AAP Private Payer Advocacy Update. 1. AAP clarifies immunization administration documentation to regional carrier

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1 AAP Private Payer Advocacy Update January AAP clarifies immunization administration documentation to regional carrier 2. National carriers providing coverage for smoking cessation counseling 3. UHC covering HPV vaccine for males 4. AAP successful in securing RVUs for CPT code TriWest offers webinars on TRICARE 6. AAP News articles related to payment issues and private payer advocacy Pediatric council efforts lead to improved payment, access to care When can practice mergers spark antitrust investigations? (from Pediatrics and the Law) CPT updates definition of other qualified healthcare professional (from Coding Corner) To assist in AAP private payer advocacy, AAP Members are urged to report any carrier concerns to the AAP Hassle Factor Form on the AAP Member Center at: ( 1. AAP clarifies immunization administration documentation to regional carrier The AAP sent a letter to Physicians Plus objecting to its practice of denying payments for immunization administration and clarified the documentation for reporting the service. The AAP responded to concerns by members of the Wisconsin Chapter that Physicians Plus, which is a regional carrier in Wisconsin, required extensive and confusing documentation that is not aligned with CPT guidelines for documentation for reporting immunization administration. A copy of the letter ( will also be posted on the AAP Member Center, private payer advocacy page. 2. National carriers providing coverage for smoking cessation counseling In August 2010, CMS announced Medicare coverage benefits for tobacco cessation counseling from a qualified physician or other Medicare recognized practitioner. Most private payers mirror CMS regarding coverage benefits under their health plans. As part of AAP private payer advocacy, discussions with some of the largest national private carriers (Aetna, CIGNA, Humana, HealthNet and UnitedHealthcare), reveal smoking and tobacco use cessation counseling is a covered and payable benefit when reported using CPT codes and

2 Some plans, such as Aetna, have annual limits to the number of smoking cessation counseling episodes. Other carriers may have claims edits based on age for patients receiving smoking cessation counseling or limiting benefits coverage for counseling only to the patient. Therefore, it is important to verify benefits coverage by the particular health plan, otherwise the family would be responsible for payment of any non-covered services and an advanced beneficiary notice should be signed when appropriate. 3. UHC covering HPV vaccine for males The AAP clarified that UnitedHealthcare (UHC) coverage for the HPV vaccine for males will be effective February 1, UHC s Vaccine Reimbursement policy calls for coverage for recommended vaccines within 60 days after publication in the MMWR to update its multiple claim platforms. UHC was the only national private carrier that did not provide benefits coverage for the HPV vaccine for males. Prior to the February 1, 2012 coverage date, UHC beneficiaries are responsible for payment for the HPV vaccine for males. UHC Reimbursement policies, including the UHC Vaccine policy can be accessed on the UHC website at: c520720a 4. AAP Successful in securing RVUs for CPT code Reprinted from the January 2012 AAP News OnCall Efforts by the AAP and its members have led to the Centers for Medicaid and Medicare Services (CMS) reversing its recent decision to not publish RVUs for CPT code (Developmental Screening). CMS responded to the concerns of AAP leadership and AAP members who filed comments objecting to the removal of published values for payment for this important procedure. Attached is a copy of the CMS memo ( clarifying continued use of CPT code and that RVUs for this code will be published. 5. TriWest offers webinars on TRICARE TriWest Healthcare Alliance, which is the regional TRICARE program for the Western US, offers webinars to physicians and practice staff on TRICARE. Topics include TRICARE 101 and gives a comprehensive review of TRICARE programs, clinical information, referrals and authorizations, claims and reimbursement, and provider resources and Behavioral Health TRICARE 101 which gives a comprehensive review of TRICARE programs and the behavioral health benefit, clinical information, referrals and authorizations, claims and reimbursement, and provider resources. Participants can access these free webinars on-line at 6. AAP News articles related to private payer advocacy The following articles related to private payer advocacy and payment issues were published in the January 2012 AAP News Pediatric council efforts lead to improved payment, access to care When can practice mergers spark antitrust investigations? (from Pediatrics and the Law) CPT updates definition of other qualified healthcare professional (from Coding Corner)

3 Upcoming AAP Webinars on Coding and Payment ICD-10-CM Transition: It s Not Just a Myth It s Coming! Thursday, February 9, 2012: 12:00 pm Central Time It is vital that coders and physicians alike be well versed in the changes because this will not only affect coding but what will be required by way of documentation from physicians and other health care practitioners in choosing the appropriate code. To register and access the listing of current and archived webinars, go to I want you to want me: How to Foster a Relationship as an Employed Physician Thursday, March 22, 2012: 12:00 pm Central Time Before the deal is officially sealed on an employment offer, clinicians must overcome the hurdle of the employment negotiations. Being prepared to ask the right questions can ensure a successful negotiation. This exciting webinar will assist clinicians with employment negotiations. To register and access the listing of current and archived webinars, go to Register Now! The following attachments are provided in the following pages: AAP letter to Physicians Plus December 28, 2011 memo from CMS on FY 2011 CHIPRA Performance Bonuses and CPT Code 96110

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