- Announcements -

- Feedback -

Reimbursement for Well Child Care

for young Medicaid (EPSDT) patients can be

as high as a commercially insured patient,

if you do developmental screening.

The new Medicaid reimbursement rates, beginning July, 2006, provide incentives for practices to provide preventive care for young children and for developmental screening.

           Visit code – 99391 – infant - $69.02
           Visit code – 99392 – 1-4 year old - $77.31
           For administration of each injection - $6.50
                    (vaccine is provided free through VFC and is not charged, but the
                    administration code can be   charged for each injection)
           Developmental screening - EPSDT code 96110 - $34.33
                    This requires documentation of the developmental test performed:
                    ASQ, DDST, Denver II or PEDS are acceptable.

So, for example, a 4 month old Medicaid well child visit with 4 injections:
          99391 – visit - $69.02
          90700 – injection - $6.50
          90648 - injection - $6.50
          90713 - injection - $6.50
          90669 - injection - $6.50
          96110 – developmental screening- $34.33
          Total - $129.35

Comparison of Medicaid reimbursement with commercial health insurance

*When comparing immunization reimbursement – the question is whether the commercial health insurance company reimbursement for each immunization exceeds the practice cost. If so, that is compared with the $6.50 injection fee paid by Medicaid

A 4 year old Medicaid child, who receives well child care and 3 injections:
          99392 – visit - $77.31
          690700 – injection - $6.50
          90648 - injection - $6.50
          90713 - injection - $6.50
          96110 – developmental screening- $34.33
Total - $131.14 (remember vaccine for Medicaid children is free)
Commercial payers average reimbursement. - $130

Please help us document that 96110 is being paid by Medicaid. Tell us your experience and ideas regarding Medicaid reimbursement for well child care, by participating in our discussion board (click here). Also help us address the following controversies:

1. Some practices bill for
          99173 Vision Screening (Titmus, Illiterate E)
          92551 Hearing Screening
and they say they get additional reimbursement in the range of $10 for each code. At the present time, State Medicaid feels these 2 screenings are bundled into the EPSDT visit payment. What is your experience?

2. The most controversial is the modifier –25: “Significant, separately identifiable evaluation and management services by the same physician on the same day of the procedure or other service.”

Lee Thompson proposes the following: Consider the following scenario. You are doing a well care visit (new patient 99381-99384, infant through 17 years) or (established patient 99391 – 99394). At some point in the history, review of systems, or physical exam, the parent says, “What about the ………?” They may bring up allergies, asthma, eczema, enuresis, night terrors, attention deficit disorder, etc. The CPT descriptor for Preventive Medicine Services says nothing about diagnosing and treating disorders or conditions.

If the visit is significantly extended, as you provide care for the other condition(s) in addition to providing the well child care, these diagnoses can be billed with modifier –25 appended to the standard E/M Codes, using new patient codes (99201 – 99205) and established patient codes (99212 – 99215). You can bill an E/M visit with Modifier –25 in addition to the well care code visit. The choice of E/M code will depend upon documenting the key components of history, physical exam and medical decision making. Finally, consider that when counseling and coordination of care uses more than 50% of the typical time of an E/M visit, this controls the choice of the E/M code, not the key components. See Table, below.

A small survey of metro Denver pediatricians indicates that most caution that providers should not use the Modifier – 25, unless they can clearly document that they provided the equivalent of two visits in terms of time and care. They say this should be a relatively uncommon event. Some pediatricians, however, use this approach as much as 1/3 of the time.

Folks at Colorado Department of Health Care Policy and Financing say they would not normally reimburse for both charges at the same visit. Has anyone documented that they have been reimbursed using the modifier – 25? Click here to visit our discussion board to give us your opinion or to see what others think.

                                  Counseling, care
Code    Typical Time    coordination time
99201          10’           > 50%
99202          20’           > 10’
99203          30’           > 15’
99204          45’           > 22 ½’
99205          60’           > 30’

99211          N/A           N/A
99212          10’           > 5’
99213          15’           > 7 ½’
99214          25’           > 12 ½’
99215          40’           > 20’

Improving Health Outcomes

For Spanish Speaking Families

[From: Flores G. Language Barriers to Health Care in the United States. New England Journal of Medicine. Volume 355:229-231. July 20, 2006]

Case: A 10-year-old Latino boy comes to your office with the complaint of dizziness and a headache. The patient, Raul, seems to speak English pretty well and his mother speaks no English. You, as his provider, speak a little Spanish. Your office has one receptionist who speaks Spanish, but this is her day off. So, Raul acts as his own interpreter. His mother described his symptoms: "La semana pasada a el le dio mucho mareo y no tenía fiebre ni nada, y la familia por parte de papá todos padecen de diabetes." (Last week, he had a lot of dizziness, and he didn't have fever or anything, and his dad's family all suffer from diabetes.) The mother goes on. "A mí me da miedo porque el lo que estaba mareado, mareado, mareado y no tenía fiebre ni nada." (I'm scared because he's dizzy, dizzy, dizzy, and he didn't have fever or anything.)
          Turning to Raul, you ask, "OK, is she saying you look kind of yellow?" 
          Raul interprets for his mother: "Es que si me vi amarillo?" (Is it that I looked yellow?) 
          "Estaba mareado, como pálido" (You were dizzy, like pale), his mother says. 
          Raul turns back to you and says, "Like I was like paralyzed, something like that."

If Raul receives inappropriate care due to his misinterpretation, he would not be alone. A receptionist in one office mistranslating for a nurse practitioner, told the mother of a seven-year-old girl with otitis media to put (oral) amoxicillin "in the ears." In another case, a Spanish-speaking woman told a resident that her two-year-old had "hit herself" when she fell off her tricycle; the resident misinterpreted two words, understood the fracture to have resulted from abuse, and contacted the Department of Social Services (DSS). DSS sent a worker who, without an interpreter present, had the mother sign over custody of her two children. Another provider misinterpreted “intoxicado” as intoxicated, rather than nauseated and treated the teenager for intoxication for 48 hours, when the patient actually had nausea and vomiting associated with increased intracranial pressure. That resulted in a malpractice suit. Clearly, catastrophes can and do result from such miscommunication.

Nearly 50 million Americans (18.7 percent of U.S. residents) speak a language other than English at home; 22.3 million (8.4 percent) have limited English proficiency, according to self-ratings. Between 1990 and 2000, the number of Americans who spoke a language other than English at home grew by 15.1 million (a 47 percent increase), and the number with limited English proficiency grew by 7.3 million (a 53 percent increase).

Research clearly shows that language barriers impede access to health care, compromise quality of care, and increase the risk of adverse health outcomes among patients with limited English proficiency (LEP). When a parent has LEP, the family is less likely to adhere to medication or treatment plans, is more likely to miss appointments, is more likely to defer needed medical care, is less likely to have a medical home, receives less preventive care, and is more likely to experience medication complications. Language barriers can lead to inefficient care because clinicians are unable to elicit LEP patients’ symptoms and, thus, use more diagnostic resources or invasive procedures. Children with asthma, whose families have LEP are less likely than others to return for follow-up appointments, have higher rates of hospitalization and drug complications, have more expensive care for acute illness, have an increased risk of intubation, and have lower levels of patient/parent satisfaction. The risk of medical errors and malpractice suits is higher. Many studies document that trained professional interpreters and bilingual providers improve health outcomes, reduce the number of tests and hospitalizations and improve parent and provider satisfaction.

In a busy office practice, ad hoc interpreters, including family members, friends, untrained members of the support staff, and the patient are commonly used as interpreters. Unfortunately, these ad hoc interpreters are considerably more likely than professional interpreters to commit errors that may have adverse clinical consequences. Ad hoc interpreters are also unlikely to have had training and knowledge needed to be effective: medical terminology, confidentiality, proficiency in English as well as the foreign language and the role of the interpreter. Ad hoc interpreters also may have priorities that conflict with those of patients and their presence may inhibit discussions regarding sensitive issues such as domestic violence, substance abuse, psychiatric illness, and sexually transmitted diseases. It is especially risky to have children interpret, since they are unlikely to have a full command of two languages or of medical terminology; they frequently make errors of clinical consequence; and they are particularly likely to avoid sensitive issues. In some cultures (especially Asian cultures), the child is expected to “take care of” the parent who does not speak English well. So, be sure to reassure the child that it is not anything against them personally, but that Federal guidelines require an older person to translate.

The Office for Civil Rights 2003 guidelines seem to allow smaller health care facilities (i.e., practices) to opt out of providing language services for which costs are too burdensome. But, private practices are expected to at least have one of the following for languages often spoken in their patient population: bilingual staff, staff interpreters, volunteer interpreters, contract interpreters, or telephonic interpretation.

Commentary: In 13 states, Medicaid and State Children's Health Insurance Program (SCHIP) reimburse practices for interpreter services. Unfortunately, of course, Colorado is not one of them. And, commercial insurers do not reimburse primary care practices for interpretation services.

So, private practices face the difficult bind that many of the interpreters they can afford probably are not adequate and third party payers do not reimburse for the trained interpreters (either professional, contracted interpreters or translation phone lines) their patients need. What are the options for the private pediatric practice?

• A professional, trained interpreter costs $20–$26 per hour. This, of course, is not a very good option, because the volume of Spanish speaking patients in a private practice is too low and the hourly rate too high.
• Commercial telephone interpretation services cost $125 per hour. Inadequate health care reimbursement, of course, rules this out as an option.
• Use of ad hoc interpreters is discouraged because of possible errors and deleterious effects.
• A good option is to engage the family in the search for a qualified interpreter. They may be aware of resources in the community, such as Promotoras (lay health workers), nurses at their church, or trained volunteers in their community.
• Two other good options are:
• Obtain medical translation training for bilingual staff, who speak Spanish.
• Train providers in medical Spanish
• SEE BELOW!

 

Convenient, Affordable Training in Spanish Interpretation For You and Your Staff In response to this current difficult situation, CCHAP and International Language Services plan to offer two convenient, affordable courses for providers and staff in pediatric practices. Both courses will be available at convenient times for office staff members by telephone conference. The two courses are:          · Medical Terminology for bilingual staff          · Medical Spanish for providers and staff who are not as fluent in Spanish as they            would like to be. During our teleconference at 12:30PM on December 7, 2006, we will brainstorm regarding the details of this program.

Cross-cultural Health Care

Points to Ponder

Health disparities exist. Children from minority households and children from low income households, as a group, have poorer health outcomes. You may be saying to yourself, “I don’t need this curriculum. I am not prejudiced. I treat everyone the same.” Of course you do….pediatric healthcare professionals are very special people in that way. But cross-cultural care is not about treating everyone the same…..it is about recognizing how each family is unique in how they think about and understand the illness, their customs and beliefs, hidden concerns, other remedies or treatments, how they interpret your recommendations, etc.

So, what can you do to understand how your patient’s family is unique? It is not what you know…..it is what you ask . Learning about other cultures may be helpful so we can become more aware that there are other ways to view the world. However, attempts to memorize norms or values of the “Latino”, “Asian”, or “African American” cultures and apply them to individual patients may not be effective and may instead contribute to stereotyping. Instead, respectfully ask questions to understand how your patient’s (parent’s) unique culture will influence the child’s health outcomes.

Click here to read more on cross cultural health care and what questions to ask. 

Announcements

Telephone Conference

Join the conference simply by dialing us up during your lunch

Thursday, December 7th
12:30 PM
Topics:
(1) Reduce language barriers in your office
(2) Help design a Spanish interpretation training for your office staff
To sign up contact:
Joanie Muzzulin
Muzzulin.Joan@tchden.org
303-861-6309
and get the phone number and password for the teleconference

Discussion Board

Controversies in Coding and Billing For Medicaid (EPSDT) Well Child Care

Give us your opinion, See what other practices do

click here

Feedback

What topics would you like to hear more on?

What problems do you face that you would like to hear what others do to handle?

Are there tips you would like to share with others?

Send your suggestions, topic, thoughts, tips to:

Steven Poole MD

Poole.Steven@tchden.org

Contents:

- Good Reimbursement For Medicaid Well Child Care (EPSDT) -
- Improve Health Outcomes For Spanish Speaking Families -
- Cross-Cultural Health Care, Point To Ponder -

- Announcements -

- Feedback -