Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar

1. Alberta Health Care Insurance PlanAHCIPClaim Submission Seminar GI Group Jeffrey P Schaefer, MD January 25, 2012

2. Objective • Know the anatomy of an AHCIP claim • Know the common situations • Comprehensive Consultation • Minor and Repeat Consultation • Hospital Visits • Emergency Detention • After Hours Time Premiums • Conferences • Office Visits • Telephone Consultations • Telephone Calls from Allied Health Care • Procedures

3. billing.schaeferville.com • Sources of Truth - 5 documents to download • Medical Governing Rules • Medical Benefits Procedure List • Medical Benefits Price List • Fee Modifier Definitions • Explanatory Code List http://www.health.alberta.ca/professionals/somb.htmlhttp://www.health.alberta.ca/professionals/fees.html

4. What's Needed? • 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 for some Services • 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 • 03.03F office / 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 • LEVL (level.... relates to admission date) • INMDH1, INMDH2... • SKLL (programmed into software once) • INMD, GAST, OBGY, HEME • AGE (calculated from PHN or DOB) • G75 (age surcharge)

8. Relevant Explicit Modifier CategoriesMD must supply these • CARE (complex patient care) • COMX, CMXC30, CMXV15, CMXV20 • SURC (services unscheduled) • EV, NTPM, NTAM, WK • SURT (after hours premium: 03.01AA) • TDES, TEV, TNTP, TNTA, TWK, TST • BMISRG (body mass index > 35) • LVP (repeat procedures): LVP75, LVP 50, ADD, ADD2 • TELE (telehealth): TELES

9. procedure list price list

10. Comprehensive Consultations

11. 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

13. Governing Rules… sample

15. Unscheduled Service (SURC)

16. 03.08I Prolonged Consult 30’+

17. Minor / Repeat Consults

19. Hospital Visits

21. COMX

22. After Hours Time Premium • this is a Health Service Code per 15 min or major portion thereof • hospital care provided outside of regular hours (08-17 M-F) • requires a SURT modifier (e.g. TDES, TEV, TNTP, TNTA, TWK, TST)

23. After Hours Time Premium 03.01AA + explicit modifier x number of 'calls'

25. Test your skills…

26. Claims • Consulted for obese (BMI 36) pt with GIB • ED MD called at 2145 • saw pt at 2230 - 2315 (45 min) • gastroscopy 2345 - 0045 (1 hr) • banding x 3 esophageal varices

27. Services? • Comprehensive Consultation • Endoscopy • Banding of 4 esophageal varices • After hours time premium

28. Claim? • 03.08A • 03.08I x 2 • 01.14 • $156.08 $115.40+25% $35.35 x 3 = $250.03 $1,211.70 $42.84 x 8=$390.72

29. Transfers of Care

30. Transfers of Care Not for GI... whose your AMA rep?

31. Emergency Detention per 15 min- series of codes here… resuscitation • needs supporting text… e.g. patient in respiratory failure / distress.

33. Office Visits

34. INMD: 15, 30, eligible

35. Prolonged Office VisitNot for GI… yet

36. MD to MD Advice

37. 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

38. Ref-dRef-ev/wkRef-a/pCon-dCon-ev/wkCon-a/p

39. CallbacksTypically 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)

40. devpmamwk

41. 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

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

43. 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

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

45. Advice to Allied Health Care Workers dev/wkpm/am

46. Certification

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

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

49. Audits...

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