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July 2003 • Volume 37 • Number 7

News

August target date
Pediatric Vaccine Counseling Code In Development - Code would separate physician work from vaccine administration itself.

Jennifer Silverman
Associate Editor, Practice Trends

WASHINGTON — A single code for pediatric vaccine counseling is under development.

The American Academy of Pediatrics and the American Medical Association's CPT Editorial Panel are working to develop the code, “which would allow physicians to report to payers their work involved in vaccine counseling,” Dr. Joel Bradley, medical director of the Cumberland Pediatric Foundation in Nashville, Tenn., said at a meeting of the National Vaccine Advisory Committee.

The code would be used only for visits when one or more vaccines are administered and the physician counsels the patient and family face-to-face about the risks and benefits. It would be used just once per visit, regardless of the number of vaccines administered.

The code “would essentially separate physician work from the vaccine administration itself,” said Dr. Bradley, a member of the AAP's Committee on Coding and Nomenclature. Previously, codes for vaccine administration did not include the relative value for physician work “and are thus undervalued.”

The code would be available for use by any physician who administers vaccines to children.

Most pediatric vaccines are administered in the context of a well-child visit—not in problem-oriented office visits—Dr. Bradley said. Such preventive medicine visits are not covered by the Centers for Medicare and Medicaid Services' payment policy and are not valued with the work of vaccine counseling.

In other words, physicians who spend significant time counseling about vaccines are not currently being paid in the preventive codes or the existing vaccine administration codes.

Dr. Stuart Cohen, AAP delegate to the American Medical Association, said he believes that work expenses of vaccine counseling should have been included in codes 90471 and 90472, the codes for vaccine administration. Doing so, however, would affect Medicare's budget neutrality.

“If you increase the work expense, thus the [relative value units] for codes 90471 and 90472, as they also apply to influenza vaccine administration in the elderly under the Medicare program, the budget neutrality for Medicare would cause a decrease in RVUs for another area of codes, which would cause even greater problems,” said Dr. Cohen, who practices in San Diego.

From his perspective, the development of a single code for vaccine counseling “is a compromise to what's really needed.”

Some pediatricians, such as Dr. Gary Gardner, are excited by the prospect of a separate code.

The counseling work a physician does always increases when a new vaccine such as Pediarix goes on the market, said Dr. Gardner, who practices in Darien, Ill. “To code and bill for counseling is a great idea.” How it would be applied universally remains the larger question, as counseling time varies from physician to physician.

This latest effort to develop the code came about after the CPT panel rejected an initial proposal from the AAP in February for four pediatric codes that would have been applied to various immunization procedures for children up to age 12 years.

Dr. Tracy Gordy, CPT panel chair, wouldn't comment on why the panel rejected the initial codes. “As always, the panel has the option of change,” he said.

The AAP will present the code to the CPT panel for review in August. If the panel accepts it, then CMS will decide whether to pay for the code and establish relative value units for the physician work associated with the new code. The change would likely be published in the proposed rule on the Medicare physician fee schedule.

CMS' decision would affect physicians who care for children, since the majority of private and state Medicaid payers use the resource-based relative value scale as their fee schedule, Dr. Bradley said. “They adopt many of the codes and the RVUs published by CMS,” adjusting the conversion factor to meet their own financial needs.

The agency's position in the past has been that the physician work involved in vaccine administration is already accounted for. But in the 2003 physician fee schedule, CMS specifically said it would consider whether the amount of counseling of the patient and/or family was different for childhood immunizations than for the typical Medicare service—and whether coding changes would be appropriate. “CMS has been encouraging the pediatricians to work through the CPT process” on this code, an agency spokeswoman said.