Pediatric Coding Alert

Office and telephone E/M increases significantly offset preventive service decreases.

Forecasting the future is hard enough during the best of times. But add in the doubt and uncertainty of a global pandemic and even the best crystal ball can get foggy.

However, as we have done for a number of years now, we turned to Chip Hart, director of PCC’s Pediatric Solutions Consulting Group in Vermont and author of the blog “Confessions of a Pediatric Practice Consultant,” for some clear predictions about 2021 pediatric practices, and here’s what he had to say.

Preventive Medicine Continues Downward Trend …

First, the bad news. “As I noted last year, 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,” Hart observes.

In fact, while 2021 Medicare rates for some preventive codes such as 90460 (Immunization administration through 18 years of age … with counseling by physician or other qualified health care professional; first or only component of each vaccine …), +90461 (… each additional vaccine …), 90471 (Immunization administration; … 1 vaccine), +90472 (… each additional vaccine), 96160 (Administration of patient-focused health risk assessment instrument …), 96161 (Administration of caregiver-focused health risk assessment instrument …), and 96127 (Brief emotional/behavioral assessment …) have either shown modest gains over, or stayed the same as, 2020, the four-year trend for the codes shows that they have mostly decreased:

Takeaway 1: Hart praises the role of the American Academy of Pediatrics (AAP) in lobbying to keep fees high for 90460, +90461, 90471, and 90472 “The AAP’s work to restore immunization administration values was partially successful, and the values were returned to 2019 levels, which is better than 2020!” Hart notes.

Takeaway 2: “The 96160/96161 health risk assessments combo got a nice boost, too. This is a good reminder that you should be doing postpartum screenings on your parents,” Hart recommends.

… While E/Ms Save the Day …

“In an effort to move more money into primary care, the Feds pushed a lot of RVUs [Relative Value Units] into the E/Ms [evaluation and management codes],” Hart notes. In other words, “The tide has turned. Not entirely, not quite the way we’d hope, but significantly so,” Hart believes.

Here’s how the Medicare fees look for the 99202-99215 (Office or other outpatient visit for the evaluation and management of a new/established patient …) codes:

Of special note, while new patient office and outpatient E/Ms have mostly seen modest gains, level 2-5 established patient sick visits get large increases (23.12, 21.43, 18.80, and 23.50 percent respectively, according to Hart’s analysis).

Takeaway 3: This is great news for peds practices, as “although we are beginning slowly at this point, if sick visit volumes return to a more typical level, the positive financial impact will be significant,” Hart predicts.

… and Telephone Services

Last, fees for telephone E/M services 99441-99443 (Telephone evaluation and management service by a physician or other qualified health care professional who may report evaluation and management services provided to an established patient, parent, or guardian …) received massive increases this year:

The Bottom Line

Pediatric offices could be looking at significant revenue increases in 2021. “Using 2020’s volume and 2021’s RVUs, the implication is that an FTE [full-time equivalent] pediatrician would see an increase of about $50,000 in revenue. That’s not how this works, but it’s an encouraging result!” Hart notes.

However, not all pediatric practices will see such increases. Medicare and private payers use geographic practice cost indices (GCPIs) “to adjust the payments or valuation of CPT^® codes based on where you work. For example, Long Island is a more expensive locale in which to practice than Alabama, and insurance payments reflect that fact,” Hart explains. So, where you practice will have a large impact on your revenue.

But the increase is also good news for “practices working on their insurance contracts this year. They should heartily avoid contracts based in years 2018-2020,” in Hart’s opinion, and peg their contract to 2021 to take advantage of this year’s revenue increases.

For more information, go to chipsblog.pcc.com/impact-of-2021-rvus-on-pediatricians.