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The Principles of Billing March 21, 2014 Queens Family Medicine Tom Faloon MD CCFP FCFP

The Principles of Billing March 21, 2014 Queens Family Medicine Tom Faloon MD CCFP FCFP. Educational materials. cma.ca Module 8 – Physician Remuneration Options - Appendix 1 www.oma.org – Health System Programs – practice management Un-insured service guidelines 2014 at oma.org

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The Principles of Billing March 21, 2014 Queens Family Medicine Tom Faloon MD CCFP FCFP

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  1. The Principles of BillingMarch 21, 2014Queens Family MedicineTom Faloon MD CCFP FCFP

  2. Educational materials • cma.ca • Module 8 – Physician Remuneration Options - Appendix 1 • www.oma.org – Health System Programs – practice management • Un-insured service guidelines 2014 at oma.org • Ontario SGFP www.sgfpnet.ca • Fall 2013 Billing & Practice Guide is fabulous • January 2013 Common Family Practice Codes • Latest updates available at wwwsgfp.net.ca • OHIP schedule of fees: www.health.gov.on.ca • Now must pay for hard copy ~ $27 • Electronic copy was sent to your program to distribute • Billing questions: economics@oma.org

  3. Obtaining Your Billing Number? • health.gov.on.ca • MOHLTC – Info Line – 1-800-268-1154 • HealthForce Ontario – “Practice U” • One stop resource when looking to work in Ontario – • www.healthforceontario.ca – search Practice U

  4. Golden Rules of Billing • Be accountable • Be honest • Be able to defend with accurate documentation • Be knowledgeable • Be meticulous • Be effective • Be efficient • Always close the loop

  5. Residents - Are You Billing Now? • What process? • Encounter sheets or billing day sheet? • Written diagnosis or specific code? • Service and procedural codes? • Billing for all on-call & hospital at handover rounds? • Tracking & capturing Chronic disease management & Preventative Care Management bonuses • Are these discussed and reviewed? • With whom? • Do you know what $$ you would be generating per day if you were practicing now?

  6. Understanding FFS Billing is Vital • 90% of GPs still have a significant % of their income based directly or indirectly on FFS billings • FHGs, FHNs, FHTs, FHOs all require shadow FFS billing • Salaried Docs have a vested interest in staying up to date with FFS billing • e.g. academic, hospitalist, gov’t sponsored salary • Institution must collect data re equivalent FFS billing to justify global funding • Salaries depend on “bottom line”

  7. “Is This Code In The Basket or Out?” • Providing appropriate services to patients … • SHOULD NOT BE INFLUENCED BY WHETHER THEY ARE IN OR OUT OF THE BASKET

  8. Honesty & Accountability • All physicians billing the MOH are responsible and liable to bill honestly and accountably • Failure to do so is unprofessional and illegal • Ignorance of the rules and regulations is not a defense • Random audits • Red Flags

  9. Doctor identification (automatic) Patient identification (automatic) Date of service Place of service (location code for hosp, OPD,ER) Responsible party (HCP, WCB, 3rd party or patient) Service code (visit) Diagnostic code (dx) Procedural code (if done) Premiums and modifiers To be paid…Complete all Components of a Bill

  10. General Definitions • Billing • Professional services & Diagnostic codes • Technical services & tray fees • Premiums or Modifiers • Bonuses • Responsible party • Reciprocal Billing **** Quebec • Remittance • Remittance Review and Reconciliation • Billing Period

  11. The “Anatomy of a Bill “SOAP format for Billing • “Fee for Service” Billing requires the following: • Every clinical encounter can be broken down into the following billing components • Diagnostic code • Service code • Procedure code(s) – Professional, Technical & additional office based (tray) fee codes • Special premiums, modifiers and /or bonuses • CCM, CDM, PCM & PEM bonuses

  12. Premiums, Modifiers, Bonus” • A Premium or Modifier is an additional fee that reimburses the physician for: • traveling to provide the service • making special visits • providing after-hours, weekend or holiday services. • The premium or modifier fee will have a specific code and fee • CCMs & FHGs are given bonuses of 10 -30% of FFS fee for many comprehensive services as well as for comprehensive & preventative care • Preventative Care Management Bonuses, Comprehensive Care Management, and Chronic Disease management

  13. Worker’s CompensationWSIB in Ontario • WCB/WSIB should be billed for most work related medical complaints. • Knowingly billing the Provincial HCP for WCB/WSIB services is…fraudulent • Patient refusal makes the service non-insured • WCB/WSIB pays for form completion • Form 8 & progress forms • Latest WSIB fee schedule is December 10, 2012

  14. Common WSIB Forms and Fees December 2012 • Form 8 – First Report • 8M – paper submission - $65 • 8ME - electronic submission - $85 • Form 26 – progress report – ‘ • 26M – paper - $45 • 26ME - Electronic - $60 • Complex Report – M649 • Written or dictated $112.10 – no electronic • This is a narrative report • Verify with WSIB by fax first

  15. Billing Documentation • Patient record must be able to stand alone as an indicator of what services and procedures were provided without your interpretation!!! • Random audits occur • Dictation / typed notes are recommended for both traditional and electronic medical records

  16. Billing Day Sheet - Example * Date:________ Dr. ______________

  17. Doctor’s #1 Complaint ‘I am underpaid for the services I provide’ • Who should they blame? • First & foremost - themselves • Majority fail to capture and submit bills for > 5% of services rendered • Plus - majority fail to collect on > 3% of unpaid services submitted • Failure = >8% reduction in gross income = >12% reduction in net income • Easily can = $25,000 insured / year!!! • = $750,000 over your career !!!!!!!!

  18. Know Your Fee Schedule • Provincial HCP’s “Schedule of Benefits” dictate the fees you receive • Fees change - Read all Bulletins & Fact Sheets from MOH, OMA, SGFP • Have these automatically sent to your inbox!! • Don’t assume “what you have seen or heard” during residency is best practicebilling • Stay up-to-date • review the Fee Schedule and the explanatory preamble • IGNORANCE leads to LOST INCOME

  19. Your new bible…

  20. What our patients think we get…. • For regular office visit • For complete checkup • For a delivery

  21. The “Bread & Butter” of Billing • In general, most specialties use 5-6 service codes more often than any others • Family Docs must be aware of many, many more! • Learn what criteria must be met before using these billing service codes • Each code is explained in the preamble of the HCP “Schedule of Benefits”

  22. A001 & A007Definition/required elements of service • A001 = minor visit includes one or both of the following; A. a brief history and examination of the affected part or region or related to a mental or emotional disorder….or B. brief advice or information regarding health maintenance, diagnosis, treatment and or prognosis

  23. A007 = The Foundation of GP BillingDefinition/required elements of service • A007 = An intermediate assessment is a primary care GP or pediatric service that requires a more extensive examination than a minor assessment. It requires a history of the presenting complaint(s), inquiry concerning, and examination of the affected part(s), region(s), system(s) or mental or emotional disorder as needed to make a diagnosis, exclude disease, and/or assess function

  24. Latest MOH Contract = December 2012 PSAPhysician Services Agreement • Present contract ends soon. OMA & MOH are in negotiations. • In 2012 the MOH obliged reductions and no fee increases to the 2011 fee schedule. Some new services / fees were addes • 0.5% reduction on all physician payments across the board • 3% reduction on A007 remains • Impacts bonuses for FHG and seniors • Changes will be highlighted in red! • For example purposes we will use the 2011 fees and not factor in the 0.5% reduction but the 3% reduction in A007 is factored in

  25. Bread and Butter GP Codes: Ontario Fees as of December, 2013 Code / service description FFS FHG • A007A - intermediate exam $33.70$37.07 • 15% premium to A007 if >65 yo $42.12 • A001A - minor exam $21.70 $23.97 • A003A - general assessment $77.20 $84.92 • 15% premium to A003 if > 65 yo $96.50 • K017 – child annual health exam $43.60 $47.96 • K005A - primary mental health $62.75 $69.02 • K013A - counseling $62.75 $69.02 • P003 – 1st prenatal visit $77.20 $84.92 • P004 – routine prenatal visit $34.70 $38.17

  26. Geriatric Premiums Geriatric premiums also apply to: • A004 general reassessment - $38.35 • FHG = 10% + geriatric 15% = $47.94 • A901 house call - $45.15 • FHG = 10% + geriatric 15% = $56.44

  27. Periodic Health VisitReplaces ‘Annual Check-up’ A003 Dx 917 • Criteria: Patient presents and reveals no apparent physical or mental illness • Includes an intermediate assessment focusing on age/gender appropriate Hx / OE / health screening & relevant counselling • K017 – child – 2-15 $43.60 • K103 – adolescent 16-17 $77.20 • K131 – adult 18-64 $50.00 • K132 - adult 65+ $77.20 • If you do a complete history and exam and have a legitimate dx the A003 and Dx code – e.g 412 still applies

  28. Periodic Health Visit What Criteria is Recommended • CFPC Website • Preventative Care Checklist Form • Male and Female (2010) • CFPC and Canadian Pediatric Society • The Greig Health Record: Ages 14, 15, 16, 17 (2010)

  29. Immunization Codes Have Changed To Allow MOH to Track Delivery • G840 = Quad (DTaP-IPV) = $4.50 for all • G841 = Penta (DTaT-IPV-Hib) • G842 = Hep B • G843 = HPV • G844 = Conj meningococcus C • G845 = MMR • G846 = Conjugated Pneumococcus • Add G700 ($5.10) if sole reason for visit

  30. Immunization Codes Have Changed To Allow MOH to Track Delivery • G847 = TdaP • G848 = Varicella • G538 = “other • G590 = Flu • Add G700 ($5.10) if sole reason for visit

  31. The Most Commonly Missed Procedural Codes • Examples • Chemical Treatment of Minor Skin Lesions - Z117 $11.65 • Ear syringing - G420 $11.25 • Urinalysis - G010 $2.07 • Strep tests - G014 $5.50 • Pregnancy tests `` - G005 $3.88 • Immunizations - Gxxx $4.50 • Supervision of Anti-Coagulation - G271 $12.75 • Tray Fees for procedures - E542 $11.15 All procedures performed by support staff! REVIEW ALL procedure codes for applicable tray fees

  32. Important (frequently forgotten) codes • K028 - STD management (2/yr) $62.75 • K030 - diabetic management (4/yr) $39.20 • K037 – chronic fatigue / fibromyalgia (795) $62.75 • K023 – palliative care support $62.75 • G512 – telephone support in pal care $62.75 weekly (!!)

  33. Frequently Forgotten Codes • P005 - antenatal prevent health $45.15 • may be billed with P004 and P003 • E430 - Pap tray fee (regardless of service) $11.55 • NB only if pap is done – not apply for speculum exam only • E542 – procedural tray fee $11.15 • K070 – homecare application $31.75 • K071/072 – homecare supervision $21.40

  34. Forgotten codes.. • K035 – MTO Reporting $36.25 • Ontario Ministry of Transportation home page • Vehicles>Driver Licensing>Driver Improvement>Medical Review>Physician Reporting Requirements • Download – Medical Condition Report (PDF – 376KB) • Or email – driverimprovementoffice@ontario.ca • Also Download latest CMA “Physician’s Guide to Driver Examination” • Cma.ca>cma publications>cma books. CMA Drivers Guide

  35. Forgotten codes.. • B998 – (7h-24h hours) special home visit premium to see palliative care patient $ 82.50 • Plus new travel premium B966 $36.40 • W010 –Monthly management fee of nursing home patients $108.85

  36. Hospital Care Now Rewarded • C122 day one hospital visit, C123 day two hospital visit, C124 discharge day hospital visit - $58.80 – this is a significant increase for offering in-patient care • If MRP, add 30% ($17.64) (E082, E083) = $76.44 • C002 regular visit = $31.00 if MRP = $40.30 • E080 – first visit premium within 2 weeks of discharge from acute care hospital (not OB or newborn) - $25.00 in addition to regular service fee (A001, A007, A003, A888, A901, K013, K023, K030, P003, P004, P008 – see preamble for other codes)

  37. Special Visit Premiums

  38. Enhanced Annual Bonuses For House-calls to Frail and Elderly • Introduced in 2010 – apply to and are captured with: • A901, A902, B990, B992, B994, B996, B910, B914, B916 • Bonus payments increased in latest PSA • # patients # encounters bonus • Min 3 min 12 $1500 • Min 6 min 24 $3000 • Min 17 min 68 $5000 • Min 32 min 128 $8000 • Palliative Care Bonus is different

  39. Diabetic Care Management Fee – Q040 • $60 – may bill once per 365 days starting April 1 – Mar 31st • Must complete and meet all examination criteria of Diabetes Patient Care Flow Sheet • www.oma.org/PC/documents/Diabetesmanagement.pdf • Suggestion: • Search and cross reference Dx code 250, tracking code Q040 & last billing date every 3 months • Track & cue yourself to bill Q040, E079 along with the other PCM bonuses on front of chart / EMR

  40. Smoking Cessation • For all docs offering smoking cessation counseling (FFS,CCM,FHG,FHN etc) • E079 - $15.40 bonus 1/yr – billable with several service codes e.g. A007, K013, P003, P005, W001 etc • K039 - $33.45 – 2 / yr – must document on flow sheets meeting Clinical Tobacco Intervention (CTI) guidelines • www.oma.org/PC/documents/smokingcessationapril42006.pdf • For FHG, FHN - Q042 - $7.50 – 2 / yr is added to K039

  41. Congestive Heart Failure Management • Q050 = $125 per 365 days • Form completion twice yearly • Suggest - Search diagnostic codes 428 to establish your list. If 428 not used cross reference 412, 427 to see if criteria met. • Excellent clinical tool of latest CHF Rx Guidelines • www.anl.com/MOHGUIDE/05%20Heart%20Failure%20Management

  42. Palliative Care • G512 – Palliative care management fee - $62.75 • billable once per week / patient • includes K070 (home care application), K071, K072 (acute & chronic home care supervision) • Includes G511 (phone care for palliative care patients 2 calls per week - $17.75) • Document in chart!

  43. Hospital Case Conferences K121 Hospital case conference - for inpatient (acute, chronic, rehab hospital) • Participation in person or by phone with 2 or more allied health care givers for a pre-booked case conference • Eligible for each doc participating • Document & individually initial summary and attendance time in chart. • $31.35 per time unit, maximum 4 conferences per 12 months • 1unit - 10 minutes, 2units - 16 minutes, 3units - 26 minutes, 4units - 36 minutes, 5units - 46 minutes, 6units - 56 minutes, 7units - 66 minutes, 8units - 76 minutes

  44. LTC Case Conferences K124 long term care / CCAC case conference • For LTC institution patient or CCAC patient • Prebooked 20 minute minimum attendance in person with 2 or more caregivers and if available patient and relatives • Same billing criteria as K121 • 2 per year / physician/patient

  45. New Codes!!! • K700 = Palliative care out patient case conference – new fee = $31.35 / 10 minute with 2 or more care givers directing out patient palliative care

  46. New Codes Telephone consultation fees • K730 – Physician to Physician – referring doc = $31.35 • K731 - “ “ - consultant = $40.45 • K732 – CritiCall – tele-consult - referring doc = $31.35 • K733 - “ “ - consultant = $40.45 If ER duty doc • K734 – physician to physician – referring doc = $31.35 • K735 - “ “ “ - consultant = $40.45 • K036 , K037 = CritiCall • Minimum of 10 minutes • NB. These codes are in the basket for FHN and FHOs but qualify for shadow billing

  47. New Incentives to Provide More Timely Skin Biopsies • Simple excision of pre-malignant lesions • dysplastic nevi, actinic keratosis • Face or neck • R160 1 lesion $53.20 • R161 2 lesions $87.40 • R162 3 or more $174.75 • Other areas • R163 1 lesion $43.30 • R164 2 lesions $71.80 • R165 3 or more $143.55 • Don’t forget the tray fee E542 - $11.15

  48. Third-Party Billing & Uninsured Services • Services not covered by provincial HCP or WCB/WSIB • Physician bills the responsible party (insurance company, employer, lawyer, or directly to the patient) • OMA recommended fee schedule = guideline for uninsured service fees – 2013 on web now

  49. Self Audit • Is your preceptor comfortable and consistent in billing for non-insured services? • How comfortable will you be?

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