Pediatric Pediatric ReimbursementReimbursement

Secretary’s Advisory Secretary’s Advisory Committee on Infant Committee on Infant Mortality Meeting Mortality Meeting

(SACIM)(SACIM)Charles Schulte M.D, FAAPCharles Schulte M.D, FAAP

March 1, 2005March 1, 2005

OUR GOAL OUR GOAL

BUILDING THE BUSINESS BUILDING THE BUSINESS CASE FOR AN CASE FOR AN

SUCCESSFUL CARE SUCCESSFUL CARE MODELMODEL

THE PLANTHE PLAN

1.1. Review the Reimbursement Review the Reimbursement Infrastructure for Pediatric Service Infrastructure for Pediatric Service DeliveryDelivery

2.2. Discuss Existing /Future NeedsDiscuss Existing /Future Needs

An OverviewAn Overview

THE BIG PICTURE - HOW THE BIG PICTURE - HOW SERVICES ARE PAIDSERVICES ARE PAID

HOW SERVICES ARE HOW SERVICES ARE PAIDPAID

First…DEFINE THE SERVICEFirst…DEFINE THE SERVICE

Then…GET A CODE! (AMA CPT)Then…GET A CODE! (AMA CPT)

The Coding SystemThe Coding System

The Coding System Forms a The Coding System Forms a

Key ComponentKey Component

of the Reimbursement of the Reimbursement InfrastructureInfrastructure

for Physician Servicesfor Physician Services

The Coding SystemThe Coding System

Physicians Report Services Provided Physicians Report Services Provided to Patients to Payers Using to Patients to Payers Using Numeric CodesNumeric Codes

HIPAA Requires Certain Code Sets HIPAA Requires Certain Code Sets for Electronic Transactionsfor Electronic Transactions

CPT and ICD are the Core Code Sets CPT and ICD are the Core Code Sets Used by All PhysiciansUsed by All Physicians

The CPT Process -- The CPT Process -- The genesis of a The genesis of a

codecode

Table P roposal C P T C ode C hange

R ejec t P roposal

C PT Panel

C P T S pec ialty A dvisors

A M A S taf f R eview

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

CPT- CURRENT CPT- CURRENT PROCEDURAL PROCEDURAL TERMINOLOGYTERMINOLOGY

• BEGAN IN 1966BEGAN IN 1966• >8000 CODES- OFFICIAL CODE SET >8000 CODES- OFFICIAL CODE SET

FOR HIPAAFOR HIPAA• OWNED BY AMAOWNED BY AMA• REVISED YEARLY –FALL (October)REVISED YEARLY –FALL (October)

CPT – THE EDITORIAL CPT – THE EDITORIAL PANELPANEL

• 17 VOTING MEMBERS17 VOTING MEMBERS• 16 MD’S 1 PT16 MD’S 1 PT• 3 ARE PAYERS (CMS, BCBS,PVT)3 ARE PAYERS (CMS, BCBS,PVT)

• NOMINATED BY SPECIALITY NOMINATED BY SPECIALITY SOCIETYSOCIETY

• APPOINTED BY AMA BOARDAPPOINTED BY AMA BOARD• 4 AND 8 YEAR TERMS4 AND 8 YEAR TERMS

CPT ADVISORY CPT ADVISORY COMMITTEECOMMITTEE

• ADVISES the EDITORIAL PANELADVISES the EDITORIAL PANEL• 100 SPECIALTY SOCIETIES100 SPECIALTY SOCIETIES• EACH HAS ONE ADVISOREACH HAS ONE ADVISOR

• ADVISOR PRESENTS CODE ADVISOR PRESENTS CODE PROPOSALPROPOSAL

• ADVISOR COMMENTS ON ALL ADVISOR COMMENTS ON ALL CODESCODES

HOW SERVICES ARE HOW SERVICES ARE PAIDPAID

Next…GET A VALUE (AMA Next…GET A VALUE (AMA RUC)RUC)

Then….CMS (RBRVS-Medicare Then….CMS (RBRVS-Medicare FEE SCHEDULE) FEE SCHEDULE)

The RUC ProcessThe RUC Process Genesis of Relative Value for Genesis of Relative Value for

Physicians Physicians

F ederal R egis ter

C M S &C arrier M edical D irectors

RVS Update Com m ittee

R U C Survey

R eview by Spec ialty S oc iety A dvisors

RBRVSRBRVS

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

Value”Value”

RBRVS AND RBRVS AND PEDIATRICIANSPEDIATRICIANS

RResource esource BBased ased

RRelative elative

VValue alue SScalecale

RBRVS by PAYERRBRVS by PAYER

0

10

20

30

40

50

60

70

80

90

BC/BS MCO-pvt MCAID OTHER

RBRVS

HOW SERVICES ARE HOW SERVICES ARE PAIDPAID

Plus… PAYERS- (ADOPT RBRVS –Plus… PAYERS- (ADOPT RBRVS –VARIATIONS in PAYMENT POLICY)VARIATIONS in PAYMENT POLICY)

““PAINMENT POLICY”PAINMENT POLICY”

Example- Obesity Services Are Example- Obesity Services Are Excluded from Coverage (by ICD Excluded from Coverage (by ICD Code)Code)

HOW SERVICES ARE HOW SERVICES ARE PAIDPAID

Combine…EMPLOYER (PURCHASE A Combine…EMPLOYER (PURCHASE A PACKAGE OF “COVERED BENEFITS”)PACKAGE OF “COVERED BENEFITS”)

Example-The Policy May Not CoverExample-The Policy May Not CoverAny Preventive Services- excludes Any Preventive Services- excludes

Well Child CareWell Child Care

HOW SERVICES ARE HOW SERVICES ARE PAIDPAID

Last……PROVIDER CONTRACTS Last……PROVIDER CONTRACTS With PAYERSWith PAYERS

Individual physician , Group Individual physician , Group Practice, IPA Practice, IPA

HOW SERVICES ARE HOW SERVICES ARE PAIDPAID

PROBLEMS PROBLEMS ANDAND SOLUTIONS SOLUTIONS

ARE FOUND AT ARE FOUND AT

EACH LEVEL!EACH LEVEL!

If Services Are Not If Services Are Not Paid…….Paid…….Where Is The Where Is The

Problem?Problem?Code- CPT/ICD (system or individual)Code- CPT/ICD (system or individual)

RBRVS- RUC or CMSRBRVS- RUC or CMS

Payment Policy of Payer- Payment Policy of Payer-

Patient- Covered Benefit-Patient- Covered Benefit-

The Contract-The Contract-

Payment PolicyPayment Policy““Good Codes Do Not a Dollar Make”Good Codes Do Not a Dollar Make”

Finding the Value !Finding the Value !

• Payers Will be Insurance Companies, Payers Will be Insurance Companies, Employers, State and Federal Agencies, Employers, State and Federal Agencies, and our PATIENTSand our PATIENTS

• All Must Find the Value in Preventive and All Must Find the Value in Preventive and Treatment ServicesTreatment Services

• How Do WE Create Value?How Do WE Create Value?

BEST PRACTICES-BEST PRACTICES-THE CHARGETHE CHARGE

1.1. DEVELOP THE BEST DEVELOP THE BEST CLINICALCLINICAL CARE CARE MODEL USING EBMMODEL USING EBM

2.2. ENSURE AVAILABILITY of ADEQUATE ENSURE AVAILABILITY of ADEQUATE CPT and ICD CODES for CPT and ICD CODES for REIMBURSEMENT and REGISTRIESREIMBURSEMENT and REGISTRIES

3.3. TEACH BOTH to PROVIDERS TEACH BOTH to PROVIDERS and and PAYERSPAYERS

PEDIATRIC PEDIATRIC CODING RESOURCESCODING RESOURCES

Resources-PublicationsResources-PublicationsBOOKSBOOKS

• AMA- AMA- • Current Procedural Terminology 2005Current Procedural Terminology 2005• Physician’s Guide to the RBRVSPhysician’s Guide to the RBRVS• ICD 2005ICD 2005• Code Manager- 2005 (Electronic)Code Manager- 2005 (Electronic)

• AAP- AAP- Coding for Pediatrics 2005Coding for Pediatrics 2005 Quick Reference Guide to Pediatric Quick Reference Guide to Pediatric

Coding and Coding and DocumentationDocumentation -2005 -2005

Resources- PublicationsResources- PublicationsNewslettersNewsletters

• AMA- CPT AssistantAMA- CPT Assistant• AAP News- Coding Corner (monthly)AAP News- Coding Corner (monthly)• AAP Coding CompanionAAP Coding Companion

• Pediatric Coders Pink SheetPediatric Coders Pink Sheet• Pediatric Coding AlertPediatric Coding Alert