National Vaccine Advisory

CommitteeJoel F. Bradley. MD, FAAP

Washington, D.C.June 4, 2003

NVAC

VACCINE ADMINISTRATION:

BETWEEN THE RUC and

A HARD PLACE

THE PLAN

1. HOW PHYSICIANS ARE PAID- CPT AND THE RUC

2. THE RBRVS3. VACCINE CODING AND REIMBURSEMENT

HOW WE GET PAID

(KEY TO SOLVING REIMBURSEMENT

PROBLEMS)

SERVICE CODE

VALUE RBRVS

FEE SCHEDULE

CONTRACT $

1. THE CODE

First…DEFINE THE SERVICE

Then…GET A CODE! (AMA CPT)

The CPT Process: The genesis of a code

Table P roposal C P T C ode C han ge

R eject P roposal

CPT Panel

C P T Spec ialty Advisors

AM A S taf f R eview

Specia lty SocietyW e 've go t a n id e a ...

CPT: CURRENT PROCEDURAL TERMINOLOGY

• BEGAN IN 1966• 8,000 CODES; OFFICIAL

PROCEDURAL CODE SET FOR HIPAA• OWNED BY AMA -- BIG BUSINESS• REVISED ANNUALLY IN THE FALL

CPT: THE EDITORIAL PANEL• 16 VOTING MEMBERS

– 11 PHYSICIANS NOMINATED BY AMA BOARD OF TRUSTEES PLUS:

– 1 HCPAC REPRESENTATIVE– CMS, BCBSA, AHA AND HIAA REPRESENTATIVES

• NOMINATED BY SPECIALITY SOCIETIES• OF THE 11 AMA-APPOINTED SEATS, FOUR

ARE 4-YEAR TERMS AND SEVEN ARE 8- YEAR TERMS

CPT: THE EDITORIAL PANEL

• CPT ADVISORY COMMITTEE

– 100 SPECIALTY SOCIETIES– EACH HAS ONE ADVISOR– ADVISOR PRESENTS CODE PROPOSAL– ADVISOR COMMENTS ON ALL CODES

2. THE VALUE

SECOND…GET A VALUE

AMA/SPECIALTYSOCIETY RELATIVE VALUESCALE UPDATE COMMITTEE (RUC)

The RUC Process Genesis of Relative Value for

Physicians

F ederal R egis ter

H C F A &C arrier M edical D irec tors

RVS Update Com m ittee

R U C S u rvey

R eview by Spec ia lty S oc iety Advisors

RUC: THE RBRVS UPDATE COMMITTEE

• 29 MEMBERS– 23 SEATS ASSIGNED TO SPECIALTIES– ALSO AMA, AOA, HCPAC, PEAC, CPT

EDITORIAL PANEL• NOMINATED BY SPECIALITY

SOCIETIES• APPOINTED BY AMA BOARD• NO TERMS

RUC: THE RBRVS UPDATE COMMITTEE

• CMS ATTENDS/COMMENTS• RUC ADVISORY COMMITTEE

– ADVISORS PRESENT SOCIETY RVU RECOMMENDATIONS ON WORK AND PE

– PRESENTATION DATA BASED ON MEMBER SURVEYS AND EXPERT PANELS

RUC: THE RBRVS UPDATE COMMITTEE

• RUC VOTES ON RELATIVE VALUE• RECOMMENDATIONS TO CMS

– Physician work RVU– Direct practice expense inputs (CMS

calculates PE RVU)

CPT VS. RUCCPT RUC

AAP SEAT (VOTE) (-) +AAP ADVISOR + +OPEN MEETING +/- +ARBITRATION - (appeal) +CMS + +

3. THE FEE SCHEDULE (RBRVS)

• NEXT…CMS AGREES (90%!), OR…• CAN OR • PUBLISHES THE VALUE (FEDERAL

REGISTER); MEDICARE FEE SCHEDULE OR RBRVS

CMS OPTIONS: PAYMENT POLICY

• PUBLISHESRUC RECOMMENDED VALUEAMENDED VALUE-OMIT WORKMAKE NON-ACTIVE (not paid)

• DOES NOT PUBLISH VALUES

– OTHER PAYERS ASSIGN OWN VALUES– OFTEN NOT PAID

4. THE PAYERS

THEN…PAYERS ADOPT RBRVS AS THEIR PHYSICIAN FEE SCHEDULE

• PAYERS SELECT MANY CODES/VALUES -- OMIT OTHERS!

• PAYMENT POLICY -- LMRP

5. THE PATIENTS

EMPLOYER PURCHASES PLAN=

PACKAGE of COVERED BENEFITS

6. PHYSICIAN REIMBURSED

PROVIDER - PAYER CONTRACT

• PROVIDER PERFORMS THE SERVICE• SUBMITS a CLEAN CLAIM (CPT CODE)• PAYER PAYS THE CLAIM per

CONTRACTED FEE SCHEDULE

REIMBURSEMENT

PROBLEMS AND SOLUTIONS

ARE FOUND AT

EACH LEVEL!

RBRVS AND PEDIATRICIANS

Resource Based Relative

Value Scale

RBRVS AND PEDIATRICIANS

• RELEVANCE TO PRACTICE

– IT IS THE BASIS OF HOW WE GET PAID!

RBRVSResource Based Relative

Value Scale• Fee Schedule of CMS-Medicare• Used by most ALL Payers• Most CPT codes have a “Relative

Value”

RBRVS by PAYER% WHO USE

0102030405060708090

BC/BS MCO-pvt MCAID OTHER

RBRVS

RBRVS AND PEDIATRICIANS• RBRVS

– Began January 1, 1992 (CPT E/M codes)– Authorized by Congress 1989: OBRA ’89– Revised the Medicare Fee Schedule

(1965)•A CPR system (customary,

prevaling,reasonable)•Maintains budget neutrality ($20 million)

RBRVS AND PEDIATRICIANS

CONCEPT- Services are ranked relative to the costs of the resources used to perform them.– If service A is twice as hard,takes

twice as long, used twice the overhead expense of service B, then A will have twice the value of B.

RBRVS: MAJOR COMPONENTS

1. PHYSICIAN WORK2. PRACTICE EXPENSE3. PROFESSIONAL LIABILTY

INSURANCE (PLI) (MALPRACTICE) EXPENSE

RBRVS-Relative Value-RVU• RVU = value of a service relative to

another– Total RVU= work RVU + practice

expense RVU + PLI RVU

– 99213 –reference = 1.39 RVU

RBRVS AND PEDIATRICIANS

MAJOR COMPONENTS

WORK53%

PE44%

PLI3%

PHYSICIAN WORK

• PHYSICAN TIME• TECHNICAL SKILL/PHYSICAL

EFFORT• MENTAL EFFORT/JUDGEMENT• STRESS-IATROGENIC RISK

PHYSICIAN WORK

SERVICE PERIODS– PRE-SERVICE (PREPARATION)– INTRA-SERVICE (PATIENT ENCOUNTER

TIME)– POST-SERVICE (CHARTING, PHONE

CALLS ABOUT THE PROBLEM)

PRACTICE EXPENSE

1. DIRECT COSTSCLINICAL LABOR,MEDICAL SUPPLIES, AND MEDICAL EQUIPMENT2. INDIRECT COSTSADMINISTRATIVE LABOR,OFFICE EXPENSE, AND OTHER COSTS

PRACTICE EXPENSE

SITE OF SERVICE “ADJUSTMENTS” (CMS ADJUSTS PE DOWNWARD IF DONE

IN A FACILITY-AVOIDS DOUBLE PAYMENTS)

• FACILITY=HOSPITAL,ASC,SNF • NON-FACILITY= PRIVATE OFFICE

PLI- PROFESSIONAL LIABILITY INSURANCE

– 1-3% of the total RVU– ORIGINALLY CHARGE BASED– RESOURCE BASED SINCE 2000– BASED ON SPECIALTY SPECIFIC

PREMIUM DATA, RISK, AND UTILIZATION

RBRVS-Relative Value-RVUTOTAL RVU= Work RVU + Practice

Expense (PE) RVU + Professional Liability Insurance (PLI) RVU

– 99213 reference = 0.67 RVU (work) + 0.69 (PE) + 0.03 RVU (PLI) = 1.39 total RVU (For 2003)

So…can you take an RVU to

the bank?

• Pay $ = Total RVU (in units) x Conversion Factor (CF) in $/RVU

CONVERSION FACTOR

• 1999 - $34.73• 2000 - $36.61• 2001 - $38.25• 2002 - Nov. Fed. Register-

$36.19 %5.4 CMS changes conversion factor annually to maintain budget neutrality

CONVERSION FACTOR2003

• 2003 Proposed = $34.59 4.4% Federal Register – Dec. 02-2003 Final Rule

• FEB. LEGISLATIVE “FIX”- $36.78 1.5%

This only has to apply to Medicare!

RBRVS-Relative Value-RVU

• Your pay = RVU x CF =$• At “100%” of Medicare RBRVS • 99213

– 1.32 RVU x $38.25 = $50.50 (2001)– 1.39 RVU x $36.19 = $50.32 (2002)– 1.39 RVU x $36.78 = $51.12 (2003)

CONVERSION FACTOR$ BY PAYER

05101520253035404550

BC/BS MCO-pvt MCAID OTHER

CF

OTHER MEDICARE “ADJUSTMENTS”

• GPCI– GEOGRAPHIC PRACTICE COST INDEX– ACCOUNTS FOR GEOGRAPHIC

DIFFERENCE IN COST OF RESOURCES– 1.0 = AVERAGE– DIFFER BY AREA (STATE) AND TYPE OF

RESOURCE (WORK, PE, PLI)

Vaccine Administration Codes

and the

THE PROBLEMS

• CMS (other payers) has not valued physician work of counseling (o rvu) in vaccine administration

• Combination vaccines present a unique reimbursement issue regarding physician counseling

THE SIZE of the PROBLEM

• Four million births a year• Each child receives over 20 vaccines • The majority of vaccines are

administered in the private sector

BIG!

THE AAP VISION• Have all payers value physician work

of face to face counseling about vaccines

• Remove any financial barriers inherent in current coding system to using combination vaccines

THE BEST SOLUTIONS

• Create or revise codes so that work is recognized

• Work with CMS and all payers to obtain reimbursement for the “new” codes

THE SERVICE-CODESGIVING VACCINES-

PHYSICIANS REPORT (BILL):1. CPT Code for the Product

and always2. CPT code for Vaccine

administration

Immunization Administration2000

• 90471 Immunization administration, one vaccine, single or combination(includes percutaneous, intradermal, subcutaneous, intramuscular and jet injections )

• 90472 Each additional vaccine

Immunization AdministrationVaccines-new for 2002

• 90473 Immunization administration, one vaccine -intranasal or oral(single or combination)

• 90474 Each additional vaccine

*CMS CONSIDERS THESE “SELF-ADMINISTERED”-NO RVU’S

Vaccines/Toxoids• 90476 – 90749

– Identify the specific vaccine product only

– Use in addition to administration codes

– Use even if vaccine supplied for free ( data used by payers/CDC to monitor immunization practice)

Immunization AdministrationExample

• 6 month infant-preventive visit- receives 4 immunizations-

– DTaP- 90700 + 90471– IPV - 90713 + 90742– PCV7- 90669 + 90472– HIB - 90648 + 90472– HepB- 90744 + 90472

(VFC-Enter charge of $0 for CPT product codes, usual charge for administration codes)

THE VALUE-AMA RUC1999 RUC 90471/90472

• RECOMMENDS PHYSICIAN WORK VALUE- – 90471- 0.17 rvu– 90472-0.15 rvu

• FORWARDS TO CMS (who adds pe/pli values)

CMS-RBRVSMEDICARE FEE SCHEDULE

2000 - No values published. Uses “G” code

2001 – No values published2002- Value published total rvu

0.11=$3.98omitted physician work componentsame value as simple injection

CMS-RBRVSMEDICARE FEE SCHEDULE

• 2003 - CMS REVISES VALUE– PE value based on resources used– Values increase– 90471 – rvu 0.21 -$3.98 to $7.75– 90472 – rvu 0.15 -$3.98 to $5.25

• STILL NO WORK VALUE

CMS-RBRVSMEDICARE FEE SCHEDULE

FEDERAL REGISTER- DEC 31, 2002- CMS would consider adding physician work to pediatric vaccine administration if codes reflect pediatric services- In general- won’t publish work in the existing codes- not typical of Medicare vaccines admin., may code in other ways

Vaccine Administration2003

AAP Works with AMA and CMS • AAP DEVELOPS A CODE PROPOSAL

FOR PEDIATRIC-SPECIFIC VACCINE ADMINISTRATION

• IF CPT EDITORIAL PANEL APPROVES, CMS could ADD WORK VALUE FOR 2004/2005

CURRENTLY….

FEB. 2003 – CPT REJECTS INTIAL AAP PROPOSAL FOR 4 PEDIATRIC CODES

MAY 2003- PANEL and AAP AGREE TO DEVELOP A SINGLE CODE FOR PEDIATRIC VACCINE COUNSELING

(AAP will present in August 2003)

COMBINATION VACCINES

THE PARADOX:• AS NUMBER OF COMPONENTS in 1

vaccine INCREASES:-physician work per shot increases-practice administrative costs decrease (nurse time , syringes charting)

Immunization AdministrationExample-Combination Vaccine

• 4 month infant-preventive visit- now receives same components in 3 immunizations-

– DTaP-HepB-IPV- 90723 + 90471– PCV7- 90669 + 90472– HIB - 90648 + 90472

Immunization Administration-Combination Vaccine

Financial Impact on Practice

1. Loss of income from 2 vaccine administration services (90472)

= $5.52 x 2= $11.04 per visit2. Physician time to counsel is

the same

“New” New Code Proposal-Single Code for Counseling

1. Is reported once per visit when vaccine administration and physician counseling are documented (regardless of the number of separate vaccines given)

2. Recognizes physician work-valued based on existing components.

3. Can be “revalued” through the RUC as new components are licensed.