Medicaid Reimbursement Survey, 2007/08. North Carolina

Transcription

1 Reimbursement Survey, 2007/08 North Carolina

2 North Carolina /08 AAP Reimbursement Survey Survey Summary : As part of its effort to monitor the impact of the program on pediatrics, the American Academy of Pediatrics (AAP) conducts its Reimbursement Survey periodically. The Survey, which collects state-administered fee-for-service program payment rates for most commonly reported pediatric Current Procedural Terminology/CPT codes and dental codes, was most recently mailed to State Directors in the 50 states and the District of Columbia during July 2007 to request payment rates effective July 1, 2007, the beginning of the fiscal year for most states. 47 states and the District of Columbia returned this survey. Data for New York and Hawaii are based on a search of the two states websites by AAP staff. Tennessee, which does not have a state-administered fee-for-service program, is not included in this report series. This and earlier AAP Reimbursement Survey reports can be found at URL: Caveats and Notes : fees shown in this report represent fee-for-service payments reported by states for state-administered programs only. Nationally, the majority of children enrolled in programs are enrolled in managed care plans, which may or may not benchmark provider payment rates to fees shown in this report. Attempts by the AAP to collect plan-to-provider payment rates in managed care plans have been unsuccessful since such information has typically been classified as confidential and proprietary by the states and the plans with which they contract. Depending on managed care penetration levels, the impact of state-administered fee-forservice payment rates varies by state. All children enrolled in were covered by a state-administered FFS program according to state reply to the 2007/8 AAP Reimbursement Survey. rates in this report are (a) based on non-facility payment published by the Center for and Services for 2007, and (b) adjusted with Geographic Practice Cost Index (GPCIs) published by CMS. Certain codes are assigned RVUs but not covered by. CPT is a trademark of the American Medical Association. Dental codes (CDT Codes) are copyright 2006 American Dental Association. Reprinted with permission.

3 Abbreviations : BC : BI / BR / PR : BO : FFS : FP : MP : NA : : NL : NP : : LFS : OM : RBRVS: RNE : RVU(s) : : MRC : Billed charges By invoice/ by report/ per review, 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. 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. Discounted fee-for-service 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. Not applicable Not covered Contact Information : North Carolina /08 AAP Reimbursement Survey Facility payment Information not found on state website or physician fee schedule Information not provided by state in returned AAP survey RVUs not included in RBRVS or Clinical Diagnostic Lab Fee Schedule National limit amount per Clinical Diagnostic Lab Fee Schedule Other method used Resource-Based Relative Value Scale, the physician payment schedule for Rate not established Relative Value Unit(s), the numeric value of the resources needed to provide services according to the Resource-Based Relative Value Scale Vaccines for Children Program. Providers are typically paid a vaccine administration fee for administering vaccines made available through programs. Maximum regional charge, the maximum amount a provider may charge for the administration of qualified pediatric vaccines to federally vaccine-eligible children under the Program. States with universal purchase programs may establish maximum charges that differ from this level. MRCs were established by federal regulation published October 3, 1994, can be found online at: and have not been updated since initial publication of this regulation. Contact Suk-fong Tang, Department of Practice, for questions about this report. Contact Dan Walter, Division of State Government Affairs, for questions and advocacy advice. Contact Elizabeth Sobczyk, Division of Pediatric Practice, for pediatric immunization questions and advocacy advice. Contact the Division of Health Care Finance and Quality Improvement at dhcfqi@aap.org for information on child health financing or RBRVS. Suggested Citation: 2007/08 AAP Reimbursement Survey. American Academy of Pediatrics. Elk Grove Village, Illinois.

4 AAP Reimbursement Survey: North Carolina 2007/08 Payments for Commonly Reported 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 $98.51 $98.51 $81.57 $81.57 $89.61 $95.50 $95.30 $ $ $70.06 $78.08 $77.38 $85.17 $85.86 $36.10 $ % 84.1% 84.3% 114.7% 102.9% 103.8% 95.8% Office and Other Outpatient Services New Patient, office visit $32.01 $ New Patient, expanded office visit $56.13 $ New Patient, low complexity $83.11 $ New Patient, moderate complexity $ $ % New Patient, high complexity $ $ % Established Patient, office visit $17.91 $ Established Patient, expanded office visit $33.01 $ Established Patient, low complexity $47.67 $ % Established Patient, moderate complexity $74.87 $ % Established Patient, high complexity $ $ % Screening test, hearing evaluation $ Tympanometry, hearing evaluation $18.29 $ Screening test, visual acuity $2.34 Newborn Care Initial newborn care Subsequent newborn care Admit and discharge on same day Physician attendance at delivery Newborn resuscitation Circumcision; newborn $50.55 $26.92 $68.55 $64.57 $ $ $53.22 $28.34 $72.16 $67.97 $ $121.04

5 AAP Reimbursement Survey Report, 2007/8 - North Carolina, Continued (page 2 of 7) Immunizations: One immunization administration, physician $17.25 counseling < 8 yrs Each additional immunization administration, $9.71 physician counseling < 8 yrs One immunization administration, oral or intranasal, $11.27 physician counseling < 8 yrs Each additional immunization administration, oral $8.56 or intranasal, physician counseling < 8 yrs One immunization administration $ Each additional immunization administration $ One immunization administration, oral or intranasal $ Each additional administration, oral or intranasal $ Hemophilus Influenza B HPV Influenza virus (6-35 months) Influenza virus (3+ years) Influenza virus, intranasal use Pneumococcal conjugate vaccine Rotavirus DTaP (< 7 years) DTP DT (< 7 years) Measles, mumps, rubella IPV Tdap Varicella Td (>= 7 years) DTaP, HIB DTaP-HepB-IPV Hepatitis B, (pediatric/adolescent age) Observation Observation care discharge, day management $ Initial observation care, low severity $ Initial observation care, intermediate severity $ Initial observation care, high severity $ $18.15 $9.71 $11.86 $9.01 $18.15 $9.71 $12.21 $8.31 reimburses for vaccine products using 106% of the product's average sale price (ASP) $63.53 (FP) $60.04 (FP) $99.26 (FP) $ (FP) % 100.0% 100.0% 94.9% of FP of FP of FP of FP

6 AAP Reimbursement Survey Report, 2007/8 - North Carolina, Continued (page 3 of 7) Prolonged Physician Services Prolonged service, outpatient, 1st hour, face-to-face Same as 99354, each additional 30 min Prolonged service, inpatient, 1st hour, face-to-face Same as 99356, each additional 30 min Prolonged service, 1st hour, not face-to-face Same as 99358, each additional 30 min $83.62 $83.06 $76.95 $77.18 $88.02 $87.44 $81.00 $81.24 % Team Medical Conferences Team medical conference, 30 min Team medical conference, 60 min Telephone Care Telephone call, simple or brief Telephone call, intermediate Telephone call - complex or lengthy Care Plan Oversight Supervision of patient in home, minutes per month Same as 99339, 30 minutes or more per month Supervision of patient under home health agency care, minutes per month Same as 99374, 30 min or more per month Hospital Care Initial hosptialization, per day, low complexity Initial hosptialization, per day, moderate complexity Initial hosptialization, per day, high complexity Subsequent hosptialization, per day, low complexity Subsequent hosptialization, per day,moderate complexity Subsequent hosptialization, per day,high complexity Hospital Discharge $31.71 $62.04 $ $62.06 $ $ $31.35 $51.34 $ had been replaced by new codes prior to publication of this report. $64.14 $89.62 $61.77 $ $82.49 $ $ $34.52 $61.95 $ % 90.0% 85.8% 90.8% 82.9% 82.4% Hospital discharge, day management, 30 min or under $60.13 $ Hospital discharge, day management, more than $87.05 $ minutes Consultations Office consultation, problem focused Office consultation, straightforward decision Office consultation, low complexity Office consultation, moderate complexity $43.59 $80.69 $ $ had been replaced by new codes and prior to publication of this report. $45.89 $84.93 $ $ %

7 AAP Reimbursement Survey Report, 2007/8 - North Carolina, Continued (page 4 of 7) Consultations (continued) % Office consultation, high complexity $ $ Initial inpatient consultation, moderate complexity $ $ % Initial inpatient consultation, high complexity $ $ Pathology and Laboratory Urinalysis, non-automated with microscopy $4.43 $4.43 (LFS) 100.0% of LFS Urinalysis, non-automated without microscopy $3.57 $3.57 (LFS) 100.0% of LFS Tuberculosis, intradermal $8.09 $ % Throat culture $8.06 $9.26 (LFS) 87.0% of LFS Rapid Streptococcus screen $16.01 $16.76 (LFS) 95.5% of LFS Mental Health Psychiatric diagnostic interview examination $ $ Individual psychotherapy, min face-to-face $56.86 $ Individual psychotherapy, min face-to-face $82.94 $ Individual psychotherapy, min face-to-face $ $ Pharmacological management $55.48 $ % Interpretation or explanation of results $78.26 Developmental Testing Developmental testing, limited $10.06 $ Developmental testing, extended $ $ Specialty Care Codes Allergy/Immunology Percutaneous tests with allergenic extracts $4.21 $ Percutaneous tests, sequential and incremental $15.20 $ Intracutaneous tests, with biologicals $10.22 $ Intracutaneous tests with allergenic extracts $5.20 $ % Allergenic immunotherapy, single injection $12.07 $ Allergen immunotherapy, two or more injections $15.06 $15.85 Cardiology Thoracostomy tube $ $ Cardiopulmonary resuscitation Transthoracic echocardiography Echocardiography, real-time with image documentation Doppler echocardiograph Right heart catheterization $ $ $ $75.60 $ $ $ $ $79.58 $ % Left heart catheterization $ $ %

8 AAP Reimbursement Survey Report, 2007/8 - North Carolina, Continued (page 5 of 7) Critical Care Critical care, first hour $ Critical care, additional 30 minutes $ Inital pediatric critical care $ Subsequent pediatric critical care $ Inital neonatal critical care $ Subsequent neonatal critical care $ $ $ $ $ $ $ % 94.6% Procedures Intubuation, endotracheal Insertion of non-tunneled CVC~ ; <5 yrs old Insertion of peripherally inserted CVC~; <5 yrs old Arterial puncture, diagnostic Arterial line placement $96.72 $ $ $27.16 $45.97 $ $ $ $28.59 $ Umbilical vein catheterization $ $ Umbilical artery catheterization $61.15 $ Simple surgical removal of foreign body $ $ Simple surgical repair of facial wound( cm) $ $ Venipuncture necessitating physician skill, < 3 yrs, $22.55 $23.73 femoral or jugular vein Venipuncture necessitating physician skill, >= 3 years $15.95 $ % Routine venipuncture $3.00 $3.00(LFS) 100.0% of LFS Finger, heel, ear stick Lumbar puncture, diagnostic $ $ Moderate Sedation Moderate sedation provided by same physician performing the service that sedation supports; younger than 5 years of age, first 30 minutes intra-service time Moderate sedation provided by same physician performing the service that sedation supports; age 5 years or older, first 30 minutes intra-service time Moderate sedation provided by same physician performing the service that sedation supports; each additional 15 minutes intra-service time

9 AAP Reimbursement Survey Report, 2007/8 - North Carolina, Continued (page 6 of 7) Moderate Sedation Moderate sedation provided by a physician other than the health care prefessional performing the service that sedation supports; age 5 years or older, first 30 minutes intra-service time Moderate sedation provided by a physician other than the health care prefessional performing the service that sedation supports; each additional 15 minutes intra-service time Emergency Care (continued) Moderate sedation provided by a physician other than the health care prefessional performing the service that sedation supports; younger than 5 years of age, first 30 minutes intra-service time ED visit, low complexity $ ED visit, moderate complexity $ ED visit, detailed $89.00 $36.14 $58.49 $ % 70.2% 83.2% 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 $ $ Subsq intensive care, gm present body weight $ $ Plastic Surgery Cleft lip repair $ Cleft palate repair $ $ $ %

10 AAP Reimbursement Survey Report, 2007/8 - North Carolina, Continued (page 7 of 7) Pulmonology Bronchoscopy $ Thoracentesis $ Spriometry, including graphic record $ Inhalation treatmen $ Continuous inhalation treatment, first hou $30.99 Radiology Frontal chest x-ray $23.04 $ $ $30.51 $11.66 $32.62 $24.25 % 158.3% Same as 94644, each additional hour $11.74 $ Demonstration/evaluation $23.86 $ % Surgery Extensive clubfoot release $ Appendectomy $ Bilateral inguinal hernia, 6 mos to under 5 yrs $ Bilateral inguinal hernia, 5 years or over $ Nephrology Renal biopsy $ ESRD (end stage renal disease) services, < 2 years $ ESRD, 2 through 11 years $ ESRD, 12 through 19 years $ Peritoneal dialysis $64.22 Dental Services D Periodic exam $27.01 D Topical fluoride treatment, child $15.44 D1120 Prophylaxis, child $24.50 D2150 Amalgam two surfaces, primary or permanent $79.41 D2330 Resin-based composite one surface anterior $62.78 D1351 Sealant, per tooth $29.93 D Stainless steel crown on a primary tooth $ D3220 Pulpotomy $78.11 D7140 Extraction $57.50 Dental codes (CDT Codes) are copyright 2006 American Dental Association. $ $ $ $ $ $ $ $ $67.60 Footnotes: None