Pediatric Coding Alert

Many commonly used codes will negatively impact this year’s bottom line.

As we reach the end of the first quarter of 2019, are you noticing a drop in your practice’s income? If you’ve seen a reduction in revenue, you’re not alone. And if you haven’t, chances are you will soon enough.

Here’s why.

“Even with the mild increase in the Medicare Multiplier from $35.99 to $36.04, the overall impact of the 2019 RBRVS [resource-based relative value scale] on typical pediatricians will be a 1.45 percent reduction in revenue” explains Chip Hart, director of PCC’s Pediatric Solutions Consulting Group in Vermont and author of the blog “Confessions of a Pediatric Practice Consultant,” in a recent blog post “The (Negative) Impact of the 2019 RBRVS on Pediatricians” (Source: chipsblog.pcc.com/the-negative-impact-of-the-2019-rbrvs-on-pediatricians).

To find out why, you’ll need to look at your most commonly used codes. Eight in particular could be responsible for having a significant negative impact on your bottom line. And one — “the most common code performed in pediatrics,” according to Hart’s data — could well be the biggest culprit.

What’s Dragging Revenues Down?

First, here’s a look at ten of the most commonly coded pediatric services and procedures along with the percentage decrease in their values for 2019.

Many in the pediatric coding community have expressed great concern over these reimbursement reductions. “While the decrease in 95004 will probably only affect a few pediatric offices, it is important for everyone to realize that a devaluation in the administration and screening codes is coming,” says Donelle Holle, RN, president of Peds Coding Inc., and a healthcare, coding, and reimbursement consultant in Fort Wayne, Indiana.

“CMS has targeted the lifeblood of pediatrics, the most important service in all of medicine: vaccine administration. They have also targeted screenings of all kinds — developmental, hearing, behavioral,” concurs Hart. In particular, “the almost 20 percent cut to 90460, the most common code performed in pediatrics,” is, or may be, responsible for the largest reduction in your income, according to Hart.

Is Anything Going Up?

If there’s a bright side to Hart’s analysis, it’s that four of the top 30 pediatric codes did show an increase of one percent or more:

“The values of some codes have been improved, but overall, it doesn’t bode well. The total 1.5 percent decrease translates to a $3,000 to $10,000 decrease in a pediatrician’s actual take home pay,” Hart observes.

Why Is This Happening?

Experts are baffled by the reduction. “There seems to be no reason for the decision,” says Holle. “CMS must have just decided that the RVU [relative value unit] was just too high for the services rendered,” Holle speculates.

“Ultimately, it looks like CMS tied the antigen-based codes to the therapeutic injection codes, so when those values changed, so did the antigen-based admin codes,” adds Hart.

How Can You Offset the Revenue Loss?

“Ultimately, you should make sure you are coding correctly in the first place. Even with the 1.5 percent decrease in expected RVU values, more money is left on the table every year due to unrecorded procedures, missed opportunities to provide vital preventive services, or simply just coding poorly,” advises Hart.

In part, this means understanding pricing and the way RBRVS works. “Too many practices are undercharging for these immunization administration codes already, so they’ve never even been paid properly in the first place,” Hart cautions.

Lastly, you and your practice should offer your input whenever the American Academy of Pediatrics (AAP) “reaches out to the membership to ask for inputs on certain procedures in order to inform CMS about the real costs of providing each CPT^® code. Unfortunately, AAP don’t get enough volunteers or data and don’t paint as compelling a picture as the other specialties do,” Hart believes.

For a full explanation of how the RBRVS affects code values and pricing, see Pediatric Coding Alert volume 21 number 1.