I received this trigger hypothesis from a faithful reader:
Large risk averse groups, like ours, that currently code 99214 at 14% will net out positively under the 2020 revised CPT guideline while small practices who code 30-40% 99214's will find a small net loss in transitioning to the new guideline.
...just in time for me to perform my annual dig into the latest RBRVS relase and determine the impact on pediatricians. This was how I figured out what was happening with immunization administration codes in 2018 and helps me counsel many practices working on fee schedule offers from the payers.
A review of my methodology:
- I start by grabbing the full CPT utilization of our customers and determining which RVU-valid (i.e., codes with RVU values) have real impact on pediatric revenue. In 2019, that amounts to just under 100 CPT codes that make up 99%+ of pediatric revenue. Our sample crossed the billion dollar threshhold a few years back, so it's a decent size.
- Using mildly proprietary math, I distribute those codes based on what I'd consider to be the most typical FTE arrangement. In other words, imagine a pediatrician with about 3000 sick visits a year - how many 99213s would that be, how many screenings, etc.? Every practice and every pediatrician is different, of course, but it is helpful to have a baseline from which to predict.
- I then plug in the 2019 RVU data, using a neutral GPCI, and compare it to the 2020 data. Which codes change the most - and which codes, by virtue of their pediatric volume - have the biggest impact? Where do we land?
The results for 2020?
- A typical FTE pediatrician will lose 1% of expected RVUs in 2020 vs. 2019 and .9% of expected revenue. Why don't those numbers match? Because the Medicare Conversion Factor (what the Feds pay for each RVU) changed, too. Don't forget to adjust by your GPCI!
- For the 3rd year in a row, the key elements of preventive care - the most important work that pediatricians do and the obvious place where our economy and culture need to invest - have been cut significantly. Imms admins (90460-1, 90471-3), health risk assessments (96160, 96161), and behaviorial/emotional screening (96127) have taken double-digit hits. The 90460 dropped by 15% this year and was supposed to drop more, I believe, before the AAP intervened. Devastating and hard to understand. These are TINY codes that make up the thinnest sliver of our healthcare expense, yet they are what keep pediatricians alive. Further, it's not like these even affect the Medicare budget!
You'd think the state of immunization-preventable disease outbreaks would move the needle in the other direction.
- On the positive side, there aren't any huge wins. Tb test (86580) gets bumped up. And wart removal (17250). None of the real improvements happen to codes that make up most pediatric revenue.
- If we go beyond the RVUs and actually look at the dollars involved, there are really only two codes to look at, the same as last year. The 15% drop in the 90460 and 90471 alone will contribute, on average, to ~$4-7,000 drop in a typical pediatrician's revenue. N.B.: this comes straight out of your personal income, remember. Your overhead didn't go down. This is all post-expenses revenue.
- On the flip side, the 99213 inches up slightly, but even with the high volume it represents, we're only talking a grand or two (relative to 100% of Medicare) for the year.
Let's go back to the trigger hypothesis at the top. What if your practice is very (too!) risk averse and does 15% 99214s and 80% 99213s (vs. the 30/65 that is closer to my prototype). Is there much of an impact?
Maybe $500/year/doc. It's tiny. The 99213 moved from 2.09 RVUs to 2.11. If it jumped to, say, 2.25 it would make more than enough difference to offset the imms admin losses, but that won't ever happen.
Note, however, the conservative E&M distribution described above leaves about $15,000/year/doc on the table regardless of RVU year we're using. Whether you are one doc or 150...that's real money. If you're coding and charting only 15-20% 99214s, you're only making various c-level people at private insurance companies wealthy.
The bottom line? Practices working on their insurance contracts should heartily avoid 2019 and 2020 RBRVS-based contracts.