Payment & Finance
Implementing medical home makes a practice better positioned to advocate and negotiate for improved and appropriate payment. As a "work in progress" these contract and other negotiations will be specific to the unique nature of your practice—whether you are a small/large independent group, a community health center, or an integrated delivery network. Please note that this page provides additional resources as to what is provided in the Payment & Finance section of the Building Your Medical Home toolkit.
Medical Home Coding Fact Sheet 
The AAP offers a coding fact sheet that highlights most of the commonly reported codes for the medical home. This resource is updated annually to provide you with the most current coding information.
2012 Pediatric ICD-9-CM Coding Pocket Guide
This newly revised reference from the AAP includes the basic guidelines for selecting appropriate codes for commonly encountered pediatric diagnoses and diseases. All 2012 changes to ICD-9-CM codes are indexed by diagnosis and organized alphabetically for easy code identification.
Coding for Pediatric Preventive Care
This newly updated coding resource contains comprehensive listings for all 2012 CPT and ICD-9-CM codes commonly reported for providing preventive care services.
Developmental Screening Coding Fact Sheet
Developmental screening, surveillance, and assessment are often complemented by the use of special tests, which vary in length. This resource, developed by Committee on Coding and Nomenclature and the Section on Developmental and Behavioral Pediatrics, provides guidance on how pediatricians can appropriately report limited and extended developmental screening and testing services. For more resources on coding, please visit AAP Practice Management Online or contact the AAP Coding Hotline at 800/433-9016 extension 4022 or aapcodinghotline@aap.org.
Early Hearing Detection and Intervention (EHDI) Coding Fact Sheet
While coding for hearing screening is relatively straightforward, ensuring that appropriate payment is received for such services is a more complicated matter. This Coding Fact Sheet will provide you with a guide to coding for pediatric hearing screening. While it provides suggested codes, it should be noted that payer recognition of codes might vary.
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Catalyst Center: Financing Care for Children and Youth with Special Health Care Needs (CYSHCN) and Medical Homes
The Catalyst Center seeks to promote adequate financing for comprehensive, family-centered care of CYSHCN. The Center works with a broad range of stakeholders in financing and coverage issues including government agencies, parent groups, health and social service agencies, employers, payers and other stakeholders to determine family and community needs, identify gaps in current funding to meet those needs, and develop creative funding strategies. As researched by the Catalyst Center, states are developing innovative ways to finance initiatives that strengthen the existing health care system. For example, states have developed strategies to procure services in ways that improve quality or delivery of care, whether it be through medical home supports, youth transition services, or primary care case management. States are developing strategies to fund new services for CYSHCN that are not typically covered by health insurance, including care coordination (by blending state Title V and Medicaid funding, or by blending Title V and private insurance funding) and integrated care for children with specific diagnoses (by blending funding from multiple state agencies).
CDPHP Pilot Program Shows Good Results
This article in The Business Review discusses how the Capital District Physicians' Health Plan, based in Albany, NY, is saving $32 per member, per month, at the three primary care practices that made up the first phase of its medical home pilot. The health insurer is working with 21 other area practices for the second phase, and it will select the third-phase practices by the end of May 2011.
Evaluating the Patient-Centered Medical Home: Potential and Limitations of Claims-Based Data
National Academy for State Health Policy (NASHP)
This State Health Policy Briefing summarizes the advantages and disadvantages of using claims-based data to evaluate patient-centered medical home initiatives and highlights pilots in Oklahoma and Rhode Island using claims-based data in part to evaluate their medical home programs. Understanding the potential uses and limitations of both claims data and other data sources that can aid evaluators will help states to design appropriate evaluative criteria for their medical home programs.
How Can States Get Federal Funds to Help Pay for Language Services for Medicaid and CHIP Enrollees? 
National Health Law Program
This resource aims to assist states in evaluating best practices for setting up language services reimbursement. The report details federal funding available to states to pay for language services and describes technical requirements that vary from state to state.
Paying for the Medical Home—Payment Models to Support Patient-Centered Medical Home
Transformation in the Safety Net
Safety Net Medical Home Initiative
Operating as a medical home requires increased non-reimbursed activity (eg, care team meetings, patient self-management education, care coordination, data analysis, communication with other clinicians) and care management. In order for patient-centered medical home (PCMH) practice transformations to be sustainable, there must be payment reform to incentivize high-value, first-contact, primary care, and support medical home costs that are traditionally not reimbursed (eg, non face-to-face encounters). This publication provides an introduction to a series of policy briefs focusing on payment reform opportunities to support and sustain the medical home.
Payment Rate Brief
Patient Centered Primary Care Collaborative (PCPCC)
Although the PCMH is taking hold in dozens of demonstration projects across the nation, there is a wide range of payment methodologies and rate arrangements with providers within those projects. This brief provides a detailed look at the payment arrangements and dollar value of a sample of 12 PCMH initiatives that represent a diverse mix of initiatives, including those involving a single commercial payer, multiple payers and a state Medicaid agency acting alone. The brief is a reference for primary care practices and payers interested in creating new PCMH initiatives, or to refine existing ones.
Payment Reform to Support High-Performing Practice
Patient Centered Primary Care Collaborative (PCPCC) Payment Reform Task Force
This report was represents the work of a diverse group of PCPCC stakeholders and collaborators interested in exploring payment reform as a means of supporting the PCMH and transforming primary care in the US. Many other organizations are examining payment reform proposals; the PCPCC's task force is focusing on them from the unique perspective of their impact on the PCMH. The task force's goal was not to identify a "best" payment reform proposal, but rather to point out the strengths and shortcomings of available models so that PCMH advocates could choose the model that best suits their needs and circumstances.
Supporting the Patient Centered Medical Home in Medicaid and SCHIP: Savings and Reimbursement
National Academy of State Health Policy (NASHP)
This brief explains the Patient Centered Medical Home model of care and explores reimbursement strategies states are using to help medical practices become medical homes.
Who Pays? Taking the Maze Out of Funding Manual
Minnesota Children and Youth with Special Health Needs (MCYSHN)
This manual is designed to inform both families and professionals about a wide range of potential funding sources. The goal is to help persons know what programs and resources exist in order to improve access to health care and more effectively advocate for children, youth, young adults and their families. The content in the manual is geared towards all children and youth, including but not limited to those with special health needs. It includes major funding programs, other possible funding options, and "tools" to help in identifying funding resources.
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Effect of Hospital-Based Comprehensive Care Clinic on Health Costs for Medicaid-Insured Medically Complex Children
Arch Pediatr Adolesc Med. (2011)
This study examines the Medicaid costs associated with care for children with multiple chronic illnesses before and after Arkansas Children's Hospital launched a medical home program.
Incremental Cost Estimates for the Patient-Centered Medical Home
The Commonwealth Fund (2009)
Looming Financial Issues for Medical Homes in Healthcare Reform
Wegner SE, Humble CG, Antonelli RC. Pediatric Annals. 2009;38(9):524-528
The Medical Home, Access to Care, and Insurance: A Review of Evidence
Starfield B, Shi L. Pediatrics. 2004;113(suppl):1493-1498.
The Medical Home Gets Updated Improving Outcomes While Reducing Costs
Spencer, A. National Conference of State Legislatures, State Health Notes. 2008;29,511
Medical Home and Out-of-Pocket Medical Costs for Children with Special Health Care Needs
Porterfield SL, DeRigne L. Pediatrics. 2011.
This article discusses how parents of children with special health care needs pay less in out-of-pocket expenses when the children are cared for in a medical home setting. Researchers analyzed 2005-2006 data from the National Survey of Children with Special Health Care Needs, including information about 31,808 children; 73 percent had private insurance, 27 percent had public insurance. The study's results indicated the care coordination component of the medical home helped to lower out-of-pocket medical costs per $1,000 of household income.
NC Mercer Study on Evidence of Savings in Medicaid
The State of North Carolina's Division of Medical Assistance requested Mercer
Government Human Services Consulting to analyze the cost effectiveness of the state's
ACCESS program for state fiscal year 2004, covering dates of service from July 2003 - June 2004. This letter summarizes the methodology Mercer used to compare costs against benchmarks as part ofthe cost-effectiveness analysis for specified services provided to the Aid to Families with Dependent Children category of aid .
Patient-Centered Medical Home Demonstration: A Prospective, Quasi-Experimental, Before and After Evaluation
Am J Manag Care. 2009;15(9):e71-e87).
A Review of the Evidence for the Medical Home for Children With Special Health Care Needs
Homer C. , Perrin J, et al. Pediatrics. 2008;122;e922-e937 .
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Many funding opportunities exist for supporting community-based projects for medical home implementation, or for targeted patient populations. Visit the Funding Opportunities page for more information.
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AAP Policy Statement—Principles of Health Care Financing
Pediaitrics. 2010
This policy statement discusses how access to care depends on the design and implementation of payment systems that ensure the economic viability of the medical home, as well as other factors including the support and grow the of the professional pediatric workforce, and the promotion of the adoption of health information technology. Health insurance plans must be affordable and have cost-sharing policies that protect patients and families from financial strain and are without risk of loss of benefits because of plan design, current illness, or preexisting condition.
Chapter Pediatric Councils
Pediatric councils serve as forums to address pediatric issues with payers involving covered services, plan policies, and payer administrative procedures that impact access, quality, and cost. For more information, contact Lou Terranova at lterranova@aap.org
Committee on Coding and Nomenclature
The AAP Committee on Coding and Nomenclature (COCN) is responsible for reviewing all proposed changes to CPT and ICD-9-CM coding structures to determine whether the Academy will endorse the proposal; participates in the American Medical Association/Specialty Society Relative Value Scale Update Committee's (RUC) survey process by validating clinical vignettes, evaluating survey data, and deciding on physician work and practice expense relative value units (RVUs) to recommend to the RUC; and serves as a review panel regarding other activities such as identifying Academy positions on the RBRVS. The COCN also monitors the Medicare RBRVS physician fee schedule and its adoption by private and public payers.
Payment for Telephone Care: A Toolkit (Note: This link requires AAP member log-in)
The Payment for Telephone Care: A Toolkit is a practical, hands-on resource intended to help pediatricians and their office staff take the steps necessary when deciding to charge for telephone encounters with patients.
Pediatric Coding Newsletter Online
Developed by the AAP, with careful review by the AAP Committee on Coding and Nomenclature, this monthly newsletter provides broad coverage of coding for both pediatric primary care and subspecialty services. Look here for peer-reviewed, AAP-endorsed coding solutions, alerts on upcoming coding developments, and exclusive insights from experienced practitioners, all custom-built for ready access and easy comprehension by physicians and office staff alike.
AAP News Coding Corner (monthly column)
Contract Negotiation With Payers from AAP’s PediaLink module (must be an AAP member to access)
The Medical Home for Children: Financing Principles
Prepared by the AAP Committee on Child Health Financing, which monitors and makes policy recommendations to the AAP Board of Directors on various aspects and sources for financing health care for children, both private and public, and in all modes of delivery. This white paper is intended to provide guidance on the financing of medical home programs at the federal, state, and health plan levels.
Medicaid Reimbursement Report for Commonly Used Pediatric Services, 2007-2008
As part of its effort to monitor the impact of the Medicaid program on pediatrics, the AAP conducts its Medicaid Reimbursement Survey periodically. The Survey, which collects state-level data on Medicaid programs and Medicaid fee-for-service payment rates for most commonly reported pediatric CPT® (Current Procedural Terminology) codes and dental codes, is mailed to state Medicaid Directors in the 50 states and the District of Columbia.
Pediatric Medical Cost Model (Note: This link requires AAP member log-in)
To support child health and medical home advocacy in ongoing health reform discussions, the AAP launched the new Pediatric Medical Cost Model in September 2009. Based on an actuarial analysis of physician fees paid by insurers for children's services during 2008, this cost model provides state-by-state data for both public and private insurers for pediatric service categories such as well visits, sick visits, lab, immunizations, psychiatric visits, allergy tests, and others. Overall Medicaid/CHIP physician payment for children's services was 72% of Medicare payment during 2008, compared to commercial payment estimated at 113% of Medicare. Wide variations in Medicaid and CHIP fees were observed among states.
The Care Coordination Toolkit
Cincinnati Children's Hospital Center for Infants and Children with Special Needs
This tooklkit outlines billing for the care coordination through a review of individual codes, proper documentation, and an easy to follow billing slip.
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