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Billing of Influenza Vaccinations in a Pediatric Practice

September 27, 2012 in Uncategorized by support Team  |  Comments Off on Billing of Influenza Vaccinations in a Pediatric Practice

It is very typical for Pediatric practices to begin the process of vaccinating patients with the flu vaccines during September. Although most Pediatric practices maintain a protocol for medical billing related to giving flu vaccinations, it is a good idea to review the common billing practices.
Some questions to ask related to the influenza vaccine include: Will the physicians be examining the high risk patients as part of the flu vaccination process? Will the office set up a flu clinic for which either a Medical Assistant or Nurse administers the vaccine? Will the practice allow flu shots to be administered on weekends or after hours?
Below is the list of CPT as well as vaccination administration codes associated with influenza vaccination.
90655 Influenza virus vaccine, split virus, preservative-free, for children 6–35 months of age, for intramuscular use
90656 Influenza virus vaccine, split virus, preservative-free, when administered to 3 years of age and above, for intramuscular use
90657 Influenza virus vaccine, split virus, 6–35 months of age, for intramuscular use
90658 Influenza virus vaccine, split virus, 3 years and older, for intramuscular use
90660 Influenza virus vaccine, live, for intranasal use

Vaccine Administration Codes also need to be associated with Flu Vaccinations
If the patient is 18 years of age or younger and obtains vaccine counseling by the physician or other qualified health care professional Report CPT code 90460. If both of the criteria are not met (either over 18 years of age or does not obtain vaccine counseling by the provider), utilize the appropriate code from the 90471-90474 series. Utilize CPT Code 90471 if the influenza injection is given as the only vaccine or CPT Code 90473 if the intranasal form is the only provided vaccine. If the influenza vaccine is provided with other vaccines and the patient is either over 18 or the provider does not provide counseling, report 90472 for the influenza injection or 90474 if the intranasal form. Note that the appropriate diagnosis code for the flu vaccine is v04.8

Some Potential Effects on Pediatric Care due to September 11th, 2001

September 11, 2012 in Uncategorized by support Team  |  Comments Off on Some Potential Effects on Pediatric Care due to September 11th, 2001

My 9th grade daughter asked me, as an assignment for school, where I was and what was my first reaction when I learned of the news related to the tragic events of 9-11-01. Most of us whom were adults at the time could describe the exact location and what we were doing when we learned this shocking news. The tragic events of this day changed many things in our country. What are some of the potential additional treatments in Pediatrics due to 9-11-01? The answer to this question is that it depends.

If you were a Pediatrician in New York, NY, you might have children that had early development of asthma. The Pediatrician would need to do a detailed history to see if there is any link to the events of 9-11-01. Where was this patient on 9-11-01? Where their parents exposed to the debris and air associated with 9-11-01? Asthma is not the only disease that the Pediatrician needs to complete a detailed history. Other potential diseases such as acid reflux, depression, anxiety, or sinus congestion might also might have a link.

Today is a day to remember the tragic events of that day as well as to remember our brave fire fighters, police officers, and other public servants that risked their lives to help others in a difficult situation. Although 9-11-01 was 11 years ago, the negative impact is still felt today.

A Virtual Accountable Care Organization (ACO) and the link to Pediatric Practices

September 5, 2012 in Uncategorized by support Team  |  2 Comments

With Healthcare costs increasing at a rapid rate in the United States, there are a number of payment models being investigated that look to encourage preventative care while reducing costs. Although most practices generate the majority of their revenue from Fee for Service insurance products, there is much talk as well as movement related to Accountable Care Organizations (ACOs). The concept of ACOs is that an organization manages a large group of providers and hospital systems to provide patient care. The ACO and the providers would be compensated for management of a population. The leaders in this field are exploring many different methods for payment – a set fee per patient for all care, bundled payment per episode of care as well as other risk sharing arrangements. ACOs are most thought about as hospital systems that purchased provider groups (e.g. Integrated Delivery Systems) and form an ACO entity. In this case, the Pediatric Group would need to be owned by the hospital system to participate in the ACO.

Although the Medicare Shared Savings Program ACO sponsored by the Centers for Medicare and Medicaid Services (CMS) has the most publicity, the commercial payers are beginning to experiment with ACO payment models as well. The Medicare Shared Savings Program ACO shares the savings of ACO effort between the ACO and CMS (the providers continue to receive Fee for Service payments at this time).

There is another type of ACO model known as the Virtual ACO or community ACO. This model would be an organization that is the contracting agent with payers and would like to privately owned practices. For example, ABC Pediatrics (privately own), could participate in a virtual ACO without selling their practice. The virtual ACO would develop the guidelines on how to participate as well as the payment stream. There is much question as to how this will impact Pediatrics. The good news is that private practices should not be required to sell their practices as the ACO model evolves.

Practices and practice managers should continue to keep an eye on the payment methods in the field. Improper coding as well as low collection rate continues to be a very common issue with Practices that if managed appropriately, optimize the revenue to the practice. In Pediatrics, this requires a team that receives routing training in Pediatric coding, systems that gain intelligence as payers change reimbursement policies and consistently reporting and follow-up. So although there is much talk and experimentation with new payment models, most practices need to look how to appropriately manage the revenue cycle in today’s payment system.

Consumer Directed Health Plans (CDHP) in Pediatric Practices

June 7, 2012 in Uncategorized by support Team  |  Comments Off on Consumer Directed Health Plans (CDHP) in Pediatric Practices

What is a Consumer Directed Health Plan (CDHP)?
A CDHP is a health plan option for which the family usually has a high deductible of $1500, $2500, $3000 or higher. The individual that has this high deductible is ‘trading’ the high deductible for lower Health Insurance Premiums. Additionally, a family might save money in a health care savings account for use when in the deductible phase. The family can roll over money from year to year in the Healthcare Savings Account.
Do all CDHP plans have a high deductible for well visits at a primary care Pediatric Office? No. Many CDHP plans cover well visits which usually includes vaccines. In most cases, the deductible/co-pay is $0.

How common are CDHP plans?
CDHP plans, due to the ability to save the employer and employee cost on the premium are growing in popularity. It is estimated that approximately 50% of small employers offer this option and between 20-30% of Medium to large employers. Many employees prefer to work with the ‘known’ and therefore select the traditional HMO and PPO plan. In Pediatrics, parents usually try to offer a plan that has more coverage due to the need to treat their sick kids. We evaluated some of our Pediatric groups and noticed that CDHPs are significantly below 10% currently.

How might CDHP Plans impact my Pediatric Practice?
Studies show that patients whom are insured using CDHP plans have between a 10% and 20% utilization rate of outpatient care. These studies do not look at the impact of Pediatrics versus specialists and other forms of outpatient care. Parents with this type of insurance are much more knowable of what their policy covers versus parents whom have traditional HMO/PPO coverage. Many will check to see what the plan covers as well as request generic medications versus branded medications.

How might CDHP Plans impact my collections and AR Rate? If a pediatric practice did not have strong patient responsibility follow-up as well as a high penetration of CDHP plans, the practice might see the collection rate reduced as well as an increase in AR days. The Medical Group Management Association as well as other organizations provides benchmarks for collection rates and AR days. The average collection rate is around 95% of the contract amount with 97% used by many groups as a benchmark. Achieving well above 99% consistently should be the minimum benchmark for each Pediatric Practice. Related to AR days, a pediatric group should have AR days less than 30 (less than 30 days of Accounts receivable) with the goal of being at 25.

Although CDHP plans are just starting to penetrate the market place they will continue to be an offering as the country struggles with rising healthcare costs. Monitoring and Management of CDHP plans is one component that will help improve the success of a Pediatric Practice.

Phase I Meaningful Use for Pediatric Practices: The Need to Change or Modify Practice Processes

May 18, 2012 in Uncategorized by support Team  |  Comments Off on Phase I Meaningful Use for Pediatric Practices: The Need to Change or Modify Practice Processes

I was on the phone with one of our valued customers this morning discussing Phase I Meaningful Use and the details on the “how” related to Meaningful Use. The overall goal of Health and Human Services is that providers utilize a certified E.H.R. in a meaningful way. A group of individuals invested months of discussions and feedback to obtain a list of parameters. One challenge for the group is to provide a universal list that applies across all fields of medicine. Some of the parameters in Pediatrics only apply to a certain segment of the population. For example, smoking status is for patients greater than 13 years of age. There are core measures that each provider needs to meet the benchmark for all these measures during the 90 day period being measured as well as selecting a list of 5 of the 10 menu measures.

A good E.H.R. system should provide a simple manner for a physician and/or Practice Administrator to evaluate performance of each of these benchmarks as well as very easily ‘drill down’ to identify how to correct/update patient data associated with the measure. How to use a meaningful use dashboard should take minimal training and review. The E.H.R. vendor should be able to guide an individual in the practice on the process via a web meeting or teleconference. So if you selected the ‘right’ E.H.R. system for Pediatrics, using the software and monitoring meaningful use should be straight forward.

The ‘tough’ part of Meaningful use: Changes to how the practice operates. For example, most practices did not record language, race and ethnicity as part of their intake/demographics. This needs to be captured for over 50% of patients seen during the 90 day measurement period for Phase I. If your E.H.R. system is well design, the practice should be able to click on a link and show the patients that do not have this information during the 90 day period. The most efficient way to enter this information is to capture the data when the patient visits the office. The “ah-ha” moment for many individuals is when they first run a meaningful use report, then they make the changes to their office flow and intake forms as needed.

Some questions to ask related to Meaningful use and your Pediatric Practice: Are we entering all medications in the system and sending medications via electronic prescriptions? Do we list the problems for each visit and maintain the patient problem list? Are we maintaining our Medication list and Allergy List? Does our standard protocol for demographics include recording smoking status of patients >13 years of age? Do we record vitals on each visit? Can we connect to the immunization registry? Are we connected to the lab companies that we send the majority of our labs?
This is not meant to be an a complete list of questions but a list to stimulate thinking around meaningful use. There are many resources, websites and references to obtain detailed information. Good luck on meeting Phase I Meaningful Use!