Alberta Health Care Insurance Plan

AHCIPClaim Submission Seminar

Jeffrey P Schaefer, MD

June 29, 2006

Objective• Appropriate claim submission is in

everyone’s interest– members– alternative relationship plan– billing clerks– patients– payers– society

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.

Website

billing.healthlearner.com

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

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

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)

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

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

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

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

22-07 asthma attack...$172.65+$28+$176.70+$14 = $391.35

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

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

$38.09 +

$36.00

$74.09

INMDH1INMDH2

Emergency Detention per 15 min

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 > 75 years if geri

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

Ref-d

Ref-ev/wk

Ref-a/p

Con-d

Con-ev/wk

Con-a/p

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

d

ev

pm

am

wk

Callback Rules1. 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

Callbacks and Emergency Visits:Emergency Depts, Outpatient Departments,

Auxillary Hospitals, Nursing Homes

• similar to inpatients

• billing.healthlearner.com

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

Team Conference Family Conference

$32 / 15 min = typical of all

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 can’t initiate, 2/day, your location...

Inpatient Advice

d

ev/wk

pm/am

Procedures53.81A 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...) $ 40

Residents….

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

Audits...

Diagnostic Codes• ICD-9 codes

• see billing.healthlearner.com

Summary• email me:

– codes you use– questions / concerns– tips