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Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar

Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar. Jeffrey P Schaefer, MD Sept 12, 2007. Appropriate claim submission is in everyone’s interest members alternative relationship plan billing clerks patients payers society. Rules for Today.

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Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar

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  1. Alberta Health Care Insurance PlanAHCIPClaim Submission Seminar Jeffrey P Schaefer, MD Sept 12, 2007

  2. Appropriate claim submission is in everyone’s interest • members • alternative relationship plan • billing clerks • patients • payers • society

  3. 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 • 12 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.

  4. Website billing.healthlearner.com

  5. 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 www.health.gov.ab.ca/professionals/somb.html

  6. Elements of a Claim

  7. 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 Codes and Modifiers • implicit modifier • explicit modifier

  8. HSC and Modifiers • HSC • refers to a service rendered • 03.08A comprehensive consultation • 03.03D hospital visit • 03.01AA after hours time premium • 03.01LJ telephone consult MD to MD

  9. Modifiers • Modifiers • change the value of the service • change the rules associated with the service • Explicit Modifiers • must be entered with each claim • Implicit Modifier • pre-entered or derived by the Claim Submitter

  10. 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

  11. Implicit Modifier Categories • Implicit Modifiers are programmed into the billing software by the Claim Submitter • LEVL (level) • INMDH1, INMDH2  week according to D.O.A. • 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

  12. 03.03D is very similar since July 1, 2007

  13. Consultations

  14. Consultations • 03.08A • Comprehensive Consultation • Modifier: SURC (EV, NTPM, NTPM, WKTEV) • Modifier: CARE (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

  15. Services Unscheduled: SURC • EV • weekday evening: 1700 to 2200 • NTPM • night evening: 2200 to 2400 • NTAM • night morning: 2400 to 0700 • WK • weekend & stat holiday: 0700 to 2200

  16. Called to see a fever at 20:50You see the patient at 22:02 You leave the ward at 22:48 • HSC 03.08A $155.98 • SURC NTPM $176.70 • CARE CMXC30 $ 28.00 • HSC 03.01AA $ - • SURT TNTP x 4 $ 42.00 • Total $402.68

  17. Repeat and Minor Consultations • 03.07A, 03.07B • Limited or Repeat Consultation • Modifier: SURC (EV, NTPM, NTPM, WKTEV) • Modifier: TELE (TELES) • Modifier: CARE (CMXV 15) • 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

  18. Hospital VisitsTransfer of Care

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

  20. Hosp Visit03.03D $50.00 COMX $36.00Total $86.00

  21. Major increase…. $155.98 !!!

  22. Emergency Detention per 15 min • consider this option for emergent return visits on your inpatients for which there is no call-back option

  23. Office Visits

  24. Office / Clinic Visits • 03.03F • Repeat office or scheduled outpatient visit in a regional facility, referred cases only • Explicit Modifier • CARE (CMXV 15)

  25. Office Visit $49.91 $14.00 $63.91

  26. MD to MD ConsultationsTelephone / Telehealth

  27. 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

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

  29. Call-backs

  30. Callbacks • 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). • 03.05BA • Second and subsequent patient seen after initial after-hours callback to hospital inpatient • Use SURT: TEV, TNTP, TNTA, TWK, TST

  31. devpmamwk

  32. 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

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

  34. Conferences Calls to Allied Health Care Team

  35. 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

  36. Team Conference Family Conference$34.35 / 15 min = typical of all

  37. Inpatient Advice dayev/wkpm/am

  38. ProceduresResidentsAudits

  39. Procedures 53.81A bone marrow aspiration (SURC) $ 52 53.81B bone marrow biopsy (SURC) $ 52 16.81A spinal tap (SURC) $120 66.91A abdominal paracentesis (SURC) $ 49 46.91 thoracentesis (SURC) $ 58 Check for eligible modifiers!

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

  41. Audits...

  42. Summary • email me: jpschaef@ucalgary.ca • codes you use • questions / concerns • tips

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