus vaccine, inactivated, (IPV), for Poliovirus vaccine, inactivated, (IPV), for subcutaneous or intramuscular usesubcutaneous or intramuscular use

9071490714Tetanus and diphtheria toxoids (Td) adsorbed, Tetanus and diphtheria toxoids (Td) adsorbed, preservative free, for use in individuals seven years or preservative free, for use in individuals seven years or older, for intramuscular useolder, for intramuscular use

9071590715 Tetanus, diphtheria toxoids and acellular Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), for use in individuals 7 years or pertussis vaccine (Tdap), for use in individuals 7 years or older, for im useolder, for im use

NEW FOR 2005Influenza Vaccine Coding Changes-Influenza Vaccine Coding Changes- 90655-preservative free 6-35 mos90655-preservative free 6-35 mos 90656-preservative free age 3 yr-over90656-preservative free age 3 yr-over 90657-split virus, age 6-35 mos 90657-split virus, age 6-35 mos 90658-split virus, age 3 yr-over (90659 90658-split virus, age 3 yr-over (90659

deleted)deleted)

Note cost differentials above! Check Payers!Note cost differentials above! Check Payers!

NEW for 2005 –Pediatric Immunization Administration

Codes Why created- because CMS (and other Why created- because CMS (and other

payers undervalued the codes for payers undervalued the codes for vaccine administration by omitting the vaccine administration by omitting the “work” value (50% of total value)“work” value (50% of total value)

CPT approved “Pediatric” specific codes-CPT approved “Pediatric” specific codes-CMS agreed to publish the relative work CMS agreed to publish the relative work value in the Medicare Fee Schedulevalue in the Medicare Fee Schedule

Pediatric Immunization Administration

9046590465 Immunization administration under Immunization administration under 8 years of age (8 years of age (includes percutaneous, includes percutaneous, intradermal, subcutaneous, or intradermal, subcutaneous, or intramuscular injectionsintramuscular injections)) when the when the physician counsels the patient/family; physician counsels the patient/family; firstfirst injection (single or combination injection (single or combination vaccine/toxoid), per dayvaccine/toxoid), per day(Do not report 90465 in conjunction with (Do not report 90465 in conjunction with 90467)90467)

9046690466 each additionaleach additional injection (single injection (single or combination vaccine/toxoid), per day (List or combination vaccine/toxoid), per day (List separately in addition to code for primary separately in addition to code for primary procedure)procedure)(Use 90466 in conjunction with 90465 or (Use 90466 in conjunction with 90465 or 90467)90467)

Pediatric Immunization Administration

9046790467 Immunization administration Immunization administration under age 8 years under age 8 years (includes intranasal or (includes intranasal or oral routes of administration)oral routes of administration) when the when the physician counsels the patient/family; first physician counsels the patient/family; first administration (single or combination administration (single or combination vaccine/toxoid), per dayvaccine/toxoid), per day(Do not report 90467 in conjunction with (Do not report 90467 in conjunction with 90465)90465)

9046890468 each additionaleach additional administration administration (single or combination vaccine/toxoid), per (single or combination vaccine/toxoid), per day (List separately in addition to code for day (List separately in addition to code for primary procedure)primary procedure)(Use 90468 in conjunction with 90465 or (Use 90468 in conjunction with 90465 or 90467)90467)

Pediatric Immunization Administration

Report codes 90465-90468 only when Report codes 90465-90468 only when the the physician provides face-to-facephysician provides face-to-face counseling of the patient and family counseling of the patient and family during the administration of a during the administration of a vaccine. vaccine.

For immunization administration of any For immunization administration of any vaccine that is not accompanied by vaccine that is not accompanied by face-to-face-to- face physician counseling face physician counseling to the patient/family, report codes to the patient/family, report codes 90471-90474.90471-90474.

Pediatric Immunization Administration

90465-8

1.1. Reflects Vaccine Risk Benefit Reflects Vaccine Risk Benefit Counseling by physician -VISCounseling by physician -VIS

( In CPT Physician = NP = PA )( In CPT Physician = NP = PA )2.2. Use for patients < 8 y.o.Use for patients < 8 y.o.3.3. Different Codes for –Different Codes for –

-First vs Subsequent-First vs Subsequent-Route- injected vs Oral/IN-Route- injected vs Oral/IN

Existing Immunization Administration

90471 90471 Immunization administration Immunization administration (includes percutaneous, intradermal, (includes percutaneous, intradermal, subcutaneous, or intramuscular subcutaneous, or intramuscular injections); one vaccine (single or injections); one vaccine (single or combination vaccine/toxoid) combination vaccine/toxoid)

90472 90472 –each additional vaccine –each additional vaccine (single or combination (single or combination vaccine/toxoid)vaccine/toxoid)

Existing Immunization Administration

90473 90473 Immunization administration by Immunization administration by intranasal or oral route; one vaccine intranasal or oral route; one vaccine (single or combination vaccine/toxoid)(single or combination vaccine/toxoid)

90474 90474

Each additional vaccineEach additional vaccine (single or combination vaccine/toxoid) (single or combination vaccine/toxoid)

Immunization AdministrationExisting Codes Revised

Use (90471-4) for all Use (90471-4) for all encounters when-encounters when-

– Patient is 8 yrs of age or >Patient is 8 yrs of age or >

– Physician Counseling does not Physician Counseling does not occuroccur

ICD-9 PEDIATRICS 2006New and revised ICD vaccine codesNew and revised ICD vaccine codes

V06.1 Diphtheria-tetanus-pertussis, combined [DTP] V06.1 Diphtheria-tetanus-pertussis, combined [DTP] [DtaP] [DtaP]

V06.5 Tetanus-diphtheria [Td][DT] V06.5 Tetanus-diphtheria [Td][DT] V04.81 Need for prophylactic vaccination and V04.81 Need for prophylactic vaccination and

inoculation, Influenza inoculation, Influenza V04.82 Need for prophylactic vaccination and V04.82 Need for prophylactic vaccination and

inoculation, Respiratory synctial virus (RSV).inoculation, Respiratory synctial virus (RSV). V04.89 Need for prophylactic vaccination and V04.89 Need for prophylactic vaccination and

inoculation, Other viral diseases inoculation, Other viral diseases

ICD-9 UPDATE

VACCINE CODING CHANGES 2006

New and revised ICD vaccine codesNew and revised ICD vaccine codes

Released in the Federal Register in Released in the Federal Register in the the

Summer- Active 1 OctoberSummer- Active 1 October

ICD-9 PEDIATRICS 2006New and revised ICD vaccine codes New and revised ICD vaccine codes

V64.00 ..... Vaccination not carried out, unspecified V64.00 ..... Vaccination not carried out, unspecified reason reason

V64.01 ..... Vaccination not carried out because of V64.01 ..... Vaccination not carried out because of acute illness acute illness

V64.02 ..... Vaccination not carried out because of V64.02 ..... Vaccination not carried out because of chronic illness or condition chronic illness or condition

V64.03 ..... Vaccination not carried out because of V64.03 ..... Vaccination not carried out because of immune compromised state immune compromised state

ICD-9 PEDIATRICS 2006New and revised ICD vaccine codes for -New and revised ICD vaccine codes for -

cont.cont. V64.04 ..... Vaccination not carried out because V64.04 ..... Vaccination not carried out because

of allergy to vaccine or component of allergy to vaccine or component V64.05 ..... Vaccination not carried out because V64.05 ..... Vaccination not carried out because

of caregiver refusal of caregiver refusal V64.06 ..... Vaccination not carried out because V64.06 ..... Vaccination not carried out because

of patient refusal of patient refusal V64.07 ..... Vaccination not carried out for V64.07 ..... Vaccination not carried out for

religious reasons religious reasons

Reimbursement Update

CMS and the

Vaccine Administration-

What’s all the fuss? 2000- AMA CREATES CPT CODE2000- AMA CREATES CPT CODE 2000- AMA RUC RECOMMENDS 2000- AMA RUC RECOMMENDS

VALUE VALUE 90471- work rvu 0.20 (est $15 90471- work rvu 0.20 (est $15

total fee)total fee)90472- work rvu 0.17 (est $13 90472- work rvu 0.17 (est $13

total fee)total fee)RUC forwards to CMSRUC forwards to CMS

Vaccine Administration-

What’s all the fuss? CMS omits RVU’s for all Vaccine CMS omits RVU’s for all Vaccine

Administration Codes!Administration Codes!In the Medicare program- Physician In the Medicare program- Physician

Counseling Is Not Typical and Payments Counseling Is Not Typical and Payments Are Bundled Into Other ServicesAre Bundled Into Other Services

CMS Creates Its Own “G” Codes CMS Creates Its Own “G” Codes (HCPCS) for Payment(HCPCS) for Payment

Vaccine Administration-

Private and state Medicaid Payers Private and state Medicaid Payers Select Variable PaymentsSelect Variable Payments– ““carrier priced”- $0-20carrier priced”- $0-20

AAP, AAFP, ACP Comment AAP, AAFP, ACP Comment

2000VACCINE ADMINISTRATION

-BETWEEN A RUC and a Hard

PLACE

Vaccine Administration-

What’s all the fuss? 2001- NO RESPONSE2001- NO RESPONSE 2002- CMS PUBLISHES Relative 2002- CMS PUBLISHES Relative

Values–But…. Values–But…. -value omits work rvu!-value omits work rvu!- pe value cross walked from - pe value cross walked from

simple injection code ($3.98)simple injection code ($3.98) AAP, AAFP, ACP COMMENTAAP, AAFP, ACP COMMENT

Vaccine Administration-

2003- CMS REVISES VALUE2003- CMS REVISES VALUE– PE value now based on resources usedPE value now based on resources used– Values Values increaseincrease– 90471 $3.98 to $7.7590471 $3.98 to $7.75– 90472 $3.98 to $5.2590472 $3.98 to $5.25

BETTER- BUT STILL NO WORK VALUEBETTER- BUT STILL NO WORK VALUE CMS suggests (Federal Register) a CMS suggests (Federal Register) a

coding change might allow physician coding change might allow physician work recognition in childrenwork recognition in children

Vaccine Administration-

2003- AAP Begins Work with AAFP, 2003- AAP Begins Work with AAFP, ACP, and CMS for a Coding ChangeACP, and CMS for a Coding Change– CPT Codes for Vaccine Delivery in ChildrenCPT Codes for Vaccine Delivery in Children– Would Distinguish Codes that Recognize Would Distinguish Codes that Recognize

Physician Counseling Physician Counseling – Would Allow CMS to Publish Physician Work Would Allow CMS to Publish Physician Work

ValueValue

CDC , NVAC, and CMS Support to AMACDC , NVAC, and CMS Support to AMA

Vaccine Administration-

2004- CMS UPDATES VALUE2004- CMS UPDATES VALUE– PE value based on resources usedPE value based on resources used– Values increase under MMA 1.5%Values increase under MMA 1.5%– 90471 $7.75 to 90471 $7.75 to $8.21$8.21– 90472 $5.25 to 90472 $5.25 to $5.60$5.60

STILL NO WORK VALUESTILL NO WORK VALUE

SO, NEW FOR 2005

VACCINE ADMINISTRATION VACCINE ADMINISTRATION CODES for CHILDREN CODES for CHILDREN

MEDICARE MODERNIZATION ACTMEDICARE MODERNIZATION ACT

RBRVS FOR 2005 Good News!

Medicare Fee Schedule RBRVS

CPT CODE RVU $$ 20 04 CPT CODE RVU $$ 20 04 2006 2006

90471-90471- .21 .21 .49 .49 $8.21 $8.21 $17.73$17.7390472-90472- .15 .15 .31 .31 $5.60 $5.60 $10.49$10.49

90465- .49 90465- .49 $8.21 $8.21 $17.73$17.7390466-90466- .31.31 $5.60 $5.60 $10.99$10.99

99213- 1.39 $ 52.6899213- 1.39 $ 52.68

2006 Conversion factor = $37.892006 Conversion factor = $37.89

RBRVS FOR 2006Now… Good News for Oral/

Intranasal!CPT CODE RVU $$ -2006CPT CODE RVU $$ -2006

90473-90473- .0 .0 .37 .37 $0 $0 $13.39$13.3990474-90474- .0 .0 .26 .26 $0 $0 $9.41$9.41

90467- .35 90467- .35 $$12.6612.6690468-90468- .27.27 $9.77$9.77

99213- 1.39 $ 52.6899213- 1.39 $ 52.68

2006 conversion factor = $37.892006 conversion factor = $37.89

All IA Codes Now Fully Valued!Primary Primary CodesCodes

Add-on Add-on CodesCodes

CPT CPT codecode

Short DescriptionShort Description Total Total RBRVRBRV

SS

Avg Avg Medicare Medicare AllowanceAllowance

Total Total RBRVRBRV

SS

Avg Avg Medicare Medicare AllowanceAllowance

9046590465 11stst Injection w/counseling, Injection w/counseling, < age 8 years< age 8 years

.49.49 $18.57$18.57

9046690466 Each Add’l Injection Each Add’l Injection w/counseling, < age 8 w/counseling, < age 8 yearsyears

.29.29 $10.99$10.99

9046790467 11stst Intranasal or oral Intranasal or oral w/counseling, < age 8 w/counseling, < age 8 yearsyears

.35.35 $12.66$12.66

9046890468 Each Add’l Intranasal or Each Add’l Intranasal or oral w/counseling, < age 8 oral w/counseling, < age 8 yearsyears

.27.27 $9.77$9.77

9047190471 First InjectionFirst Injection .49.49 $18.57$18.579047290472 Each Add’l InjectionEach Add’l Injection .29.29 $10.99$10.999047390473 11stst Intranasal or oral Intranasal or oral .37.37 $13.39$13.399047490474 Each Add’l Intranasal or Each Add’l Intranasal or

oraloral.26.26 $9.41$9.41

RBRVS FOR 2005 Good News!

POTENTIAL IMPACT-POTENTIAL IMPACT-4,000,000 births a year in the US4,000,000 births a year in the US25 Vaccines birth to five25 Vaccines birth to five100,000,000 vaccine admin. 100,000,000 vaccine admin. (Possible)(Possible)$1,000,000,000$1,000,000,000 potential to potential to support vaccine delivery!!support vaccine delivery!!

Immunization Administration 2006 Relative Values

Contracting

These Relative Values Are Resource These Relative Values Are Resource Based and Validated Through a Based and Validated Through a Rigorous Process (RUC/CMS Review)Rigorous Process (RUC/CMS Review)

They Should Serve as the Basis (the They Should Serve as the Basis (the FLOOR) for Valuing the Service by FLOOR) for Valuing the Service by Payers and ?State Medicaid ProgramsPayers and ?State Medicaid Programs

Vaccine Product ReimbursementChanges in Payer Methodology

CMS now using Average Sales Price CMS now using Average Sales Price (ASP) for medications (ASP) for medications

Private Payers AdoptingPrivate Payers Adopting– Lower Than AWP by 10-25%Lower Than AWP by 10-25%– May Push Reimbursement of Vaccine May Push Reimbursement of Vaccine

Products to Providers Lower/Below Products to Providers Lower/Below Actual Cost to Purchase, Store, and Actual Cost to Purchase, Store, and Maintain InventoryMaintain Inventory

A CHALLENGE-COMBINATION VACCINES

THE PARADOX-THE PARADOX- AS NUMBER OF COMPONENTS in 1 AS NUMBER OF COMPONENTS in 1

vaccine INCREASE-vaccine INCREASE--physician work of counseling -physician work of counseling

increases, but……..increases, but……..-practice expenses decreases-practice expenses decreases

Immunization Coding for Future

AAP Working on-AAP Working on-1.1. CPT Code for CPT Code for

Immunization Immunization Administration of Administration of Combination VaccinesCombination Vaccines

2.2. Increasing the AgeIncreasing the Age

AAP REIMBURSEMENT INITIATIVES 2006

Private Payer Advocacy Private Payer Advocacy ProgramProgram

– Meeting with National PayersMeeting with National Payers– State Managed Care Councils State Managed Care Councils

meet with Local/regional payersmeet with Local/regional payers– Vaccines Are a Top PriorityVaccines Are a Top Priority

Immunization Task ForceImmunization Task Force

The “New World” Pay For Performance

“P4P”¡ Programs that Payers Use to Programs that Payers Use to

Provide Incentives for Physicans Provide Incentives for Physicans to Improve Performance on to Improve Performance on Selected MeasuresSelected Measures

¡ CMS- 2006- Physician Voluntary CMS- 2006- Physician Voluntary Reporting ProgramReporting Program¡ Private Payers Watching- Some Private Payers Watching- Some

ImplementingImplementing

The “New World” Pay For Performance

¡ Pediatric Programs Will Likely Pediatric Programs Will Likely Use Immunization Rates As a Use Immunization Rates As a MeasureMeasure¡ 1. Process- % of children offered 1. Process- % of children offered

vaccines at a preventive medicine vaccines at a preventive medicine visitvisit

¡ 2. Outcome- Number of children 2. Outcome- Number of children completely vaccinated by age 2.completely vaccinated by age 2.

The “New World” –P 4 P

Correct Coding –both CPT and ICD Correct Coding –both CPT and ICD will become even more will become even more important as pediatric pay for important as pediatric pay for quality programs increase. quality programs increase.

New Codes (CPT Category II) will New Codes (CPT Category II) will allow data reporting using allow data reporting using claims dataclaims data

The “New World” –P 4 PCPT Category II Codes

-Proposed By the AMA -Proposed By the AMA Performance Improvement Performance Improvement Advisory GroupAdvisory Group

-Will Be Used by CMS for PVRP-Will Be Used by CMS for PVRP

The “New World” –P 4 P

Potential Strength- Allows Finances Potential Strength- Allows Finances to Follow Vaccine Deliveryto Follow Vaccine Delivery

Potential Threat- the Potential Threat- the Administrative Burden of Administrative Burden of Reporting/Collecting Data May Reporting/Collecting Data May Be Overwhelming To PhysiciansBe Overwhelming To Physicians

The “New World” Consumer Directed Health

Plans¡ Insurance Plans that Combine Insurance Plans that Combine

¡ High Deductible PolicyHigh Deductible Policy¡ Health Savings Account Health Savings Account

¡ Provide a Fixed Cost for Provide a Fixed Cost for EmployersEmployers

¡ Transfers Risk to Patient Transfers Risk to Patient (Member)(Member)

The “New World” Consumer Directed Health

Plans¡ Potential Strength- Insurance Potential Strength- Insurance

Becomes More Affordible for Becomes More Affordible for Some PopulationsSome Populations

¡ Potential Threat- First Dollar Potential Threat- First Dollar Coverage for Preventive Services Coverage for Preventive Services (Well Care and Vaccines)(Well Care and Vaccines)¡ Will Patients Use Their $ for Will Patients Use Their $ for

Vaccines?Vaccines?

Future- Keep The

Mission! Develop a Solution for Reporting Develop a Solution for Reporting

Combination Vaccine AdministrationCombination Vaccine Administration Private and State Medicaid Payer Private and State Medicaid Payer

“Education” About New Codes/Values“Education” About New Codes/Values Involvement by Those Who Involvement by Those Who

Understand Vaccines in the P4P Understand Vaccines in the P4P Process and CDHP’sProcess and CDHP’s

Whew!....

Thank You