Get your letter writing implements out, spread the word, tell everyone you know.

Really. I can't over-dramatize this issue.

I reported the expected pediatric-focused changes to the 2009 RVUs two weeks ago and pointed out how CMS is not planning to add the appropriate value to the PE elements of immunization administration. IIRC - and of course, I do, because I went back and checked - I called this pathetic. Now the AAP agrees, but they are far more mature and constructive in their language.

Here is copy from a draft letter that the AAP plans to send to CMS before the 08/29/08 comment deadline. I have been asked to share this with as many practicing physicians as I can and encourage you to send your comments to CMS in an effort to get them to recognize the significant and growing cost of providing immunizations in this country. You are welcome to use and adopt the points made below.

From the letter, which is not official nor approved by the AAP, yet:

Immunization Administration: Practice Expense Inputs

In February 2008, the RUC Practice Expense (PE) Subcommittee approved the movement of some of the indirect PE into the pool of direct PE inputs for the immunization administration (IA) codes. During that meeting, the RUC approved moving the following, additional PE inputs into the existing pool of direct PE inputs for the IA codes:

For the "initial" codes (90465, 90467, 90471, 90473):

• 4 minutes RN/LPN/MA ($0.37 per minute) for:
  • Vaccine registry input
  • Refrigerator/freezer temperature log monitoring/documentation [2 times per day; logs kept for 3 years]
  • Refrigerator/freezer alarm monitoring/documentation
• 17 minutes for dedicated full size vaccine refrigerator with alarm/lock [commercial grade]
• 17 minutes for refrigerator/freezer vaccine temperature monitor/alarm

For the "each additional" codes (90466, 90468, 90472, 90474):

• 1 minute RN/LPN/MA ($0.37 per minute) for:
  • Vaccine registry input
  • Refrigerator/freezer temperature log monitoring/documentation [2 times per day; logs kept for 3 years]
  • Refrigerator/freezer alarm monitoring/documentation
• 8 minutes for dedicated full size vaccine refrigerator with alarm/lock [commercial grade]
• 8 minutes for refrigerator/freezer vaccine temperature monitor/alarm

In the 2009 RBRVS proposed rule, however, CMS states,"...we are in agreement with the RUC (PE) recommendations...except for inclusion of the clinical staff time related to quality activities for the following immunization administration codes: CPT codes 90465-90474. While we allow this time for mammography services due to the specific regulatory requirements required by the Mammography Quality Standards Act (MQSA) of 1992, such MQSA time is not required for immunization services."

This means that CMS is proposing to exclude the clinical staff times (as listed above) when calculating the 2009 PE RVUs for the IA codes. The Academy strongly urges CMS to reconsider this decision for the following reasons:

1) During the course of RUC deliberations, it was noted that in August 2003, the Practice Expense Advisory Committee refined code 77057 (screening mammography, bilateral (2-view film study of each breast), allotting clinical staff time for "quality services" based on MQSA regulatory requirements. This, however, was not the basis of the RUC's recommendations with regard to IA. It was simply recognition of a precedent for moving practice expenses previously designated as "indirect" into the pool of direct PE inputs.

2) While MQSA does not apply to the provision of vaccines, there are several federal/state programs that require quality assessment for the following immunization services

• • Vaccine registry input
    • Thirty states have laws authorizing a vaccine registry. Of those 30 states, 14 mandate reporting (Source: Unpublished data, Immunization Information Systems Support Branch, Immunization Services Division, Centers for Disease Control and Prevention)
    • One of the objectives of Healthy People 2010 is to increase to 95 percent the proportion of children younger than 6 years of age who are enrolled in fully operational, population-based immunization registries (http://www.healthypeople.gov/Document/HTML/Volume1/14Immunization.htm)

• • Refrigerator/freezer temperature log monitoring/documentation and refrigerator/freezer alarm monitoring/documentation
    • The Vaccines For Children (VFC) program requires providers to participate in an annual Assessment, Feedback, Incentives, and eXchange (AFIX) program, where clinical staff visit offices to conduct quality checks, including vaccine temperature monitoring (http://www.cdc.gov/vaccines/programs/afix/default.htm)
    • The Centers for Disease Control and Prevention has "Recommendations and Guidelines for Vaccine Storage and Handling" (http://www.immunize.org/catg.d/p3035chk.pdf), which include the following:
      • A designated person in charge of the handling and storage of vaccines
      • A back-up person in charge of the handling and storage of vaccines
      • A vaccine inventory log
      • Maintenance of a refrigerator temperature between 35-46°F
      • Maintenance of a freezer temperature of +5°F or colder
      • A posted temperature log on the refrigerator door where the refrigerator and freezer temperatures are recorded twice a day, as well as notation as whom to call if either temperature goes out of range
      • A contingency plan in the event of refrigerator/freezer failure

The aforementioned federal/state requirements and guidelines provide compelling evidence for the RUC-recommended clinical staff times for "quality activities" to be included in the 2009 PE RVUs for the immunization administration codes.

All letters must be sent to:

Acting Administrator Kerry Weems

Centers for Medicare and Medicaid Services

Department of Health and Human Services

Room 443-G

Hubert H. Humphrey Building

200 Independence Avenue, SW

Washington, DC 20201

Re:Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule and Other Revisions to Part B for CY 2009; Proposed Rule; CMS- 1403-P

Those of you who have had to pay for immunization registry interfaces (not our clients, but the rest of you), those of you who - as outlined nicely above - are dealing with fridge management (and I know three practices, personally, who have had this process fail spectacularly leading to $thousands$ lost), or are simply paying to double-enter your registry data should feel obligated to write to Acting Administrator Weems and give CMS an understanding of your daily chores.

Wow, that was long-winded. Sorry. Just send a letter! The deadline for commentary is August 29.