Advanced Search

Pediatric Coding Alert

2005 Fee Schedule Shocks Peds With Immunization Admin Pricing

Published on Sat Jan 22, 2005

Rate hike may offset code value declines

A small increase in the 2005 fee schedule conversion factor (CF) may not affect your bottom line much, due to E/M payment decreases and no extra money for new vaccine administration codes.
 
Remember: Even though Medicare creates the Physician fee schedule, the rule impacts pediatricians. "Over 75 percent of private payers use the fee schedule in some fashion to determine physician reimbursement," says Richard Tuck, MD, FAAP, a member of the American Academy of Pediatrics national committee on coding and nomenclature.

Congress Raises Payment

This year you'll enjoy a slight increase in the 2005 CF to $37.8975 from the 2004 CF of $37.3374.
 
How it works: To calculate approximately how much a service or procedure pays nationally, multiply the code's total relative value units (RVUs) by the CF.
 
Example: Code 99213 (Office or other outpatient visit for the evaluation and management of an established patient ...) contains 1.39 RVUs and pays $52.68 in 2005. In 2004, the office visit had 1.41 RVUs and paid $52.65. (Some payers may use different CFs and RVUs.)
 
As the 99213 payment shows, the slight CF increase may make up for RVU cuts. Some other E/Ms that received non-facility (office) RVU decreases include:
 

  • 99202 down to 1.72 RVUs from 1.73 RVUs
     
  • 99203 down to 2.56 RVUs from 2.57 RVUs
     
  • 99214 down to 2.18 RVUs from 2.20 RVUs.

    All Shot Administration Codes Pay the Same

    One of the biggest surprises, however, is that Medicare granted work RVUs to the existing vaccine administration codes (90471-90472), as well as to the new pediatric-specific immunization administration with counseling codes (90465-90468). "Prior to 2005, 90471-90474 didn't contain any physician work expense," Tuck says.
     
    The AAP fought for the creation of 90465-90468 so pediatricians could receive payment for precounseling work associated with administering immunizations in the pediatric population. The organization, however, didn't expect Medicare to give work values to 90471-90474.
     
    Problem: New codes 90465-90466 don't contain any more RVUs than the existing codes 90471-90472. "If 90465-90466 are to properly represent vaccine administration with counseling in the pediatric population, the resource-based relative value system should value them higher than the noncounseling, age-8-and-over codes 90471-90472," Tuck says.
     
    Payments: Medicare allotted 0.49 RVUs ($18.57 national unadjusted rate) to 90465 - the same amount 90471 contains - and 0.29 RVUs ($10.99 national unadjusted rate) to 90466 and 90472. Codes 90465 and 90471 both contain 0.17 work RVUs. Medicare assigned 0.15 work RVUs to 90466 and 90472.
     
    The AAP is appealing the decision. So for possible increased future payment and correct coding principles, practices should strive to incorporate the new codes.
     
    Intranasal and oral vaccine administration (90467-90468 and 90473-90474) received no published RVUs. CMS feels that patients self-administer intranasal vaccines, so the service involves no physician work. "Obviously, this is a faulty assumption when dealing with children, and the AAP is appealing the decision," Tuck says.
     
    You can download the AAP's brochure on the 2005 RBRVS including payment information from     www.aap.org/visit/2005rbrvs.pdf.

    • Other Articles in this issue of

    Pediatric Coding Alert

    View All