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.
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.
Coding for Pediatric Preventive Care
This document
has been newly updated to reflect all of the 2010 changes in both the ICD-9-CM and CPT codes. This coding resource is organized for easy access and accurate reference and contains comprehensive listings of all the current CPT and ICD-9-CM codes that are commonly reported by pediatric health care practitioners in providing preventive care services
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.
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, created in January 2009, 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 American Academy of Pediatrics 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
Developed by the Cincinnati Children's Hospital Center for Infants and Children with Special Needs, the tooklkit outlines billing for the care coordination through a review of individual codes, proper documentation, and an easy to follow billing slip.
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).
Payment Reform to Support High-Performing Practice
This report was developed by the Patient Centered Primary Care Collaborative (PCPCC) Payment Reform Task Force and 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
This State Health Policy Briefing from the National Academy of State Health Policy (NASHP) explains the Patient Centered Medical Home model of care and explores reimbursement strategies states are using to help medical practices become medical homes.
- Starfield B, Shi L. The Medical Home, Access to Care, and Insurance: A Review of Evidence. Pediatrics. 2004;113(suppl):1493-1498.
- Homer C. , Perrin J, et al. A Review of the Evidence for the Medical Home for Children With Special Health Care Needs. Pediatrics. 2008;122;e922-e937 .
- Incremental Cost Estimates for the Patient-Centered Medical Home, The Commonwealth Fund. 2009.
- Patient-Centered Medical Home Demonstration: A Prospective, Quasi-Experimental, Before and After Evaluation. Am J Manag Care. 2009;15(9):e71-e87).
- Spencer, A. The Medical Home Gets Updated Improving Outcomes While Reducing Costs. National Conference of State Legislatures, State Health Notes. 2008;29,511
- NC Mercer Study on Evidence of Savings in Medicaid
The State of North Carolina's (State's) Division of Medical Assistance (DMA) requested Mercer
Government Human Services Consulting (Mercer) to analyze the cost effectiveness of the state's
ACCESS program for state fiscal year 2004 (SFY04), 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 (AFDC) category of aid (COA).
- Wegner SE, Humble CG, Antonelli RC. Looming Financial Issues for Medical Homes in Healthcare Reform. Pediatric Annals. 2009;38(9):524-528.
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.
