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.