Pediatric Council

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Pediatric Council
Chairperson:
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.

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.
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Chapter Liaisons How can you help?
UrgentSeparate payment for E/M services

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
    • Jesse Hackell
  • 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 SJG34@Cornell.edu   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.


Separate payment for E/M services and a 0 or 10-day global procedure reported with Modifier 25


Immunization Administration

New Versus Established Patient Status

Immunization Administration CPT Codes

  • 90460 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered
  • 90461 Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; each additional vaccine or toxoid component administered (List separately in addition to code for primary procedure)
  • 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
  • 90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
  • 90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)
  • 90474 Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

New Versus Established Patient Status

The red portions of the 90460-90461 code descriptors listed above play a key role in determining patient status (ie, new versus established).

Since the 90460-90461 immunization administration (IA) codes require that a physician/qualified health care professional provide the vaccine counseling, reporting a code from the 90460-90461 family always establishes the patient.

Reporting IA codes 90471-90474 – which do not include the same requirement – may not. Since IA codes 90471-90474 do not require that a physician/qualified health care professional provide the vaccine counseling, these codes are appropriately reported for encounters where clinical staff (eg, nurse) provides the vaccine counseling – and where the physician/qualified health care professional never provides a face-to-face service.

Per CPT, “a new patient is one who has not received any professional services from the physician/qualified health care professional or another physician/qualified health care professional of the exact same specialty and subspecialty who belongs to the same group practice, within the past three years….solely for the purposes of distinguishing between new and established patients, professional services are those face-to-face services rendered by a physician or other qualified health care professionals who may report E/M services reported by a specific CPT code(s).”

The 90460-90461 codes’ specific requirement of ‘counseling by physician or other qualified health care professional,’ qualify them as professional services.

Since IA codes 90471-90474 do not specifically require ‘counseling by physician or other qualified health care professional,’ they may not qualify as professional services.

Therefore, when a codes(s) from the 90471-90474 family is reported for a clinical staff-only encounter that is the first/only encounter for a patient new to the physician/practice, the patient does not become established via the reporting of the code(s).

Vignettes

  • Q) A 13-year-old presents for his influenza vaccine as a new patient. He only sees the nurse, who administers the vaccine per standing orders. The IA CPT code reported is 90471. The patient returns in 1 month to see the physician for a sick visit – is he considered a new or established patient?
    A) He is considered a new patient. This is due to the fact that the only previously-reported CPT code is 90471 and the patient sees only the nurse. Therefore, in this situation, the 90471-90474 IA codes do not fulfill the requirement for establishing the patient to the physician/practice.
  • Q) A 7-year-old presents for her influenza vaccine as a new patient. The physician sees the patient and counsels the patient/parent on the vaccine, answering questions. The IA code reported is 90460. The patient returns in 6 months to see the physician for her annual well child exam – is she considered a new or established patient?
    A) She is considered an established patient. This is due to the fact that the only previously-reported CPT code is 90460. The 90460-90461 IA codes do fulfill the requirement for establishing the patient to the physician/practice.
  • Q) A 19-year-old presents for his influenza vaccine as a new patient. The physician sees the patient and counsels the patient on the vaccine, answering questions. The IA code reported is 90471 since the patient is over 18 years of age. The patient returns in 1 month to see the physician for a sick visit – is he considered a new or established patient?
    A) He is considered an established patient. This is due to the fact that the only previously-reported CPT code is 90471 — but the patient sees the physician. Therefore, in this situation, the 90471-90474 IA codes do fulfill the requirement for establishing the patient to the physician/practice.

While the age limit of the 90460-90461 codes (ie, through 18 years of age) prevents the physician from reporting a code from that family for the vaccine counseling performed, the encounter still represents a professional service for purposes of differentiating between a new and established patient because it is performed face-to-face by the physician, thereby establishing the patient to the practice.

**NOTE: Payers may enforce their own rules, which may not be consistent with these CPT guidelines.**


As documented in the August 2016 issue of Medicaid Update, Medicaid FFS would pay for maternal depression screening in the infant’s chart and Medicaid Managed Care would cover the service as of November 2016.  The guidance can be found here: https://www.health.ny.gov/health_care/medicaid/program/update/2016/aug16_mu.pdf and is reproduced below:

Postpartum Maternal Depression Screening Updated Billing Guidance: This article supersedes the billing guidance for postpartum maternal depression screening that was published in the July 2015 Medicaid Update. Effective September 1, 2016 for Medicaid Fee-for-Service (FFS) and effective November 1, 2016 for Medicaid Managed Care (MMC) Plans, the New York State Medicaid program will allow providers of infant healthcare to bill for postpartum maternal depression screening under the infant’s Medicaid identification number. Also, the current CPT code used for maternal depression screening (99420) will be replaced with the following:

• G8431 (with HD modifier) – Screening for clinical depression is documented as being positive and a follow-up plan is documented • G8510 (with HD modifier) – Screening for clinical depression is documented as negative, a follow-up plan is not required

Postpartum maternal depression screening using a validated screening tool may be reimbursed up to three times within the first year of the infant’s life.  This reimbursement is in addition to the payment for an Evaluation and Management (E&M) service.  Screening can be provided by the mother’s healthcare provider and/or by the infant’s healthcare provider following the birth of the baby.  This service can be integrated into the well-child care schedule.  If the mother screens positive for depression, then she must be further evaluated for diagnosis and treatment.  Medical practices that do not have the capacity to evaluate and treat mothers who screen positive for depression must have a referral process in place for these beneficiaries.  Women with current depression or a history of major depression warrant particularly close monitoring and evaluation.  The current standard of care for pregnant women requires that all pregnant women receive depression screening as part of their routine antepartum care.  Maternal depression screening that occurs antepartum is considered to be included in the payment for the E&M service.  A maternal healthcare provider is defined as a: physician, midwife, nurse practitioner, physician assistant, or other healthcare practitioner acting within his or her lawful scope of practice.  The infant’s healthcare provider is defined as a: physician, nurse practitioner, physician assistant, or other healthcare practitioner acting within his or her lawful scope of practice.

I hope that this information is of value to you in your practice. Implementing maternal depression screening is not difficult and helps insure the health of the mother-infant dyad.  If you have further questions about this coding issue or others please email me.  Please note that many private payers are not currently paying for maternal depression screening, and it is one of our priorities to advocate for this and all the other services recommended in Bright Futures.  Our recommendation is to bill all insurers for the service when provided even if they do not currently pay.  The realization by insurers that this is a valuable service may take some time.


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