Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006

Objective Appropriate claim submission is in everyone’s interest –members –alternative relationship plan –billing clerks –patients –payers –society

Rules for Today Individual physicians are ultimately responsible for their claims. My qualifications –Vice-president – AMA section of Int Med –Chair, ARP Management Committee –Chaired: two billing seminars –11 years of Specialist Practice in Alberta There will be areas I do not know… let me find out rather than get stuck on a point.

Website billing.healthlearner.com

Elements of an Int Med Claim Demographics –AHCIP  AHW requires the PHN only –OOP  requires everything –College  requires complete billing records Location –Facility and Functional Centre Diagnosis Code –ICD-9 (up to 3… 4.6%-2, 1.3%-3 of 6mil-op) Referring Physician –PRACID Health Service Code –implicit modifier –explicit modifier

HSC and Modifiers HSC –refers to the service rendered –03.08A comprehensive consultation –03.03D hospital visit –01.22 colonoscopy –03.01AA providing care in hospital after hrs

Modifiers –change the value of the service –change the rules associated with the service Explicit Modifiers –must be entered with each claim (eg COMX) Implicit Modifier –pre-entered or derived by the Claim Submitter (eg LEVL  HEMH1 (HAEMATOLOGY HD1)

Explicit Modifier Categories CARE (complex patient care) –COMX, CMXC30, CMXV15, CMXV20 LMTS (limits) –TOC… LVP (lesser value, additional procedure) –LVP50, LVP75, ADD, ADD2 SURC (services unscheduled) –EV, NTPM, NTAM, WK SURT (after hours premium: 03.01AA, 03.01BA) –TEV, TNTP, TNTA, TWK, TST TELE (telehealth) –TELES, STFO

Implicit Modifier Categories Implicit Modifiers are programmed into the billing software by the Claim Submitter LEVL (level) –INMDH1, INMDH2, HEMH1, skillcodeH(1or2) SKLL (skill) –CARD, DERM, INMD, HEME, E/M, etc –*SKLL can be explicit if not using your default –e.g. GAST  bill 03.03D under INMD

Sources of Truth Medical Governing Rules Medical Benefits Procedure List Medical Benefits Price List Fee Modifier Definitions Explanatory Code List All available in pdf format from AHW

Consultations 03.08A –Comprehensive Consultation –Modifier: SURC (EV, NTPM, NTPM, WKTEV) –Modifier: CMXC30 –Modifier: TELE (TELES) 03.01AA –Modifier: SURT (TEV, TNTP, TNTA, TWK,TST) Rules about consultations… 1 / 180 days done according to peer College AHW

22-07 asthma attack... $ $28+$ $14 = $391.35

Consultations 03.07A, 03.07B –Limited or Repeat Consultation –Modifier: SURC (EV, NTPM, NTPM, WKTEV) –Modifier: TELE (TELES) 03.01AA –Modifier: SURT (TEV, TNTP, TNTA, TWK,TST) –Rules about consultations… no limitation of quantity but caution… ensure that a valid referral was made! AHW Governing Rules

Hospital Visits 03.03D –Hospital Visit –Modifier: COMX (20 minutes) –Modifier: TOC (receiving) 03.03AO –transfer of care – receiving for some divisions Rules –one per day per physician unless supporting txt –use call backs for subsequent visits –13.99J - emergency detention time / 15

$ $36.00 $74.09 INMDH1 INMDH2

Emergency Detention per 15 min

Office / Clinic Visits 03.03F –Repeat office or scheduled outpatient visit in a regional facility, referred cases only –Modifiers: CMXV15, CMXV20 –Consider 03.03Z for age > 75 years if geri

Physician to Physician Consultation Referring Physician –03.01LG (M-F 7-17) –03.01LH (M-F 17-22, Sat-Sun 7-22) –03.01LI (22-7 anyday) Consultant –03.01LJ (M-F 7-17) –03.01LK (M-F 17-22, Sat-Sun 7-22) –03.01LL (22-7 anyday) –Lots of rules, not for expediting referrals <24h

Ref-d Ref-ev/wk Ref-a/p Con-d Con-ev/wk Con-a/p

Callbacks Inpatient Callbacks –03.05N (M-F hours) –03.05P (M-F hours) –03.05QA (All hours) –03.05QB (All hours) –03.05R (Sat, Sun, Stat hours) BA –Second and subsequent patient seen after initial after-hours callback to hospital inpatient –Use SURT: TEV, TNTP, TNTA, TWK, TST

d ev pm am wk

Callback Rules 1. May only be claimed when a special call for attendance is made on the patient's behalf. 2. The physician responds to such a call from outside the hospital, on an unscheduled basis. 3. The patient is attended on a priority basis. 4. There is direct attendance by the physician. 5. Second or subsequent patients seen during the same callback are not eligible for benefits under 03.05N, 03.05P, 03.05QA, 03.05QB or 03.05R but time spent may be claimed using the AFTER HOURS TIME PREMIUM modifier with 03.05BA. 6. May not be claimed in association with any health service code except 03.01AA. Refer to GR 15.8

Callbacks and Emergency Visits: Emergency Depts, Outpatient Departments, Auxillary Hospitals, Nursing Homes similar to inpatients billing.healthlearner.com

Family / Team Conference Team Conference (per 15 min) –03.05JA Family Conference (per 15 min) –03.05JB (?) or 03.05JC (Acute Care, In-pt) Palliative Care Family or Team (per 15) –03.05T first call, 03.05U next calls Chronic Pain Team Conference –03.05V first call, 03.05W next calls Chronic Pain Family Conference (/15 min) –03.05X

Team Conference Family Conference $32 / 15 min = typical of all

Advice to Allied Health Care Workers Home Care –03.01A (M-F 7-17) –03.01AB (M-F 17-22, S-S-S 7-22) –03.01AC (anyday 22-7) Long Term Care –03.01M, 03.01MN, 03.01MO Active Treatment Facility –03.01ND, 03.01NE, 03.01NF Rules –you can’t initiate, 2/day, your location...

Inpatient Advice d ev/wk pm/am

Procedures 53.81Abone marrow aspiration (SURC)$ Bbone marrow biopsy(SURC)$ Aspinal tap(SURC)$ Aabdominal paracentesis(SURC)$ thoracentesis(SURC)$ Apleural biopsy(SURC)$ colonoscopy(SURC,LVP)$ Acolonic polypectomy$ gastroscopy(SURC,LVP)$ Adialysis, unstable pt(SURC)$ Bdialysis, stable pt(SURC)$ excision perianal skin tag(SURC)$ Aexcisional skin biopsy (TRAY, SURC...)$ 40

Residents…. Claims may be submitted by a physician who is present and supervising a resident or intern during the provision of a service.

Audits...

Diagnostic Codes ICD-9 codes see billing.healthlearner.com

Summary me: –codes you use –questions / concerns –tips