Pediatric Coding Alert

Vaccine, CCM increases are offset by a CF reduction that may not even come to pass.

For pediatric practices, the Centers for Medicare & Medicaid Services’ (CMS’) publication of the final rule for 2022 looks to be a light at the end of a very long two-year tunnel. First, CMS’s re-evaluation of two key pediatric services looks set to increase your bottom line. More, even some potential bad news contained within the final rule’s pages could end up being a blessing in disguise for peds billing.

Here’s all you need to know to get your new year off to a great start.

Get a Shot in the Arm With These New Vaccination Rates

“I’d say there are more positives than negatives in the final rule as far as pediatrics is concerned. Among them, CMS is increasing the payment allowance for influenza, pneumococcal, and hepatitis B vaccine administration,” says Kent Moore, senior strategist for physician payment at the American Academy of Family Physicians.

For 2022, CMS will pay $30 per dose for the administration of these vaccines, up from last year’s rate of $16.94 per dose. Additionally, the final rule will “maintain the current payment rate of $40 per dose for the administration of the COVID-19 vaccines through the end of the calendar year in which the PHE ends.”

This all spells good news for pediatric practices. “In light of reports from our clients already receiving varying payment rates for administering COVID-19 vaccine, I am reassured by this expectation. Having CMS backing fairer payment through this extraordinary circumstance may make advocating for proper rates from private insurers more fruitful,” notes Jan Blanchard, CPC, CPEDC, CPMA, pediatric solutions consultant at Vermont-based PCC.

However, CMS is still holding off on its valuation of 96372 (Therapeutic, prophylactic, or diagnostic injection (specify substance or drug); subcutaneous or intramuscular), 90460/+90461 (Immunization administration through 18 years of age … with counselling by physician or other qualified health care professional; first or only component of each vaccine …), 90471/+90472 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine…), and 90473/+90474 (Immunization administration by intranasal or oral route; 1 vaccine…), codes that, as we reported in Pediatric Coding Alert vol. 24 no. 9, have significantly decreased in value for the last five years.

Manage Your Expectations of These CCM, Complex CCM, and PCM Services

“Another piece of good news in the final rule is that CMS is increasing payment for chronic care management (CCM) services,” says Moore.

The table below shows the increase in relative value units (RVUs) for the old codes, and the valuation of both the old and new codes CMS is introducing this year:

Don’t Let the Lowered CF Bring You Down

On the surface, one part of the final rule look looks like it could spell disaster for all specialties, including pediatrics. “Beginning Jan. 1, 2022, CMS will decrease the conversion factor (CF) from $34.89 to $33.59. This looks like the biggest negative in the final rule,” notes Moore.

What’s the problem? The CF is a critical part of the resource-based relative value scale (RBRVS), the complex formula CMS uses to establish payment for services. CMS uses RVUs for services based on the work, practice expense (PE), and malpractice insurance (MP) involved. They are then adjusted by geographic practice cost indices (GPCI) to reflect the variations in the costs of furnishing the services. Then everything is multiplied by a final multiplier — the CF — to produce a dollar value using the following formula:

Payment = [(RVU work × GPCI work) + (RVU PE × GPCI PE) + (RVU MP × GPCI MP)] × conversion factor (CF).

What does this mean for your bottom line? Quite simply, if Medicare lowers the CF, then payments for all services are lowered accordingly. So, a reduction of $1.30 in the CF will result in services being valued lower next year. However, the change does not mean pediatrics will be adversely affected for two reasons.

First, the finalized CY 2022 PFS estimated impact on total allowed charges by specialty for pediatrics is 0 percent, according to CMS. Second, healthcare lobbyists, including the American Medical Association (AMA), have sounded their objections to this part of the final rule. “The AMA is strongly advocating for Congress to avert this and other looming cuts to Medicare physician payments that, overall, will produce a combined 9.75 percent cut for 2022. This comes at a time when physician practices are still recovering the personal and financial impacts of the COVID public health emergency,”

says AMA President Gerald E. Harmon, MD, in a statement (URL: www.ama-assn.org/press-center/press-releases/ama-statement-physician-fee-schedule-final-rule). So, “the impact of a lowered CF could change if Congress intervenes,” Moore points out.

(To view the full final rule, go to public-inspection.federalregister.gov/2021-23972.pdf).