1. Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar New Members Jeffrey P Schaefer, MD July 14, 2010

2. Objective Know the anatomy of an AHCIP claim Know the common situations 1.Comprehensive Consultation 2.Minor and Repeat Consultation 3.Hospital Visits 4.Emergency Detention 5.After Hours Time Premiums 6.Conferences 7.Office Visits 8.Telephone Consultations 9.Telephone Calls from Allied Health Care

3. billing.healthlearner.com Sources of Truth –Medical Governing Rules –Medical Benefits Procedure List –Medical Benefits Price List –Fee Modifier Definitions –Explanatory Code List http://www.health.alberta.ca/professionals/somb.html http://www.health.alberta.ca/professionals/fees.html

4. Elements of an AHW 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 Referring Physician –PRACID if in Alberta (not required otherwise) Health Service Code –implicit modifier –explicit modifier

5. HSC and Modifiers HSC Health Service Code –refers to the service rendered –03.08A comprehensive consultation –03.03D hospital visit –03.03Foffice / clinic visit –02.82A transesophageal echocardiogram –03.01AA providing care in hospital after hrs

6. Modifiers Modifiers: changes the value of the service changes the rules for claiming the service –Implicit Modifier pre-entered or derived by the Claim Submitter –Explicit Modifiers must be entered with each claim (you write this in) up to 3 with any HSC may be submitted

7. Implicit Modifier Categories programmed into the billing software establish your SKLL code (once) LEVL (level) –INMDH1, INMDH2… SKLL –INMD AGE –G75 e.g. 03.03A

8. Relevant Explicit Modifier Categories physician must supply these CARE (complex patient care) –COMX, CMXC30, CMXV15, CMXV20 SURC (services unscheduled) –EV, NTPM, NTAM, WK SURT (after hours premium: 03.01AA) –TEV, TNTP, TNTA, TWK, TST TELE (telehealth) –TELES There are several others relating mostly to procedures…

9. Comprehensive Consultation HSC = 03.08A –Possible Explicit Modifiers: SURC: EV or NTPM or NTPM or WKTEV CARE: CMXC30 TELE: TELES Rules about consultations… 1 per 180 days per patient AHW and College rules apply

10. Procedures List

11. Price List

12. Possible Surcharges for the 03.08A (from the Price List)

13. Minor Consultation or Repeat Consultation (< 180 d) (same price)

14. Comprehensive Geriatric Assessment

15. 03.08A + CMXC30 + 03.08I vs 03.04K 1.5 hours is break point less  03.08A more  03.04K 2 hour consultation –03.08A + CMXC30 $183.86 + $28.70 –03.08I x 4 (max) 42.94/15min = $171.76 Total = $384.32 –03.04K + COMGER $300 + (2 x $50) – Total = $400

16. Hospital Visits 03.03D................... $51.25 –Hospital Visit –Modifier: COMX (20 minutes) add $36.90

17. CARE (COMX) $36.90

18. Transfers of Care 03.03D + TOC 03.03AO: hem, gim, medonc, endo…

19. Emergency Detention per 15 min bedside attendance needs supporting text… e.g. patient in respiratory failure / distress.

21. After Hours Time Premium 03.01AA –this is a Health Service Code –hospital care provided outside of regular hours (08-17 M-F) –requires a SURT modifier (e.g. TEV, TNTP, TNTA, TWK, TST) –claim by the call (unit); each call is 15 min or portion thereof –claim must be for individual patients

22. Office / Clinic Visits 03.03F –Repeat office or scheduled outpatient visit in a regional facility, referred cases only INMD: 15, 30, eligible

23. Prolonged Office Visit

24. Don’t forget the Modifiers!!! Office / Clinic Visit Modifiers

26. 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

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

28. Callbacks Typically used for patients you attend on. Pays less than new or repeat consultation Inpatient Callbacks –03.05N (M-F 0700 - 1700 hours) –03.05P (M-F 1700 - 2200 hours) –03.05QA (All 2200-2400 hours) –03.05QB (All 2400-0700 hours) –03.05R (Sat, Sun, Stat 0700-2200 hours)

29. d ev pm am wk

30. 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. 6. May not be claimed in association with any health service code except 03.01AA. Refer to GR 15.8

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

32. Family / Team Conference $42 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

33. Team Conference Family Conference $42 / 15 min = typical of all

35. Advice to Allied Health Care Workers d ev/wk pm/am

36. Certification

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

38. ARP Codes Codes paid at $0 A couple might be useful…

39. Audits...

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

41. Category Codes

43. Summary email me: –codes you use –questions / concerns –tips