Alberta Health Care Insurance Plan

AHCIPClaim 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

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

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

– refers to the service rendered

– 03.08A comprehensive consultation– 03.03D hospital visit– 01.14 esophagogastroscopy– 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

• Implicit Modifier– pre-entered or derived by the Claim Submitter

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

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

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

03.08Acomprehensive

consultation

Surcharges: consults & procedures

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)

03.01AAafter hour time

premium

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

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?

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

Minor or Repeat Consultations03.07A

03.07B

Rules about consultations… no limitation of quantity but caution… ensure that a valid referral was made!

Hospital Visits• 03.03D . . . . . . . . . . . . . . . . . . . $51.25

– Hospital Visit– Modifier: COMX (20 minutes) add $36.90– Modifier: TOC (receiving)

CARE (COMX)$36.90

Emergency Detention per 15 minbedside attendance

Office / Clinic Visits• 03.03F

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

NEPHRO:15, 30, 35 eligible

GASTRO: CMXV

GASTRO: CMXV35

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

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)

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.

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 $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

Team Conference Family Conference

$42 / 15 min = typical of all

Advice to Allied Health Care Workers

d

ev/wk

pm/am

Certification

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

Category Codes

Summary• email me:

– codes you use– questions / concerns– tips