Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar

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Alberta Health Care Insurance PlanAHCIPClaim
Submission Seminar

• Jeffrey P Schaefer, MD
• June 29, 2006

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Objective

• Appropriate claim submission is in everyones
  interest
• members
• alternative relationship plan
• billing clerks
• patients
• payers
• society

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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
• 11 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.

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Website

• billing.healthlearner.com

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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 Code
• implicit modifier
• explicit modifier

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HSC and Modifiers

• HSC
• refers to the service rendered
• 03.08A comprehensive consultation
• 03.03D hospital visit
• 01.22 colonoscopy
• 03.01AA providing care in hospital after hrs

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Modifiers

• Modifiers
• change the value of the service
• change the rules associated with the service
• Explicit Modifiers
• must be entered with each claim (eg COMX)
• Implicit Modifier
• pre-entered or derived by the Claim Submitter (eg
  LEVL ? HEMH1 (HAEMATOLOGY HD1)

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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

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Implicit Modifier Categories

• Implicit Modifiers are programmed into the
  billing software by the Claim Submitter
• LEVL (level)
• INMDH1, INMDH2, HEMH1, skillcodeH(1or2)
• 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

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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

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Consultations

• 03.08A
• Comprehensive Consultation
• Modifier SURC (EV, NTPM, NTPM, WKTEV)
• Modifier 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

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22-07 asthma attack...172.6528176.7014
391.35
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Consultations

• 03.07A, 03.07B
• Limited or Repeat Consultation
• Modifier SURC (EV, NTPM, NTPM, WKTEV)
• Modifier TELE (TELES)
• 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

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Hospital Visits

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

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38.09 36.0074.09INMDH1INMDH2
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Emergency Detention per 15 min
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Office / Clinic Visits

• 03.03F
• Repeat office or scheduled outpatient visit in a
  regional facility, referred cases only
• Modifiers CMXV15, CMXV20
• Consider 03.03Z for age gt 75 years if geri

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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 lt24h

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

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devpmamwk
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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

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Callbacks and Emergency VisitsEmergency Depts,
Outpatient Departments, Auxillary Hospitals,
Nursing Homes

• similar to inpatients
• billing.healthlearner.com

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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

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Team Conference Family Conference32 / 15 min
typical of all
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Advice to Allied Health Care Workers

• Home Care
• 03.01A (M-F 7-17)
• 03.01AB (M-F 17-22, S-S-S 7-22)
• 03.01AC (anyday 22-7)
• Long Term Care
• 03.01M, 03.01MN, 03.01MO
• Active Treatment Facility
• 03.01ND, 03.01NE, 03.01NF
• Rules
• you cant initiate, 2/day, your location...

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Inpatient Advice
dev/wkpm/am
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Procedures

• 53.81A bone marrow aspiration (SURC) 52
• 53.81B bone marrow biopsy (SURC) 52
• 16.81A spinal tap (SURC) 75
• 66.91A abdominal paracentesis (SURC) 46
• 46.91 thoracentesis (SURC) 54
• 46.84A pleural biopsy (SURC) 58
• 01.22 colonoscopy (SURC,LVP) 144
• 57.21A colonic polypectomy 67
• 01.14 gastroscopy (SURC,LVP) 111
• 13.99A dialysis, unstable pt (SURC) 113
• 13.99B dialysis, stable pt (SURC) 52
• 61.03 excision perianal skin tag (SURC) 44
• 98.12A excisional skin biopsy (TRAY, SURC...)
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Residents.

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

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Audits...
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Diagnostic Codes

• ICD-9 codes
• see billing.healthlearner.com

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Summary

• email me
• codes you use
• questions / concerns
• tips