[Ohioaap-practicemanagers] Fwd: Increase to the medically unlikely edit (MUE) for CPT code 90460

[Jon Price]

Hi Practice Management listserv,
  Here's information on retroactive corrections to the mistaken limit on how many vaccines can be paid in one encounter. 
   Pediatricians in Ohio first sounded the alarm on this policy to the AAP, so thank you all.
      Jon Price, MD FAAP
      Ohio AAP Pediatric Council Co-chair

Sent from my iPad

Begin forwarded message:

> From: "Terranova, Lou" <LTerranova at AAP.ORG>
> Date: November 23, 2016 at 8:14:45 AM EST
> To: PEDCOUNCIL at LISTSERV.AAP.ORG
> Subject: Re: Increase to the medically unlikely edit (MUE) for CPT code 90460
> Reply-To: "Terranova, Lou" <LTerranova at AAP.ORG>
> 
> 
>  
> For CPT code 90461, CMS will increase the MUE value from 5 to 8 and will appear in the MUE version scheduled for January 1, 2017 and is retroactive to July 1, 2016.
>  
> For CPT code 90460, CMS will increase the MUE value from 6 to 9 and will appear in the MUE version scheduled for April 1, 2017.  In its 11/22/2016 letter, NCCI did not state that it will be retroactive.
>  
> Regarding private payers, implementation generally coincides with the MUE schedule.  UHC has indicated that for 90461, it will follow CMS and go retroactive to July 1, 2016.
>  
> Regards,
>  
> lt
>  
> 
> Sent: Tuesday, November 22, 2016 4:31 PM
> To: Terranova, Lou <LTerranova at aap.org>
> Cc: PEDCOUNCIL at listserv.aap.org
> Subject: Re: Increase to the medically unlikely edit (MUE) for CPT code 90460
>  
> So this is separate from the edit for 90461 (additional components) that was discussed last week - that will take effect 1/1/17? With it being "included in the MUE edits for 4/1/17" does that mean this is the date it will be accepted by insurance companies? Will there be any "retroactive" to this?  (I don't think this has been a problem for my clinic, but just wanted to clarify).
> 
> Betsy Peterson, MD, FAAP
> Community Pediatrics, SC
> Beaver Dam, WI
>  
> 
>  
> On Tue, Nov 22, 2016 at 2:20 PM, Terranova, Lou <LTerranova at aap.org> wrote:
> **************************************************************************************************************
> The AAP, as a result of issues raised by SOAPM members, has requested that Correct Coding Solutions (CCS), the company responsible for the National Correct Coding Initiative (NCCI) Edits, to increase the medically unlikely edit (MUE) for CPT code 90460 (immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first or only component of each vaccine or toxoid administered) from 6 to 9. This will allow the increase in the per day limit of the code to accommodate those encounters where more vaccines are being given due to a child who may be behind in the vaccine schedule and multi-component vaccines may be unavailable.
>  
> This increase will appear in the MUE list for April 1, 2017. If you would like a copy of the letter for advocacy purposes only with specific payers, please let AAP coding staff know.  Any questions or requests for the letter, please email the coding hotline aapcodinghotline at aap.org
>  
>  
> Thank you
>  
> 
>  
> 
> ================================
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> IMPORTANT NOTICE TO USERS OF PEDIATRIC COUNCIL E-MAIL LIST AND DISCLAIMER
> 
> The following guidelines and limitations should be strictly adhered to by users of the Pediatric Council E-mail List:
> 
> (1) There should be no exchange of reimbursement information that includes price, fee, charge, or cost data.  Sharing of fee schedules and other fee, charge, or cost information by competitors in this context is strictly prohibited by the antitrust laws. (2) The Pediatric Council e-mail list must not be used in any manner to negotiate with purchasers of health care services on any term or condition of reimbursement. (3) Each health care provider must make independent decisions based on his or her own individual circumstances regarding what to charge, what capitation rates to accept, with what third-party payors to contract, what fees to accept, and the other terms and conditions of these contracts. (4) The national AAP has developed a “Pediatric Council Start-up Kit” to address issues related to forming and maintaining a pediatric council.  This kit includes guidelines on the appropriate use of the pediatric council in a manner permitted by the antitrust laws.  The Kit is available by contacting Lou Terranova, Sr. health Policy Analyst at lterranova at aap.or or a 800/433-9016  ext. 7633. (5) This notice and the kit are not intended as a substitute for legal advice.  Each physician should consult with a qualified health care attorney about the limits placed on the physician's conduct by the antitrust laws in the physician's use of the Pediatric Council E-mail List and all other contexts.  Use of the Pediatric Council E-mail List in any manner to limit competition or restrain trade is strictly prohibited by state and federal antitrust laws and is subject to severe penalties.
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> --
> Christoph Diasio MD FAAP
> Sandhills Pediatrics Inc.
> Southern Pines/7 Lakes/ Raeford, NC
> SOAPM Chair
> CoChair NC Pediatric Council
>  
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> ================================
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> IMPORTANT NOTICE TO USERS OF PEDIATRIC COUNCIL E-MAIL LIST AND DISCLAIMER
> 
> The following guidelines and limitations should be strictly adhered to by users of the Pediatric Council E-mail List:
> 
> (1) There should be no exchange of reimbursement information that includes price, fee, charge, or cost data.  Sharing of fee schedules and other fee, charge, or cost information by competitors in this context is strictly prohibited by the antitrust laws. (2) The Pediatric Council e-mail list must not be used in any manner to negotiate with purchasers of health care services on any term or condition of reimbursement. (3) Each health care provider must make independent decisions based on his or her own individual circumstances regarding what to charge, what capitation rates to accept, with what third-party payors to contract, what fees to accept, and the other terms and conditions of these contracts. (4) The national AAP has developed a “Pediatric Council Start-up Kit” to address issues related to forming and maintaining a pediatric council.  This kit includes guidelines on the appropriate use of the pediatric council in a manner permitted by the antitrust laws.  The Kit is available by contacting Lou Terranova, Sr. health Policy Analyst at lterranova at aap.or or a 800/433-9016  ext. 7633. (5) This notice and the kit are not intended as a substitute for legal advice.  Each physician should consult with a qualified health care attorney about the limits placed on the physician's conduct by the antitrust laws in the physician's use of the Pediatric Council E-mail List and all other contexts.  Use of the Pediatric Council E-mail List in any manner to limit competition or restrain trade is strictly prohibited by state and federal antitrust laws and is subject to severe penalties.
> 
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> ================================
> IMPORTANT NOTICE TO USERS OF PEDIATRIC COUNCIL E-MAIL LIST AND DISCLAIMER
> The following guidelines and limitations should be strictly adhered to by users of the Pediatric Council E-mail List:
> (1) There should be no exchange of reimbursement information that includes price, fee, charge, or cost data.  Sharing of fee schedules and other fee, charge, or cost information by competitors in this context is strictly prohibited by the antitrust laws. (2) The Pediatric Council e-mail list must not be used in any manner to negotiate with purchasers of health care services on any term or condition of reimbursement. (3) Each health care provider must make independent decisions based on his or her own individual circumstances regarding what to charge, what capitation rates to accept, with what third-party payors to contract, what fees to accept, and the other terms and conditions of these contracts. (4) The national AAP has developed a “Pediatric Council Start-up Kit” to address issues related to forming and maintaining a pediatric council.  This kit includes guidelines on the appropriate use of the pediatric council in a manner permitted by the antitrust laws.  The Kit is available by contacting Lou Terranova, Sr. health Policy Analyst at lterranova at aap.or or a 800/433-9016  ext. 7633. (5) This notice and the kit are not intended as a substitute for legal advice.  Each physician should consult with a qualified health care attorney about the limits placed on the physician's conduct by the antitrust laws in the physician's use of the Pediatric Council E-mail List and all other contexts.  Use of the Pediatric Council E-mail List in any manner to limit competition or restrain trade is strictly prohibited by state and federal antitrust laws and is subject to severe penalties.
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