Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar

1
Alberta Health Care Insurance PlanAHCIPClaim
Submission Seminar

• Jeffrey P Schaefer, MD
• Sept 12, 2007

2

• Appropriate claim submission is in everyones
  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
(No Transcript)
13

• 03.03D is very similar since July 1, 2007

14
Consultations
15
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

16
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

17
(No Transcript)
18
Called to see a fever at 2050You see the
patient at 2202 You leave the ward at 2248

• 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

19
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

20
Hospital VisitsTransfer of Care
21
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

22
Hosp Visit03.03D 50.00 COMX 36.00Total 86.0
0
23

• Major increase. 155.98 !!!

24
Emergency Detention per 15 min

• consider this option for emergent return visits
  on your inpatients for which there is no
  call-back option

25
Office Visits
26
Office / Clinic Visits

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

27

• Office Visit
• 49.91
• 14.00
• 63.91

28
MD to MD ConsultationsTelephone / Telehealth
29
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

30
Ref-dRef-ev/wkRef-a/pCon-dCon-ev/wkCon-a/p
31
Call-backs
32
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

33
devpmamwk
34
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

35
(No Transcript)
36
Callbacks and Emergency VisitsEmergency Depts,
Outpatient Departments, Auxillary Hospitals,
Nursing Homes

• similar to inpatients
• billing.healthlearner.com

37
Conferences Calls to Allied Health Care Team
38
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

39
Team Conference Family Conference34.35 / 15
min typical of all
40
Inpatient Advice
dayev/wkpm/am
41
(No Transcript)
42
ProceduresResidentsAudits
43
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!

44
Residents.

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

45
Audits...
46
Summary

• email me jpschaef_at_ucalgary.ca
• codes you use
• questions / concerns
• tips