Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar

1. Alberta Health Care Insurance PlanAHCIPClaim Submission Seminar Cardiology Jeffrey P Schaefer, MD June 16, 2009

2. Objective • AHCIP is complex • Correct claim submission is in everyone’s interest • ARP and FFS member time and effort • AHCIP benefits by fewer admin reviews • ICD-9 codes helps to target health funding • e.g. the prevalence of heart failure is inferred from claims

3. billing.healthlearner.com • Sources of Truth • Medical Governing Rules • Medical Benefits Procedure List • Medical Benefits Price List • Fee Modifier Definitions • Explanatory Code List www.health.gov.ab.ca/professionals/somb.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 • 02.82A transesophageal echocardiogram • 03.01AA providing care in hospital after hrs

6. Modifiers • Modifiers: • two categories: explicit and implicit • change the value of the service • change the rules for claiming the service • Explicit Modifiers • must be entered with each claim • up to 3 with any HSC may be submitted • Implicit Modifier • pre-entered or derived by the Claim Submitter

7. Relevant Explicit Modifier Categoriesmust be provided by physician • BMI (body mass index) • BMISRG • 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) • TEV, TNTP, TNTA, TWK, TST • TELE (telehealth) • TELES, STFO

8. Implicit Modifier Categoriesprogrammed into the billing software • LEVL (level) • INMDH1, INMDH2, GASTH1, GASTH2 • SKLL (CARD) • CARD

9. Comprehensive Consultation • HSC = 03.08A • Available 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. 03.08Acomprehensiveconsultation

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

12. After Hours Time Premium (hospital only) • 03.01AA • After hours time premium (other than 8-17 M-F) • Modifiers: SURT (TEV, TNTP, TNTA, TWK, TST) • one ‘call’ (unit) = 15 minutes • claim must be for individual patients

13. BMI • BMISRG most applicable for medicine • check Price List to determine HSC • BMI 35+

14. Hospital Consultation • You are consulted to see a patient concerning chest pain. Your skill code is CARD. • You are called at 21:50, initiate the consultation at 22:15 and finish at 22:55 (40 min). • You implant a pacemaker at 23:30 that takes 45 minutes. • The patient’s BMI is 35. • What is your claim?

15. Hospital Consultation with Procedure • 03.08A $ 167.79 • NTPM $ 107.22 • CMXC30 $ 28.70 • 03.01AA • TNTP x 5 calls ($41.00 x 3) $ 205.00 • 02.82A TEE $ 135.92 • + 25% $ 33.98 • Total $ 678.61

16. Minor or Repeat Consultations 03.07A 03.07B • Rules about consultations… no limitation of quantity but caution… ensure that a valid referral was made!

17. Hospital Visits • 03.03D . . . . . . . . . . . . . . . . . . . $51.25 • Hospital Visit • Modifier: COMX (20 minutes) add $36.90 • Modifier: TOC (receiving)

18. CARE (COMX) $36.90

19. Emergency Detention per 15 minbedside attendance

21. Office / Clinic Visits • 03.03F • Repeat office or scheduled outpatient visit in a regional facility, referred cases only CARD: 15, 30, 35 eligible

22. CARD: CMXV

23. CARD: CMXV35

24. 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

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

26. 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)

27. devpmamwk

28. 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

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

30. 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

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

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

33. Certification

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

35. Audits...

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

37. Category Codes

39. Summary • email me: • codes you use • questions / concerns • tips