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Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar. Resp Med Jeffrey P Schaefer, MD October 22, 2008. 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

Alberta Health Care Insurance PlanAHCIPClaim Submission Seminar

Resp Med

Jeffrey P Schaefer, MD

October 22, 2008

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

All Links are on my Website

  • 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

elements of an ahw claim
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
hsc and modifiers
HSC and Modifiers
  • HSC
    • refers to the service rendered
    • 03.08A comprehensive consultation
    • 03.03D hospital visit
    • 01.09 bronchoscopy
    • 03.01AA providing care in hospital after hrs
modifiers
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
relevant explicit modifier categories
Relevant 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 Modifier Categories
  • Implicit Modifiers are programmed into the billing software by the Claim Submitter
  • LEVL (level)
    • INMDH1, INMDH2, GASTH1, GASTH2
  • SKLL (skill)
    • GAST, INMD
    • *SKLL can be explicit if not using your default
    • e.g. GAST  bill 03.03D under INMD
consultations in the hospital
Consultations in the Hospital
  • 03.08A
    • Comprehensive Consultation
    • Modifier: SURC (EV, NTPM, NTPM, WKTEV)
    • Modifier: CMXC30
    • Modifier: TELE (TELES)
  • 03.01AA for being in the hospital after hours
    • Modifier: SURT (TEV, TNTP, TNTA, TWK,TST)
  • Rules about consultations…
      • 1 / 180 days
      • done according to peer
      • College has rules
      • AHW has rules
      • CHR has rules
surcharges consults procedures
Surcharges: consults & procedures

Rotation Duty Does Not Apply to Medicine

slide12

Health Service Code

- for services in an acute care facility after hours.

- attributable to individual patients.

- 1 call (service) = 15 min (or portion thereof)

03.01AAaftehour time premium

hospital consultation
Hospital Consultation
  • You are consulted to see a patient concerning asthma. You are called at 21:50, initiate the consultation at 22:15 and finish at 22:55. Your skill code is RSMD.
  • HSC = 03.08A $184.50
    • Explicit Modifier = NTPM $181.12
    • Explicit Modifier = CMXC30 $ 28.70
  • HSC = 03.01AA
    • Explicit Modifier 1 = TNTP ($10.50/15min)
    • Number of calls = 3 ($10.76 x 3) $ 32.28
  • Total = $426.60
minor or repeat consultations
Minor or Repeat Consultations
  • 03.07A, 03.07B
    • Rules about consultations…
      • no limitation of quantity but caution…
      • ensure that a valid referral was made!
      • AHW Governing Rules
procedures surcharges apply
Procedures (surcharges apply)

Consider:

BMI

SURC

LVP

03.01AA

SURT

hospital visits
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
slide20

Transfer of Care – Resp / GIM / HEME / MEDONC…

- both (giving / receiving) claim if ‘introduction rounds’

office clinic visits
Office / Clinic Visits
  • 03.03F
    • Repeat office or scheduled outpatient visit in a regional facility, referred cases only

Respiratory Medicine: CMXV20

Respiratory Medicine: CMXV35

physician to physician consultation
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
callbacks typically used for patients you attend on pays less than new or repeat consultation
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).
  • 03.05BA
    • Second and subsequent patient seen after initial after-hours callback to hospital inpatient
    • Use SURT: TEV, TNTP, TNTA, TWK, TST
callback rules
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

slide30
Callbacks and Emergency Visits:Emergency Depts, Outpatient Departments, Auxillary Hospitals, Nursing Homes
  • similar to inpatients
  • billing.healthlearner.com
family team conference 35
Family / Team Conference $35
  • 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
procedures
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...) $ 40

residents
Residents….
  • Claims may be submitted by a physician who is present and supervising a resident or intern during the provision of a service.
diagnostic codes
Diagnostic Codes
  • ICD-9 codes
  • see billing.healthlearner.com
summary
Summary
  • email me:
    • codes you use
    • questions / concerns
    • tips