Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Nephrology Jeffrey P Schaefer, MD April 17, 2009
Jan 19, 2016
Alberta Health Care Insurance Plan
AHCIPClaim Submission Seminar
Nephrology
Jeffrey P Schaefer, MD
April 17, 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– 01.09 bronchoscopy– 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 can be 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)
• Rules about consultations…• 1 / 180 days• done according to peer• College has rules• AHW has rules• CHR has rules
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
hyperkalemia. You are called at 21:50, initiate the consultation at 22:15 and finish at 22:55. Your skill code is NEPH.
• HSC = 03.08A $ 188.57– Explicit Modifier = NTPM $ 107.22– Explicit Modifier = CMXC30 $ 28.70
• HSC = 03.01AA– Explicit Modifier 1 = TNTP ($10.50/15min)– Number of calls = 3 ($41.00 x 3) $ 123.00
• Total $ 447.49
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 . . . . . . . . . . . . . . . . . . . $56.54
– 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
Nephrology: CMXV
Nephrology: 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
Dialysis
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
Procedures (old prices)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
Procedures (surcharges apply)
Consider: BMI SURC LVP
03.01AA SURT
Category Codes
Summary• email me:
– codes you use– questions / concerns– tips