Pediatric Coding Alert

It might offset proposed CF reductions.

If you’ve looked at the 2023 Medicare Physician Fee Schedule (MPFS) proposed rule issued by the Centers for Medicare & Medicaid Services (CMS) on July 7, you may have panicked at the mention of a 4.42 percent decrease in the Medicare conversion factor (CF). What you may not have noticed, though, is the proposed changes to the immunization administration RVU valuation, which could well offset the CF decrease and boost your bottom line.

Here’s a brief explanation of the proposed RVU changes that could positively affect your practice’s bottom line next year.

Reflect on RVU Increases for 90460, 90471, and +90472

RVU Refresh: RVUs are the basic component of the Resource-Based Relative Value Scale (RBRVS), which is a methodology used by the Centers for Medicare & Medicaid Services (CMS) and some private payers to determine physician payment. Total RVUs are the sum of three component RVUs:

• Physician work RVUs (to cover the cost of the provider’s “work”)
• Practice expense RVUs (to cover the cost of supplies, equipment, etc.)
• Malpractice expense RVUs (to cover the cost of professional liability expenses)

Under the RBRVS, physician payment for services are determined by three things: total RVUs, geographic practice cost indices (GPCIs), and the conversion factor (CF).

Proposed changes: According to the proposed CMS Final Rule for 2023, here is what we can potentially expect to see:

• 90460 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered): Total RVUs increase from 0.49 to 0.65, which is a 32.7 percent increase
• 90471 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)): Total RVUs increase from 0.49 to 0.58, which is an 18.4 percent increase
• + 90472 (Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)): Total RVUs increase from 0.37 to 0.42, which is a 13.5 percent increase

Note: The RVU value for + 90461 (Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)) is slated to decrease by 18.9 percent to account for the removal of the practice expense that had been calculated into previous versions of the schedule.

Do the Math, See the Money

“Between the roughly 9 percent increase from the 2021 E/M changes, and the 1-3 percent improvement with the immunization administration, the CF decrease shouldn’t be enough to make anyone sad. I expect most pediatricians would benefit significantly to a move to the 2023 RVUs,” says Chip Hart, director of PCC’s Pediatric Solutions Consulting Group in Vermont and author of the blog “Confessions of a Pediatric Practice Management Consultant.” Let’s say a pediatrician administers 2,000 units of 90460. That’s an average payment of around $20.00. For 2022, that translates to approximately $37,000 in revenue. For 2023, that would translate to about $50,000. With most pediatricians doing somewhere between 1,500 and 2,500 vaccines a year, this could make a big impact.

If you calculate those increases and the one loss, the valuation adjustments translate into a 15.4 percent RVU increase. Based on estimations, “it works out, on average, to $5,000 to $6,000 per full time equivalent [FTE] pediatrician. That is real money; as none of this work increases your overhead, it should all flow right to you.” Hart explains. (You can read more about what Chip Hart has to say about all this here: chipsblog.pcc.com/the-2023-imms-admin-rvu-changes-should-have-real-impact)

Holding Payers Accountable May Present Challenges

Private payers are not obligated to follow Medicare, of course, and can refuse or reduce the amount they pay a physician, depending on the terms of their contract. Antitrust laws ensure the right to purchase services at the lowest negotiable price.

“The impact of these [RVU] changes relies entirely on payers. Unless the payers make RVU-based payments for these services, the change remains in the realm of theory,” says Jan Blanchard, CPC, CPEDC, CPMA, pediatric solutions consultant at Vermont-based PCC. “Knowing your contracts is paramount to enforcing any adjustments for payments not made in accordance with the agreements you have in place,” she adds.

Important reminder: The RVU adjustments could change when the proposed rule becomes finalized later this year.

For a fact sheet on the CY 2023 Physician Fee Schedule proposed rule, visit www.cms.gov/newsroom/fact-sheets/calendar-year-cy-2023-medicare-physician-fee-schedule-proposed-rule

To view the full CY 2021 Physician Fee Schedule and Quality Payment Program proposed rule, visit public-inspection.federalregister.gov/2022-14562.pdf

Submit comments on the proposed rule by going to: www.regulations.gov/ (please refer to file code CMS-1770-P). The 60-day comment period closes on Sept 6, 2022.