Virginia. Medicaid Reimbursement Survey, 2004/05

Transcription

1 Reimbursement Survey, 2004/05 Virginia Contact Suk-fong Tang, PhD, Department of Practice, with comments about the report; contact Dan Walter, Division of State Government Affairs, for questions and advocacy advice.

2 AAP Reimbursement Survey: Virginia 2004/05 Payments for Commonly Used Pediatric CPT Codes TM Preventive Medicine Services % New Patient, under 1 year New Patient, 1 through 4 years New Patient, 5 through 11 years New Patient, 12 through 17 years New Patient, 18 through 39 years Established Patient, under 1 year Established Patient, 1 through 4 years Established Patient, 5 through 11 years Established Patient, 12 through 17 years Established Patient, 18 through 39 years Individual Counseling, 15 min Individual Counseling, 30 min $70.60 $76.01 $71.47 $80.91 $80.91 $53.59 $60.04 $59.26 $65.45 $66.22 $97.97 $ $ $ $ $74.61 $83.61 $82.56 $91.36 $92.41 $41.65 $ % Office and Other Outpatient Services New Patient, office visit New Patient, expanded office visit New Patient, low complexity New Patient, moderate complexity New Patient, high complexity Established Patient, office visit Established Patient, expanded office visit Established Patient, low complexity Established Patient, moderate complexity Established Patient, high complexity Screening test, hearing evaluation Tympanometry, hearing evaluation Screening test, visual acuity $24.99 $44.58 $66.22 $93.53 $ $14.69 $26.02 $36.33 $56.69 $82.20 $9.66 $14.94 $64.63 $34.72 $61.73 $91.62 $ $ $20.21 $36.12 $50.34 $78.85 $ $19.42 Source: 2004/05 AAP Reimbursement Surveys, American Academy of Pediatrics. Abbreviations used in this report: MP: Manually priced, i.e., Carrier will establish payment amounts for these services, generally on a case-by-case basis following review of documentation, such as an operative report. BR: By report, i.e., Carrier will establish payment amounts for these services on a case-by-case basis following review of documentation, such as an operative report. BO: Bundled with other services, i.e., Payment for covered services is always bundled into payment for other services not specified. If these services are covered, payment for them is subsumed by the payment for the services to which they are incident. OM: Other method(s). : Not covered. NA: Not applicable. NP: Information not provided by state. NL: Information not provided by state, nor found on fee schedule posted on state s web site. : RVUs for code not included in RBRVS schedule. LFS: National limit amount per Clinical and Diagnostic Lab Fee Schedule. Notes: (1) FFS payment (rates included in this report) may not apply to some or all services used by children in capitated plans. According to FFY2002 MSIS reports published by CMS, 64% of Virginia children (under age 19) enrolled in were in capitated plans. (2) Unless otherwise noted, the highest non-facility payment rate is presented in this report when multiple rates are used by the state. (3) rates are GPCI-adjusted for geographic variation in medical care cost. rates may vary by region in states with multiple carriers. Page 2 of 7 77%

3 Virginia Reimbursement AAP 2004/05 report, Continued (page 2 of 6) Newborn Care % Initial newborn care $41.23 $ Subsequent newborn care $21.64 $ Admit and discharge on same day $53.08 $ Physician attendance at delivery $52.05 $ Newborn resuscitation $ $ Circumcision; newborn $77.04 $ Immunizations: Does Virginia provide vaccines through a universal immunization program? Yes One immunization administration Each additional immunization administration One immunization administration, oral or intranasal Hemophilus Influenza B $ Influenza virus (6-35 months) $ Influenza virus (3+ years) $ Influenza virus, intranasal use Pneumococcal conjugate vaccine $ DTaP (< 7 years) $ DTP DT (< 7 years) Measles, mumps, rubella $12.00 $1.25 $ IPV $ Varicella $ Td (>= 7 years) DTaP, HIB $ Hepatitis B, (pediatric/adolescent age) $40.95 $7.56 $5.10 reimburses for vaccine products using 106% of the product's average sale price (ASP) Evaluation and Management Observation care discharge, day management $48.18 $ Initial observation care, low severity $45.61 $ Initial observation care, intermediate severity $76.27 $ Initial observation care, high severity $ $ Prolonged service, outpatient, 1st hour, face-to-face $66.74 $ Same as 99354, each additional 30 min $66.22 $ Prolonged service, inpatient, 1st hour, face-to-face $61.84 $ Same as 99356, each additional 30 min $32.10 $ % Source: 2004/05 AAP Reimbursement Surveys, American Academy of Pediatrics. Abbreviations: VFC: Vaccine for Children program. SSV: State-supplied vaccine. MNVP: Minnesota s Vaccine Program. VAFAC: Vaccine Assurance for All Children Program of South Carolina. Page 3 of 7

4 Virginia Reimbursement AAP 2004/05 report, Continued (page 3 of 6) Evaluation and Management, cont Prolonged service, 1st hour, not face-to-face Same as 99358, each additional 30 min Team medical conference, 30 min $ Team medical conference, 60 min $ Telephone call, simple or brief Telephone call, intermediate Telephone call - complex or lengthy Supervision of patient under home health agency care(15-29 min) $ Same as 99374, 30 min or more $70.83 $66.59 $ % 59% Hospital Care Initial hosptialization, per day, low complexity $46.12 $ Initial hosptialization, per day, moderate complexity $76.78 $ Initial hosptialization, per day, high complexity $ $ Subsequent hosptialization, per day, low complexity $22.93 $ Subsequent hosptialization, per day,moderate complexity $37.88 $ Subsequent hosptialization, per day,high complexity $53.85 $ Hospital discharge, day management, 30 min or under $48.18 $67.71 Consultations Office consultation, problem focused $34.53 $ Office consultation, straightforward decision $63.13 $ Office consultation, low complexity $83.23 $ Office consultation, moderate complexity $ $ Office consultation, high complexity $ $ Initial inpatient consultation, moderate complexity $96.88 $ Initial inpatient consultation, high complexity $ $ Pathology and Laboratory Urinalysis, non-automated with microscopy $4.37 $4.43 (LFS) Urinalysis, non-automated without microscopy $3.54 $3.57 (LFS) Tuberculosis, intradermal $7.21 $ % Throat culture $9.16 $9.26 (LFS) Rapid Streptococcus screen $16.58 $16.76 (LFS) Source: 2004/05 AAP Reimbursement Surveys, American Academy of Pediatrics. Page 4 of 7

5 Virginia Reimbursement AAP 2004/05 report, Continued (page 4 of 6) Mental Health % Psychiatric diagnostic interview examination $ $ Individual psychotherapy, min face-to-face $44.83 $ Individual psychotherapy, min face-to-face $67.25 $ Individual psychotherapy, min face-to-face $ $ Pharmacological management $35.30 $ Interpretation or explanation of results $ Developmental testing, limited $9.53 $ % Developmental testing, extended $99.20 $ Specialty Care Codes Allergy/Immunology Percutaneous tests with allergenic extracts $2.83 $ % Percutaneous tests, sequential and incremental $12.63 $ Intracutaneous tests, with biologicals $7.99 $ Intracutaneous tests with allergenic extracts $4.12 $ % Allergenic immunotherapy, single injection $10.31 $ Allergen immunotherapy, two or more injections $13.40 $17.91 Cardiology Cardiopulmonary resuscitation $ $ Transthoracic echocardiography $ $ Echocardiography, real-time with image documentation $ $ Doppler echocardiograph $61.32 $ Right heart catheterization $ $ Left heart catheterization $1, $1, Critical Care / Neonatal and Pediatric Critical Care Intubuation, endotracheal $ Bronchoscopy $ Thoracentesis $ Thoracostomy tube $ Insertion of non-tunneled CVC~ ; <5 yrs old $ Insertion of peripherally inserted CVC~; <5 yrs old $ Arterial puncture, diagnostic $ Arterial line placement $ Critical care, first hour $ Critical care, additional 30 minutes $74.47 Source: 2004/05 AAP Reimbursement Surveys, American Academy of Pediatrics. $ $ $ $ $ $ $29.16 $52.75 $ $ Page 5 of 7

6 Virginia Reimbursement AAP 2004/05 report, Continued (page 5 of 6) Critical Care/Neonatal and Pediatric Critical Care, contd Umbilical vein catheterization $ Umbilical artery catheterization $ Inital pediatric critical care $ Subsequent pediatric critical care $ Inital neonatal critical care $ Subsequent neonatal critical care $ Emergency Care Simple surgical removal of foreign body Simple surgical repair of facial wound( cm) $72.15 $ Venipuncture necessitating physician skill, < 3 yrs, femoral or jugular vein $ Venipuncture necessitating physician skill, >= 3 years $ Routine venipuncture $ Finger, heel, ear stick $ Lumbar puncture, diagnostic $ Conscious sedation; IV/IM/inhalation $ Conscious sedation; oral/rectal/intranasal $ ED visit, low complexity $ ED visit, moderate complexity $ ED visit, detailed $65.96 Gastrointestinal Upper gastrointestinal endoscopy with biopsy Colonoscopy with biopsy Sigmoidoscopy with biopsy Ophthalmology Strabismus surgery, horizontal Strabismus surgery, vertical Nasolacrimal probing Otolaryngology Tonsillectomy/adenoidectomy, under 12 years Tonsillectomy/adenoidectomy, 12 years or over Tympanostomy and tubes Intensive Low Birth Weight Services $ $ $ $ $ $ $ $ $ Subsq intensive care, <1500gm present body weight $ Subsq intensive care, gm present body weight $91.99 Source: 2004/05 AAP Reimbursement Surveys, American Academy of Pediatrics. $ $69.70 $ $ $ $ $99.10 $ $24.55 $17.43 $ BO BO $26.60 $59.17 $92.09 $ $ $ $ $ $ $ $ $ $ $ % Page 6 of 7

7 Virginia Reimbursement AAP 2004/05 report, Continued (page 6 of 6) Plastic Surgery Cleft lip repair $ Cleft palate repair $ Pulmonology Spriometry, including graphic record $ Inhalation treatment $ Demonstration/evaluation $9.28 $ $ $30.42 $11.61 $12.01 % 77% Radiology Frontal chest x-ray $19.07 $25.89 Surgery Extensive clubfoot release $ Appendectomy $ Bilateral inguinal hernia, 6 mos to under 5 yrs $ Bilateral inguinal hernia, 5 years or over $ Urology and Dialysis Renal biopsy ESRD (end stage renal disease) services, < 2 years $94.56 $ ESRD, 2 through 11 years ESRD, 12 through 19 years $ Peritoneal dialysis $52.31 Dental Services D Periodic exam $13.16 D1120 Prophylaxis, child $27.32 D Topical fluoride treatment, child $16.94 D2150 Amalgam two surfaces, primary or permanent $57.48 D2330 Resin-based composite one surface anterior $56.46 D1351 Sealant, per tooth $26.31 D Stainless steel crown on a primary tooth $ D3220 Pulpotomy $67.80 D7140 Extraction $47.56 $1, $ $ $ $ $ $ $ $73.32 Source: 2004/05 AAP Reimbursement Surveys, American Academy of Pediatrics. This report can be downloaded from the AAP website. (URL: Page 7 of 7