Pediatric Coding Alert

Don’t let decreases in revenue for common peds services drag you down.

Every year, Chip Hart, director of PCC’s Pediatric Solutions Consulting Group in Vermont and author of the blog “Confessions of a Pediatric Practice Consultant,” looks into his crystal ball (well, a custom-built pediatric relative value unit [RVU] calculator actually) to determine whether pediatric practice revenues are trending up or down.

Hart’s methodology, which compares the impact of 2020’s RBRVS (resource-based relative value scale) with 2019’s on the most common codes pediatricians perform once again shows a small yet significant loss to pediatric practices.

To see what could happen to your practice, here is a look at Hart’s analysis of pediatric revenues this year, along with some suggestions about what you can do to avoid your bottom line taking a big hit.

What Is RBRVS and Why Is it Important?

Every year, the Centers for Medicare & Medicaid Services (CMS) calculates the value of medical procedures using a complex formula known as RBRVS. The formula starts with Medicare calculating the RVUs for each procedure in three ways: based on the work involved in the service (RVU work), the expense of the procedure to the practice (RVU PE), and the malpractice insurance (RVU MP) associated with the service.

RVU work, RVU PE, and RVU MP are each then multiplied by a geographic practice cost index (GPCI), then the whole formula is multiplied by a conversion factor (CF) to arrive at a dollar value for each procedure.

Given that Medicare set the CF for 2020 at 36.0896, up from 2019’s 36.039, you would expect that each procedure would see a modest gain. But according to Hart, that’s not what happened, and revenues in pediatrics may actually go down this year.

What Is Causing Pediatric Revenues to Decrease?

“For the third year in a row, the key elements of preventive care — the most important work that pediatricians do and the obvious place where our economy and culture need to invest — have been cut significantly,” according to Hart.

That means decreases in 90460/+90461 (Immunization administration through 18 years of age via any route of administration, with counseling …), 90471/+90472 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections) …), and 90473/+90474 (Immunization administration by intranasal or oral route …).

“These are tiny codes that make up the thinnest sliver of our healthcare expense, yet they are what keep pediatricians alive,” Hart observes. “If we go beyond the RVUs and actually look at the dollars involved … the 15 percent drop in the 90460 and 90471 alone will contribute, on average, to an approximate $4,000 to $7,000 drop in a typical pediatrician’s revenue. Devastating, and hard to understand,” Hart adds.

Worse, “health risk assessments 96160 [Administration of patient-focused health risk assessment instrument …] and 96161 [Administration of caregiver-focused health risk assessment instrument …], and behavioral/emotional screening 96127 [Brief emotional/behavioral assessment …] have taken double-digit hits,” Hart points out.

But It’s not all Doom and Gloom

Some procedures your pediatric practice may see on a frequent basis, though less than immunizations and screenings — 86580 (Skin test; tuberculosis, intradermal) and 17250 (Chemical cauterization of granulation tissue (ie, proud flesh)), for example — do see increases in the 2020 PFS.

However, that’s not enough to offset the losses you may well see in other areas of your practice’s revenues. Ultimately, “it falls on physicians themselves to make a change in their practice and habits in order to remain financially solvent,” recommends Barbara Hays, CPC, CPCO, CPMA, CRC, CPC-I, CEMC, CFPC, AAPC Fellow, Senior Managing Consultant with  Soerries Coding and Billing Institute in Grain Valley, Missouri.

That’s why Hart and Hays suggest your practice take these five proactive steps to protect, and possibly even grow, your revenue in 2020 and beyond.

1. Avoid 2019 and 2020 RBRVS-based contracts. “Every insurance contract is pegged to some year of RBRVS for contracting. The hit to immunization administration codes over the last two years really zaps pediatricians, so I encourage them to anchor to years like 2018 or 2017 instead. Most payers lag by a few years, so it’s not a big deal to do this,” Hart advises.

2. Check that your 99213/99214 distribution is around 30 percent 99214, 65 percent 99213. “Regardless of the RBRVS year we’re using … if you’re coding and charting only 15 to 20 percent 99214s, you’re only making private insurance companies wealthy,” Hart calculates. However, “it is important that physicians code correctly and ethically, not just be ‘box checkers’ to obtain that higher code,” Hays cautions.

3. Review your Bright Futures-based services and make sure they are being performed and billed. “It is important that pediatricians code for the things they are already doing,” Hays notes. This includes claiming for all of your age-appropriate screenings.

4. Confirm that your immunizations and administrations are aligned. For each immunization you bill, always make sure you bill a corresponding administration code.

5. Check your pricing. Again, “make sure you are documenting and receiving full payment for such things as immunization counseling — 90460/+90461 — and dermatology services done in the office, such as wart removals. Also, look and see if you can provide services that have been farmed out over the last years, such as laboratory, respiratory, and other screening services,” Hays advises.

For more information on how the 2020 RBRVS is impacting pediatric practices, go to chipsblog.pcc.com/impact-of-2020-rbrvs-on-pediatricians.