from the AAP Division of Health Care Finance
Every year, the Centers for Medicare & Medicaid Services (CMS) publishes a
new physician fee schedule that includes updated relative value units (RVUs) and
payment statuses and a new conversion factor.
Many codes are revalued up or down based on different factors. The Academy
publishes an RBRVS (Resource-Based Relative Value Scale) brochure annually (see
resources) and makes updates throughout the year. The brochure lists many relevant primary care pediatric Current Procedural Terminology (CPT) codes and their
current year RVUs. Also, new codes that impact pediatrics are added to the list.
For 2017, two new codes for health risk assessment were added: 96160 and 96161.
Both are valued with 0.13 total non-facility RVUs. New codes for moderate sedation
also were added and valued as follows:
Moderate sedation provided by the same physician
performing the diagnostic or therapeutic service
Moderate sedation provided by a physician other than the provider
performing the diagnostic or therapeutic service
F – facility; NA – not applicable; NF – non-facility; PE – practice expense;
PLI – professional liability insurance
Non-direct prolonged services now payable
New for 2017, CMS will change the status indicator for CPT codes 99358-99359
(non-direct prolonged services) from “B” (bundled and not separately payable) to
“A” (active status and payable).
Per CMS in the Final Rule “We agreed that these codes would provide a means to
recognize the additional resource costs of physicians and other billing practitioners, when
they spend an extraordinary amount of time outside of an E/M visit performing work
that is related to that visit and does not involve direct patient contact (such as extensive
medical record review, review of diagnostic test results or other ongoing care management
work). We also believed that doing so in the context of the ongoing changes in health care
practice to meet the current population’s health care needs would be beneficial for Medicare
beneficiaries and consistent with our overarching goals related to patient-centered care.”
This is the type of work pediatricians and pediatric specialists perform but rarely
have seen compensation for. With the status change and published RVUs, private
payers and state Medicaid plans typically follow suit. AAP members are urged to
code for these services when provided.
In addition to the non-direct prolonged services, CMS has followed suit with the
same status change and published values for the complex chronic care management
codes 99487 and 99489. While these are reported less often for pediatric patients,
they are applicable.
It is important to remember that CMS now allows payment for many non-face-to-face services, including non-direct prolonged services (99358-99359), so
pediatricians should report them.
Prolonged service before/after direct patient care
Chronic care management
In addition to the RVU updates, the Medicare conversion factor (CF) has been
updated. This is the dollar amount all RVUs are multiplied with to get to the payment. The 2016 CF was set at $35.80, while the 2017 CF is set at $35.89. Even
though the increase seems small, there is always the concern that the CF will remain
the same or decrease.
Medicare Physician Fee Schedule updated for 2017
• RBRVS brochure, https://www.aap.org/en-us/Documents/2017_RBRVS.pdf
• Final rule, http://bit.ly/2hx4cJ5
• Conversion factor history, http://bit.ly/2iFc Y8m
99151 0.50 1.63 0.12 0.05 2. 18 0.67 $78.24 $24.05
99152 0.25 1. 18 0.08 0.02 1.45 0.35 $52.04 $12.56
99153 0.00 0.30 NA 0.01 0.31 NA $11.13 NA
99155 1.90 NA 0.56 0.17 NA 2.63 NA $94.39
99156 1.65 NA 0.35 0.15 NA 2. 15 NA $77.16
99157 1. 25 NA 0.27 0.11 NA 1.63 NA $58.50
99358 2. 10 0.91 0.91 0.15 3. 16 3. 16 $113.41 $113.41
99359 1.00 0.45 0.45 0.07 1.52 1.52 $54.55 $54.55
99487 1.00 1.55 0.41 0.06 2.61 1.47 $93.67 $52.76
99489 0.50 0.78 0.21 0.03 1. 31 0.74 $47.02 $26.56
After the tooth fairy has made a few visits to your home,
you might notice that your child’s pearly smile doesn’t
seem as white now that she has a few more adult teeth.
This is because the top layer (enamel) of baby teeth is
thinner and whiter than the enamel of adult teeth.
Over-the-counter tooth whitening products such as whitening strips, trays and gels have exploded in popularity in recent
years. But should children use them?
Pediatric dentists usually do not suggest bleaching until all
baby teeth have fallen out. If using at-home bleaching products,
parents should read the product label for recommended ages
Dark teeth can be caused by colas, dark juices, popsicles,
coffee and other foods. A single dark tooth could be the result
of an injury to the tooth, tooth decay or cavities.
Children should visit a dentist for a routine checkup and
cleaning every six months, according to the American Academy
of Pediatrics. There, they can talk about whitening treatments.
“I tell parents to hold off decisions about bleaching (until) after
age 14, because all the baby teeth are gone by then and the adult
teeth are fully erupted,” said Martha Ann Keels, D.D.S., Ph.D.
She suggests starting with an at-home kit with a low amount
of bleach. “It is important to pay attention to the side effects
and stop bleaching if the teeth start to be sensitive or the gums
become irritated,” she said.
A dentist should examine an injured tooth that has turned
dark or teeth with white spots and decide if in-office bleaching
would work better than at-home products, she said.
Before your child uses whitening products to improve how
her teeth look, remember that the tooth color difference won’t
be as noticeable when all her adult teeth come in.
“Once all the baby teeth are out, then the contrast with white
color is gone and the permanent teeth do not look so yellow,”
said Dr. Keels. “I try to encourage accepting natural beauty
Find more oral health tips for children at http://bit.ly/2j5o86m.
— Trisha Korioth
AAP News Parent Plus
INFORMATION FROM YOUR PEDIATRICIAN
Consider child’s age before trying tooth whitening products