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National Vaccine Advisory Committee

National Vaccine Advisory Committee. Joel F. Bradley. MD, FAAP Washington, D.C. June 4, 2003. NVAC VACCINE ADMINISTRATION: BETWEEN THE RUC and A HARD PLACE. THE PLAN. HOW PHYSICIANS ARE PAID- CPT AND THE RUC THE RBRVS VACCINE CODING AND REIMBURSEMENT.

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National Vaccine Advisory Committee

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  1. National Vaccine Advisory Committee Joel F. Bradley. MD, FAAP Washington, D.C. June 4, 2003

  2. NVACVACCINE ADMINISTRATION:BETWEEN THE RUC and A HARD PLACE

  3. THE PLAN • HOW PHYSICIANS ARE PAID- CPT AND THE RUC • THE RBRVS • VACCINE CODING AND REIMBURSEMENT

  4. HOW WE GET PAID(KEY TO SOLVING REIMBURSEMENT PROBLEMS)

  5. SERVICE  CODE VALUE  RBRVS FEE SCHEDULE  CONTRACT  $

  6. 1. THE CODE First…DEFINE THE SERVICE Then…GET A CODE! (AMA CPT)

  7. The CPT Process: The genesis of a code

  8. 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

  9. 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

  10. CPT: THE EDITORIAL PANEL • CPT ADVISORY COMMITTEE • 100 SPECIALTY SOCIETIES • EACH HAS ONE ADVISOR • ADVISOR PRESENTS CODE PROPOSAL • ADVISOR COMMENTS ON ALL CODES

  11. 2. THE VALUE SECOND…GET A VALUE AMA/SPECIALTY SOCIETY RELATIVE VALUE SCALE UPDATE COMMITTEE (RUC)

  12. The RUC Process Genesis of Relative Value for Physicians

  13. 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

  14. 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

  15. RUC: THE RBRVS UPDATE COMMITTEE • RUC VOTES ON RELATIVE VALUE • RECOMMENDATIONS TO CMS • Physician work RVU • Direct practice expense inputs (CMS calculates PE RVU)

  16. CPT VS. RUC CPT RUC AAP SEAT (VOTE) (-) + AAP ADVISOR + + OPEN MEETING +/- + ARBITRATION - (appeal) + CMS + +

  17. 3. THE FEE SCHEDULE (RBRVS) • NEXT…CMS AGREES (90%!), OR… • CAN  OR  • PUBLISHES THE VALUE (FEDERALREGISTER); MEDICARE FEE SCHEDULE OR RBRVS

  18. CMS OPTIONS: PAYMENT POLICY • PUBLISHES RUC RECOMMENDED VALUE AMENDED VALUE-OMIT WORK MAKE NON-ACTIVE (not paid) • DOES NOT PUBLISH VALUES • OTHER PAYERS ASSIGN OWN VALUES • OFTEN NOT PAID

  19. 4. THE PAYERS THEN…PAYERS ADOPT RBRVS AS THEIR PHYSICIAN FEE SCHEDULE • PAYERS SELECT MANY CODES/VALUES -- OMIT OTHERS! • PAYMENT POLICY -- LMRP

  20. 5. THE PATIENTS EMPLOYER PURCHASES PLAN = PACKAGE of COVERED BENEFITS

  21. 6. PHYSICIAN REIMBURSED PROVIDER - PAYER CONTRACT • PROVIDER PERFORMS THE SERVICE • SUBMITS a CLEAN CLAIM (CPT CODE) • PAYER PAYS THE CLAIM per CONTRACTED FEE SCHEDULE

  22. REIMBURSEMENT PROBLEMS AND SOLUTIONS ARE FOUND AT EACH LEVEL!

  23. RBRVS AND PEDIATRICIANS Resource Based Relative Value Scale

  24. RBRVS AND PEDIATRICIANS • RELEVANCE TO PRACTICE • IT IS THE BASIS OF HOW WE GET PAID!

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

  26. RBRVS by PAYER% WHO USE

  27. 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)

  28. 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.

  29. RBRVS: MAJOR COMPONENTS • PHYSICIAN WORK • PRACTICE EXPENSE • PROFESSIONAL LIABILTY INSURANCE (PLI) (MALPRACTICE) EXPENSE

  30. 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

  31. RBRVS AND PEDIATRICIANSMAJOR COMPONENTS

  32. PHYSICIAN WORK • PHYSICAN TIME • TECHNICAL SKILL/PHYSICAL EFFORT • MENTAL EFFORT/JUDGEMENT • STRESS-IATROGENIC RISK

  33. PHYSICIAN WORK SERVICE PERIODS • PRE-SERVICE (PREPARATION) • INTRA-SERVICE (PATIENT ENCOUNTER TIME) • POST-SERVICE (CHARTING, PHONE CALLS ABOUT THE PROBLEM)

  34. PRACTICE EXPENSE 1. DIRECT COSTS CLINICAL LABOR,MEDICAL SUPPLIES, AND MEDICAL EQUIPMENT 2. INDIRECT COSTS ADMINISTRATIVE LABOR,OFFICE EXPENSE, AND OTHER COSTS

  35. 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

  36. 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

  37. RBRVS-Relative Value-RVU TOTAL 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)

  38. So…can you take an RVU to the bank? • Pay $ = Total RVU (in units) x Conversion Factor (CF) in $/RVU

  39. 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

  40. 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!

  41. 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)

  42. CONVERSION FACTOR$ BY PAYER

  43. 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)

  44. Vaccine Administration Codesand the Relative Value Roller Coaster

  45. 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

  46. 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!

  47. 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

  48. 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

  49. THE SERVICE-CODES GIVING VACCINES- PHYSICIANS REPORT (BILL): 1. CPT Code for the Product and always 2. CPT code for Vaccine administration

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