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Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar PowerPoint PPT Presentation


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Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar. New Members Jeffrey P Schaefer, MD July 14, 2010. Objective. Know the anatomy of an AHCIP claim Know the common situations Comprehensive Consultation Minor and Repeat Consultation Hospital Visits Emergency Detention

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Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar

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Alberta health care insurance plan ahcip claim submission seminar

Alberta Health Care Insurance PlanAHCIPClaim Submission Seminar

New Members

Jeffrey P Schaefer, MD

July 14, 2010


Alberta health care insurance plan ahcip claim submission seminar

Objective

  • Know the anatomy of an AHCIP claim

  • Know the common situations

    • Comprehensive Consultation

    • Minor and Repeat Consultation

    • Hospital Visits

    • Emergency Detention

    • After Hours Time Premiums

    • Conferences

    • Office Visits

    • Telephone Consultations

    • Telephone Calls from Allied Health Care


Alberta health care insurance plan ahcip claim submission seminar

billing.healthlearner.com

  • Sources of Truth

    • Medical Governing Rules

    • Medical Benefits Procedure List

    • Medical Benefits Price List

    • Fee Modifier Definitions

    • Explanatory Code List

      http://www.health.alberta.ca/professionals/somb.htmlhttp://www.health.alberta.ca/professionals/fees.html


Alberta health care insurance plan ahcip claim submission seminar

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


Alberta health care insurance plan ahcip claim submission seminar

HSC and Modifiers

  • HSC Health Service Code

    • refers to the service rendered

    • 03.08A comprehensive consultation

    • 03.03D hospital visit

    • 03.03Foffice / clinic visit

    • 02.82A transesophageal echocardiogram

    • 03.01AA providing care in hospital after hrs


Alberta health care insurance plan ahcip claim submission seminar

Modifiers

  • Modifiers:

    • changes the value of the service

    • changes the rules for claiming the service

  • Implicit Modifier

    • pre-entered or derived by the Claim Submitter

  • Explicit Modifiers

    • must be entered with each claim (you write this in)

    • up to 3 with any HSC may be submitted


Alberta health care insurance plan ahcip claim submission seminar

Implicit Modifier Categoriesprogrammed into the billing softwareestablish your SKLL code (once)

  • LEVL (level)

    • INMDH1, INMDH2…

  • SKLL

    • INMD

  • AGE

    • G75 e.g. 03.03A


Alberta health care insurance plan ahcip claim submission seminar

Relevant Explicit Modifier Categoriesphysician must supply these

  • CARE (complex patient care)

    • COMX, CMXC30, CMXV15, CMXV20

  • SURC (services unscheduled)

    • EV, NTPM, NTAM, WK

  • SURT (after hours premium: 03.01AA)

    • TEV, TNTP, TNTA, TWK, TST

  • TELE (telehealth)

    • TELES

  • There are several others relating mostly to procedures…


Alberta health care insurance plan ahcip claim submission seminar

Comprehensive Consultation

  • HSC = 03.08A

    • Possible 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


Alberta health care insurance plan ahcip claim submission seminar

Procedures List


Alberta health care insurance plan ahcip claim submission seminar

Price List


Alberta health care insurance plan ahcip claim submission seminar

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


Alberta health care insurance plan ahcip claim submission seminar

Minor Consultation orRepeat Consultation (< 180 d)(same price)


Alberta health care insurance plan ahcip claim submission seminar

Comprehensive Geriatric Assessment


Alberta health care insurance plan ahcip claim submission seminar

03.08A + CMXC30 + 03.08I vs 03.04K1.5 hours is break pointless  03.08A more  03.04K

  • 2 hour consultation

    • 03.08A + CMXC30 $183.86 + $28.70

    • 03.08I x 4 (max) 42.94/15min = $171.76

      Total = $384.32

    • 03.04K + COMGER $300 + (2 x $50)

    • Total = $400


Alberta health care insurance plan ahcip claim submission seminar

Hospital Visits

  • 03.03D . . . . . . . . . . . . . . . . . . . $51.25

    • Hospital Visit

    • Modifier: COMX (20 minutes) add $36.90


Alberta health care insurance plan ahcip claim submission seminar

CARE (COMX)

$36.90


Alberta health care insurance plan ahcip claim submission seminar

Transfers of Care

  • 03.03D + TOC

  • 03.03AO: hem, gim, medonc, endo…


Alberta health care insurance plan ahcip claim submission seminar

Emergency Detention per 15 minbedside attendance

  • needs supporting text… e.g. patient in respiratory failure / distress.


Alberta health care insurance plan ahcip claim submission seminar

  • After Hours Time Premium 03.01AA

    • this is a Health Service Code

    • hospital care provided outside of regular hours (08-17 M-F)

    • requires a SURT modifier (e.g. TEV, TNTP, TNTA, TWK, TST)

    • claim by the call (unit); each call is 15 min or portion thereof

    • claim must be for individual patients


Alberta health care insurance plan ahcip claim submission seminar

Office / Clinic Visits

  • 03.03F

    • Repeat office or scheduled outpatient visit in a regional facility, referred cases only

INMD: 15, 30, eligible


Alberta health care insurance plan ahcip claim submission seminar

Prolonged Office Visit


Alberta health care insurance plan ahcip claim submission seminar

Don’t forget the Modifiers!!!

Office / Clinic Visit Modifiers


Alberta health care insurance plan ahcip claim submission seminar

Office / Clinic Visit Modifiers


Alberta health care insurance plan ahcip claim submission seminar

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


Alberta health care insurance plan ahcip claim submission seminar

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


Alberta health care insurance plan ahcip claim submission seminar

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)


Alberta health care insurance plan ahcip claim submission seminar

devpmamwk


Alberta health care insurance plan ahcip claim submission seminar

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


Alberta health care insurance plan ahcip claim submission seminar

Callbacks and Emergency Visits:Emergency Depts, Outpatient Departments, Auxillary Hospitals, Nursing Homes

  • similar to inpatients

  • billing.healthlearner.com


Alberta health care insurance plan ahcip claim submission seminar

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


Alberta health care insurance plan ahcip claim submission seminar

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


Alberta health care insurance plan ahcip claim submission seminar

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


Alberta health care insurance plan ahcip claim submission seminar

Advice to Allied Health Care Workers

dev/wkpm/am


Alberta health care insurance plan ahcip claim submission seminar

Certification


Alberta health care insurance plan ahcip claim submission seminar

Residents….

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


Alberta health care insurance plan ahcip claim submission seminar

ARP Codes

  • Codes paid at $0

  • A couple might be useful…


Alberta health care insurance plan ahcip claim submission seminar

Audits...


Alberta health care insurance plan ahcip claim submission seminar

Diagnostic Codes

  • ICD-9 codes

  • see billing.healthlearner.com


Alberta health care insurance plan ahcip claim submission seminar

Category Codes


Alberta health care insurance plan ahcip claim submission seminar

Summary

  • email me:

    • codes you use

    • questions / concerns

    • tips


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