With AAP member input, new code values for the administration and counseling of respiratory syncytial virus (RSV) immunization nirsevimab (Beyfortus) have been endorsed by the American Medical Association (AMA)/Specialty Society Relative Value Scale Update Committee (RUC).
The code values for the monoclonal antibody are scheduled to be published in 2025. The AAP and AMA, however, have asked the Centers for Medicare & Medicaid Services (CMS) to expedite publication in time for the RSV season, which begins in the fall.
The Academy’s case for the new Current Procedural Terminology (CPT) code values was bolstered by survey responses from members of the Section on Administration and Practice Management, Section on Early Career Physicians, Section on Adolescent Health, Council on Community Pediatrics, Council on Children with Disabilities, Council on Early Childhood and Council on Immigrant Child and Family Health.
“With robust survey responses … we can make a much better claim that pediatricians are familiar with a service and yes, the service can be difficult to perform,” said Suzanne Berman, M.D., FAAP, alternate adviser to the RUC.
Deciding whether to use nirsevimab is more complex than other immunizations because most infants whose mothers received an RSV vaccine during pregnancy will not need the monoclonal antibody.
“There is no other product where we have to consider the vaccine status of a patient who is not our patient — whose records we may not have access to and who may not even have an entry in our state immunization registries,” Dr. Berman said.
The RUC recommended work relative value unit (RVU), time and practice expense values for administration and counseling of nirsevimab in April. The recommendations, which have not yet been made public, were forwarded to CMS for consideration.
“Member participation is especially important for key pediatric services, such as vaccination, as other societies may not participate in those surveys or traditionally have had very low response rates,” said Steven E. Krug, M.D., FAAP, an RUC adviser.
In 2023, CMS approved interim work RVUs for CPT codes 96380 and 96381 of 0.24 and 0.17, respectively.
“When members respond to survey requests, as they did with these codes, it exponentially increases our chances for success — which translates into payment for pediatricians,” said Marsha Schofield, M.S., R.D., L.D., FAND, an AAP RUC consultant. “We’re highly dependent on members familiar with the service being surveyed to respond so our recommendations are supported by solid data.”
Resources
