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Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar

Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar. Gastroenterology Jeffrey P Schaefer, MD May 14, 2009. Objective. Appropriate claim submission is in everyone’s interest members alternative relationship plan billing clerks patients payers society.

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Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar

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  1. Alberta Health Care Insurance PlanAHCIPClaim Submission Seminar Gastroenterology Jeffrey P Schaefer, MD May 14, 2009

  2. Objective • Appropriate claim submission is in everyone’s interest • members • alternative relationship plan • billing clerks • patients • payers • society

  3. billing.healthlearner.com • 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 (up to 3… 4.6%-2, 1.3%-3 of 6mil-op) • Referring Physician • PRACID • Health Service Code • implicit modifier • explicit modifier

  5. HSC and Modifiers • HSC • refers to the service rendered • 03.08A comprehensive consultation • 03.03D hospital visit • 01.14 esophagogastroscopy • 03.01AA providing care in hospital after hrs

  6. 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

  7. Relevant Explicit Modifier Categoriesmust be provided by you • 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

  8. Implicit Modifier Categoriesprogrammed into the billing software • LEVL (level) • INMDH1, INMDH2, GASTH1, GASTH2 • SKLL (skill) • GAST, INMD • *SKLL is explicit if not using your default • e.g. GAST  bill 03.03D under INMD

  9. Comprehensive Consultations • 03.08A • Comprehensive Consultation • Modifier: SURC (EV, NTPM, NTPM, WKTEV) • Modifier: CARE (CMXC30 • Modifier: TELE (TELES) • 03.08I • prolonged consultation (GI, IM, PMR, NEUR) / 15 min • begins after 30 minutes • Rules about consultations… • 1 / 180 days • AHW and College rules apply

  10. 03.08Acomprehensiveconsultation

  11. Surcharges: consults & procedures

  12. Consultations in the HospitalAfter Hours Time Premium • 03.08A • Comprehensive Consultation • Modifier: SURC (EV, NTPM, NTPM, WKTEV) • Modifier: CARE (CMXC30 • Modifier: TELE (TELES) • 03.01AA • After hours time premium (other than 8-17 M-F) • Modifier: SURT (TEV, TNTP, TNTA, TWK, TST)

  13. Health Service Code - for services in an acute care facility after hours. - attributable to individual patients. - 1 call (service) = 15 min (or portion thereof) 03.01AAafter hour time premium

  14. Hospital Consultation • You are consulted to see a patient concerning upper GI hemorrhage. Your skill code is GAST. • You are called at 21:50, initiate the consultation at 22:15 and finish at 22:55 (40 min). • You perform an esophagogastroscopy at 23:30. • The patient’s BMI is 35. • What is your claim?

  15. Hospital Consultation • 03.08A $ 188.57 • NTPM $ 107.22 • CMXC30 $ 28.70 • 03.08I x 1 call $ 42.94 • 03.01AA • TNTP x 3 calls ($41.00 x 3) $ 123.00 • 03.14 $ 124.86 • + 25% $ 31.22 • Total $ 646.51

  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

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

  21. GASTRO: CMXV

  22. GASTRO: CMXV35

  23. 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

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

  25. 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)

  26. devpmamwk

  27. 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

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

  29. 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

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

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

  32. Certification

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

  34. Audits...

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

  36. Category Codes

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

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