Pediatric Council

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Pediatric Council
Steven Goldstein, M.D.
E-mail Dr. Goldstein

What is the New York Chapter 2 and New York 3 Pediatric Council?

The Pediatric Council is a group of pediatricians from New York Chapters 2 and 3 that has been working behind the scenes for some time representing the pediatric practitioners in our area.  The Council has been meeting with insurance companies to make them aware of the coverage, payment and logistical issues confronting our membership and has been negotiating to resolve them.

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Chapter Liaisons How can you help? July 2012 Update
Change in Medicaid billing for vaccine administration for 2013
UrgentUse modifier -25 for Vaccine Administration as of January 1, 2013
96110 June 2012 Update Aetna Denies HPV9 for Males

What has been accomplished?

To date, we have had meetings with Aetna, Empire Blue Cross, GHI-Emblem and United Health Care. Meetings generally occur about three times per year with each company.  To date, our Council has been instrumental in the facilitating the following:

  • Blue Cross reversing its denials of developmental testing codes
  • Speaking with United Health Care about its recent bundling of those codes with the office visit.   United is reprocessing the denied claims.
  • GHI has revised its 365 day rule and well visits now go by calendar year.
  • CPT Code 96110 will continue to be covered by Medicare

Who are our representatives on the Council?

  • Chapter 3
    • Andrew Racine
    • Evelyn Ha
  • Chapter 2
    • Richard Ancona
    • Stuart Beeber
    • Steven Goldstein

Our District II Executive Director also attends and has been of great assistance in scheduling the meetings and preparing our agendas and conference calls.

How can you help?

Our task is complicated by the number of insurance companies doing business in the Downstate area; currently, there are twenty seven (27). To address this situation we have devised the following strategy, but this strategy requires manpower and that is why we are soliciting your participation.  We would like to identify chapter members to act as a liaison with an individual insurance company and develop an ongoing working relationship with someone in the upper management in that company.   These liaisons would act as the Council’s contact with the company and would be invited to attend our meetings with them.   If an issue arises, the liaison would be the first to address it with his or her contact at the company. Hopefully those contacts at the insurance companies would communicate through the liaison if they needed a problem brought to the attention of the pediatric community.   We would like to have a liaison for each of the 27 companies which is why we need your participation. If you are interested, and we hope you are, please e-mail Steve Goldstein at   and we will discuss this opportunity with you.

We can do more, but we need your help. If you do not feel comfortable being a liaison, we still need your input and to hear about your problems. Please forward your concerns to us so we can add them to our agenda for future meetings with the insurance companies.

Required Immunizations
(Developed in consultation with the Commissioner of Health)

The Advisory Committee on Immunization Practices (ACIP) develops and adopts recommendations for the routine administration of vaccines for children and adults and promulgates schedules regarding the appropriate periodicity, dosage, and contraindications applicable to the vaccines.  Pursuant to Circular Letter No. 13 (2006), covered necessary immunizations for dependent children to age 19 are those vaccines and immunizations recommended by the ACIP.  ACIP recommendations are posted to the ACIP website after they are adopted.  Later, they are published in the Morbidity and Mortality Weekly Report (MMWR).  Once a recommendation is adopted, the vaccine or immunization must be covered in accordance with Circular Letter No. 13 (2006) as of the date of adoption.  Insurers and health plans should monitor the ACIP and CDC websites regularly for the most current information on recommended vaccinations.   Reliance on information published in the MMWR, should only be utilized in the absence of posted recommendations on the ACIP or CDC Websites, but even in such cases, recommended vaccines must ultimately be covered back to the date of adoption by ACIP.

Provisional recommendations and the federal Vaccines for Children Program (VFC) resolutions are posted on the ACIP and VFC websites and indicate adoption by ACIP. Please see the links below for more information.

ACIP Recommendations and VFC Resolutions (new external link)

AAP Practice Management Pearl

The AAP has recently launched a new online form for members to report challenges they have experienced with medical home recognition or certification programs, or to provide comments on specific ways standards might be made more pediatric-relevant.  To provide comments which will be reviewed and shared with certifying organizations as appropriate, visit the Medical Home Certification Hassle Factor Form. For more practice-related information, visit the AAP practice support page.

Effective January 1, 2015, the CPT code for fluoride varnish application is 99188.  It is suggested to append a V-33 modifier for preventive services.

Practitioner and Ordered Ambulatory Providers:
Change in Medicaid billing for vaccine administration for dates of service on and after January 1, 2013

HHS to partner with pediatricians as Medicaid payments increase
by Kathleen Sebelius, Secretary, U.S. Department of Health and Human Services

Council Update, July 2012 (Posted 7/21/12)

The Pediatric Council, a combined group from Chapters 2 and 3, continues to interact with insurers to advocate for child health care coverage and to address the concerns of our members.

Emblem Health (GHI and HIP) stopped paying for in-office hemoglobin testing and CBC’s sometime in May. Currently they will only pay for these tests when done by a hematologist or oncologist.   All other doctors must send the lab work out. This issue had been discussed in 2010 when it was proposed by HIP and we thought the issue had been resolved. We have been in contact with them to reverse this policy and our appeal is pending.   This policy creates another layer of difficulty for the pediatric office and patients and will delay filing of WIC forms.   It seems to be contrary to the guidelines of Bright Futures and the concept of the Medical Home as well. If this has affected you, please speak to your Emblem provider representative to register your dissatisfaction. At our last meeting with Emblem they told me that I was the only doctor to complain about their policies. I will keep you posted about the outcome of these negotiations.

The issue of payment for developmental testing by Fidelis is still active.   A new letter just went out to their Medical Director from the District Chair, making a strong case for reversal of the policy and requesting reconsideration of claims back to April 1, 2012.   The new autism law, scheduled to take effect November 1, mandates that insurers cover screening, diagnosis and therapy.

Straight Medicaid does not recognize code 96110 either.   We advocate for inclusion of this code as a payable service but budgetary constraints will not allow this.   The code is currently considered by Medicaid a part of the well visit fee. Medicaid is considering how best to distribute the extra funds available for primary care under the Affordable Care Act.

Some thoughts for practitioners about how best to deal with insurers and utilize the Pediatric Council:

  1. Fill out a Hassle Factor Form and send it in. The Councils get them and we can bring your problems to the insurers.       Issues are taken seriously and we are willing to advocate for the practitioner. We can’t add a problem to the agendas if we are not aware of it.
  2. Speak to your Provider Representatives when issues come up.       Let them know about your problem and ask them to get you an answer or direct you to someone higher up in the organization.
  3.  Ask parents and parent groups who are affected by your issue to discuss it with the insurer. No company wants a roster of unhappy clients.
  4.  Join the Pediatric Council and help us advocate for Children and Pediatricians.

Respectfully submitted,

Steven J. Goldstein, M.D., F.A.A.P.
Chair, Pediatric Council District 2, Chapter 2

Council Update, June 2012 (Posted 6/4/12)

The Pediatric Council, a combined group from Chapters 2 and 3, continues to meet with insurers to advocate for child health care coverage and to address the concerns of our members.

  • Our May meeting with Emblem Health (GHI and HIP) was disappointing.
    • We again discussed the year and a day rule for checkups (which states that a 2nd checkup must wait for one year and one day from the first one) and why payment is denied when the service is rendered in separate calendar years.  Other companies have been able to adjust their computer systems to a calendar year basis, but GHI will deny a claim that occurs in the subsequent calendar year if the patient had not yet had another birthday.  Promises were made to discuss this with the IT people at Emblem.
    • The issue of well visits for age 19 and up was also discussed.  Apparently many Emblem plans do not cover well care (visits and immunizations) after age 18.  Parents and physicians need to be aware of this provision of their plans and confirmation of well care coverage should be made prior to the visit.
    • Emblem does not recognize code 90461, the auxiliary immunization administration code, as a payable service.  Their payment for 90460 is well below the average for New York insurers.
    • The HIP Medicaid product pays a unit fee no matter what the level of service and does not differentiate between well and sick visits.  Currently their payment is below straight Medicaid.  This policy defies CMS rules and in my opinion is unethical, if not illegal.  A promise was made to look at the issue.  We are formulating a strategy to address this issue in Albany.  Elie Ward, our legislative advocate is working with us.
    • Emblem has agreed to pay separately for vision screening (99173), but is inconsistent.  They will look at this as well.
    • We will meet with Emblem again after the summer.
  • As many of you are aware, Fidelis stopped paying for developmental screening services (96110) as of April 1, 2012.  A letter went out from the District Chair, also signed by the Pediatric Council Chairs from around the state, to their Medical Director.  After a month went by with no response, I called him.  He expressed his opinion that since straight Medicaid does not recognize the code, Fidelis is not obligated to do so as well.  I explained that many codes are not recognized by the Medicaid system, that guidance from CMS intends for this code to be paid, that there is a mandate from the state to do screening, and that the service is valuable.  In addition, it takes time and expertise and there are associated costs.  The director said he would take my argument into consideration and the company would reconsider the issue.  A strategy is being formulated now to address this again if Fidelis does not rescind its decision.  The new autism law, to take effect November 1st, mandates that screening, diagnosis and therapy of autism be covered by all insurers in the state.
  • At my quarterly meeting with Empire Blue Cross, the issue of non-payment for teaching use of the nebulizer or aerochamber was discussed.  The opinion of Empire is that this service should be bundled with the visit.  A visit that includes this service might be increased by 1 level, say from a 99213 to a 99214.  Billing for the service, even though it is not paid, will help document that it was done and justify the level of service through the time component.  In addition, billing for pulse oximetry, if it was done, would also help to document the level of service.  Please note that many other companies continue to pay for this service (code 94664).

The Pediatric Council is interested in hearing about your issues with insurers and recruiting members to join us. If you have problems you would like to discuss, would like to help us, or agenda items for our meetings, please contact me at .

Respectfully submitted,

Steven J. Goldstein, M.D., F.A.A.P.

Aetna Denies Payment for HPV9 for Males (Posted 6/4/15)

PPAAC has learned from our Aetna contact that Aetna will not be covering HPV9 for boys greater than 15 years of age and if submitted claims will not be paid for that age group.  This is despite the ACIP recommendation and the recent AAP News publication that we shared with them.  Aetna revisits these policies quarterly. This will stand at least until the fall.

CPT Code 96110 (Posted 1/2/12)
CMS will assign the RVU’s for 96110 so that it can remain a covered service for pediatrics when used as developmental testing with a report using a standardized testing tool.

The American Medical Association’s CPT editorial panel recently revised the description of code 96110 to cover “developmental screening” rather than developmental testing, as it had been previously described. As Medicare does not pay for screening or preventive services unless such coverage is authorized under the Medicare statute, for Medicare purposes, CMS modified the active status of code 96110 and did not include associated value units in the 2012 Medicare Resource Based Relative Value Scale physician fee schedule (PFS).

This change resulted in many questions and potentially unintended consequences for other payers. We want to be clear that Medicaid and other private payers will be able to continue to use code 96110 even though it is a statutorily non-covered service under Medicare. In addition, many State Medicaid programs rely upon Medicare-published relative value units, including those associated with code 96110. At the request of Medicaid and concerned stakeholders, in the next few weeks Medicare will provide the relative value units for this code.

Revised payment files to reflect corrections and revisions to the physician update amount will be posted on the Physician Fee Schedule portion of the CMS website under the PFS Relative Value Files section, available here in the near future. In advance of these files, the payment rate for code 96110 will be based on 0.28 total Relative Value Units (0.27 practice expense and 0.01 malpractice).

CMS has also created a new code, G0451 (Developmental testing with interpretation and report, per standardized instrument form), and published associated relative value units, to ensure that physicians can continue to bill for the types of services encompassed under CPT 96110 when used for testing and not screening purposes.

Urgent Message for AAP Members who Provide and Bill for Vaccine Administration

On January 1, 2013 the Centers for Medicare and Medicaid Services (CMS) released the latest version of the National Correct Coding Initiative (NCCI) edits. The NCCI edits are code edits published by both Medicaid and Medicare to support correct coding and claims adjudication. Included in the new Medicaid and Medicare edits were edits on all evaluation and management (E/M) services that disallow patient with immunization administration codes without the proper modifier. The modifier indicator for all these edits is a “1,” meaning that with proper modifier placement, the edit can be overridden.

While the Academy is urgently working with National Correct Coding Solutions – the CMS contractor for NCCI edits – to have the edits suspended on all preventive medicine service codes (99381-99385 and 99391-99395) with all immunization administration codes (90460 and 90461, 90471-90474). It should be noted that the edits are currently locked in and will continue to be in effect for Medicaid, Medicare, and private payers that implement CMS coding policies until such time that AAP advocacy efforts are successful. Over the past several days, the AAP has been in telephone contact with the highest levels of the CMS contractor responsible for the NCCI edits and has delivered a formal letter demanding retraction of these edits.

Therefore, effective immediately and for all claims submitted after January 1, 2013, AAP urges its members to append modifier 25 to the preventive medicine service code (99381-99395) when it is reported in conjunction with any immunization administration service (90460-90461; 90471-90474).

A modifier 25 should also be appended to other non-preventive medicine E/M services (eg, 99201-99215) when reported in conjunction with immunization administration — but only when the E/M service is significant and separately identifiable.

We understand this is an administrative burden for you and your staff. The AAP is working diligently to unlock this change and will forward additional information on this issue as it becomes available.

Please contact the AAP Coding Hotline with any questions or issues: