General Surgery May 25, 2015 Medical Services Insurance Program Billing Information Session.

General Surgery May 25, 2015

Medical Services Insurance Program Billing Information

Session

Relationships

• DHWSets health policy

• DNSNegotiates fees with DHW via Fee

Schedule Advisory Committee • Medavie Blue Cross

Medavie is subcontracted by DHW to administer the MSI program; physicians submit claims to MSI through Medavie

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Agenda

• General MSI overview• Visits• Common visit billing errors• Hospital admission and surgery• Review of premium fees• Procedure claiming processes• Common surgical billing errors

Overview of Claims

• Medavie Blue Cross has administered MSI since 1969• More than 8M claims submitted annually - Physician

payments approximately $651M per annum• Approximately 700,000 claims submitted per month - 5,900 to

8,600 of the total claims submitted are manually assessed each month

• Approximately 80 calls per day• Bi-weekly payments to physicians, optometrists, ancillary

providers and OOP/OOC claims submitted by physicians/patients

• Support DHW and Doctors NS business initiatives i.e. physician billing seminars, column in member magazine

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Important Documents

• Physician’s Manual:- Billing rules in the section labelled “Preamble”- Explanatory Codes- Miscellaneous- Health Service Codes (HSC) and fees

-Information on claims submission process - Merged with Billing Instructions Manual September 2014• Physicians’ Bulletins:– MSI Administrative updates that indicate/clarifies

changes– Master Agreement incentive program update– provides pertinent information on assessment, fee codes,

billing guidelines, etc.

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Timing of Claims Submissions

• 90 days from the date of service to submit claims

• Exceptions can be made to allow submission beyond that timeframe in exceptional circumstances

• 185 days to resubmit from the date of service

• Reversals can also be submitted as long as the original claim is available in the production database (MSI keeps 3 years of data)

• Service to residents of other provinces must be submitted within 1 year of date of service

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• When a claim has been paid at zero with error code NR072 asking for an OR report, the original claim itself also has to be resubmitted with an action code of “R” for reassessment.

• Resubmit as per NR072 – ( R ) • Rebilling ( A ) always refuses as a duplicate claim• OR reports without a resubmit results in the claim

being permanently ‘ held ’ and will not be paid.• Same for time sheet requests GN052

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Requests for OR Reports & Time Sheets

Methods of Claims Submission

Electronic :FFS and Shadow claims are submitted electronically and must be in accordance with the rules defined in the Preamble section of the Physician’s Manual.

Manual:OOP/OOC claims are submitted manually and are keyed into the system in our office to generate payments.

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Methods of Claims Submission

Importance of Shadow Claim submission and timeliness:

• Data integrity:

in the interests of maintaining appropriate and comprehensive records, you are encouraged to submit these services in a timely fashion.

• Incentive and top up payments.

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Accurate Billing

• MSI data is used to capture services eligible for incentives

• Reduces the risk of rejected claims

• Maximizes billings

• Reduces the risk of poor audit results

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Basics of Billing

03.03 A LO=OFFC

Health Service Code (HSC): The health service performed (may or may not be a defined Canadian Classification of Procedures (CCP)

Qualifier:An alpha character appended to some HSCs to subdivide the code and distinguish differences specific to the procedure.

Modifier: MSI adjudication system uses them to determine the payment amount of a service encounter. They can affect payment by:

• Adding or subtracting an amount from basic fee• Replacing the basic fee with a different amount• Indicating role, time, method, age

Service Encounter: A transaction which describes the health service performed by the provider to the patient.

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Visits

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Visits

• Evaluation of a patient either as a sole service or in association with one or more procedures

• Umbrella term: includes consultations, directive or continuing care, ICU services, for example

• Common set of rules, some specific rules related to location, etc.

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Comprehensive vs Limited Visit

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Limited Visit

• Limited visit = limited assessment for diagnosis and treatment of a patient’s condition.

• Includes a history of the presenting problem and an evaluation of relevant body systems

• Un-referred limited visit = 03.03• Referred limited visit = limited consultation

03.07

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Comprehensive Visit

• In-depth evaluation of the patient necessitated by seriousness, complexity or obscurity of patient complaint or medical condition.

• Requires complete history and physical examination relevant to specialty and working diagnosis

• E.g. family history, medications, allergies, ROS

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Comprehensive Visit

• Referred comprehensive visit = 03.08• Un-referred comprehensive visit = 03.04

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Comprehensive Visit – Specific Situations

Office (03.04)-for diagnosis of a new condition or complications of an existing condition

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Consultations

• Requires a referral from a physician, nurse practitioner, midwife, dentist or optometrist

• Comprehensive (03.08) v. limited (03.07)• Requires a written report to the referring

provider• Follow-up visits are claimed as continuing or

directive care• Repeat Consultation – re-referral for same

problem within 30 days

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General Visit Rules

• When a visit is requested in one time period and performed in another, it must be claimed using the lesser of the two rates

• If the sole purpose of the visit is to provide a procedure or injection then only the procedure or injection may be claimed

• If the patient has never had a referral, claim using GP rates

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Transferral of Care

• If care is transferred temporarily or permanently from one specialist to another neither a consultation nor a comprehensive visit may be claimed

• Exception – medical necessity e.g. general surgeon transferring care to a thoracic surgeon

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Detention Time

• Commences 30 minutes after physician is first in attendance for visit and after 60 minutes for consultations

• Claimed in 15 minute increments• May claim either detention or other services

such as procedures during the time spent with the patient, but not both

• For active, urgent medical treatment

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Detention time

• Many exclusions including:• Discussions with family• Waiting time• Time spent reviewing or completing charts• Office visits• ICU Care• More than one patient at a time

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Urgent Visit

• May be claimed when a physician travels at the request of hospital staff to see a patient.

• Reminder – movement within a hospital does not qualify as travel

• Location office – if the physician travels to his/her office outside of 0800-1700h M-F at the request of the patient. Cannot be billed during scheduled office hours

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Case Management Conference Fee (HSC 03.03D)

A time based code that may be claimed for formal multi-disciplinary health team meeting• Meeting must be called by an employee of the Nova Scotia Health

Authority (or a Director of Nursing/Director of Care at a Long Term Care Facility )to address a specific health concern for a specific patient

• Clinical record must include start and finish times and a list of all physician participants

• Cannot be used for regularly scheduled rounds e.g. stroke rounds, tumour rounds, M &M rounds, etc.

• Use for ad hoc situations e.g. complex discharge planning issue

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Billing for Services of Medical Trainees

• May claim for services of medical students and residents provided the physician claiming the service is present or immediately available

• If services provided to separate patients concurrently bill for one or the other but not both

• May not claim for services provided by nurses or nurse practitioners

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Common Visit Billing Errors

• No documentation• Claiming a visit when the sole purpose of the encounter

was to provide a procedure• Claiming a comprehensive visit/consultation for limited

and non-complex problem e.g. ingrown toenail• No physical examination – a required element of both

limited and comprehensive consultations and comprehensive visits

• Both procedure and visit code claimed with no visit documentation

Common Visit Billing Errors

• Claiming a consultation when there has been no referral

• Claiming a new consultation for follow-up visits

• Claiming a new consultation in transferral of care situations

• Post-op hospital visits claimed by designated covering physician

Hospital admission and surgery

Pre-operative Care

• Surgical fee includes hospital admission and pre-op care for two days prior to the surgery

• May bill daily visit fee if patient is in hospital for more than two days

Intraoperative Billing

• When no other procedure is performed

• When one surgeon provides exposure so that another can perform a procedure

Method of surgical exposure may not be claimed except for laparotomy & laparoscopy:

Multiple Procedure Rules

Multiple procedures – same physicianThrough same incision or on one organ• Principal procedure 100%• Additional procedure 50%Through multiple incisions or sites • Principal procedure 100%• Additional procedure 65%

Multiple Procedure Rules

• Laparoscopy considered single incision

• Incidental procedures (Appendectomy) performed with another abdominal procedure must be supported by a pathology report.

The bilateral procedure is claimed at 50% of unilateral procedure

Multiple Procedure Rules

Bilateral procedures performed subsequent to a different major procedure through the same incision should be billed at 50% and 25%

Aortic aneurysm repair100%

Right common iliac endarterectomy

50%

Left external iliacEndarterectomy

25%

Bilateral Procedures - Same Physician

Bilateral procedures performed after a different major procedure through a different incision should be claimed at 65% and 32.5%

Bilateral Procedures – Same Physician

Surgeon #1 Surgeon #2

Multiple Procedures- Different Physicians

Morbid obesity – BMI > 50

• May be claimed once per patient per physician for major procedures

• Neck and hip surgery done by incision

• The trunk by laparotomy or laparoscopy

Cancelled Surgical Procedures

If a surgical procedure is cancelledbefore it started - claim regular visit fee

If a surgical procedure is cancelled after it started – claim for intended procedure (applies to both surgeon and assistant)

Miscellaneous Billing Rules

• Add-on procedures – never performed alone, paid at full fee

• Surgeries should not be unbundled

• Anaesthesia is not payable in addition to the surgical fee

Reasons for making these claims:– Physician performs a service with no code– Existing code does not compensate for the work

done in a specific circumstance

Compensation for these claims– Rate of 100 units/ hour – Exceptions - 130u/hr– total abdominal wall reconstruction– Laparoscopic sacral colpopexy

EC/IC Claims

What to do if you don’t have a HSC to bill for a procedure…

The Fee Schedule Advisory Committee (FSAC) is the only standing committee of the Master Agreement Steering Committee (MASG). The FSAC is responsible for making recommendations to the MASG on matters pertaining to the fee schedule.

• Applications for a new fee and fee adjustment are available on line through the Doctors NS website

• Applications are accepted at any time of the year

• When an application is submitted, DNS will review the application to ensure it is complete before it is forwarded to the FSAC

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First Surgical Assists

Some major surgical procedures do not allow for assist fees (Appendix E of MSI Physician’s Manual)• The surgical assistant is compensated at 33.8% of

the total surgical fee.• The health service codes claimed for surgical

assistant services are expected to align with those submitted by the primary surgeon.

Second Surgical Assists

• There are a few codes that have a second assist modifier.

• Second assistants are compensated at 50% of fee paid to the first assist

• a letter from the surgeon is needed to support second assist claim

In Patient Hospital – Post op billing

• Post op care for the first 14 days is included in the surgical and assistant fee

• Neither the surgeon nor a designated covering physician can claim visits

• Exceptions • If the patient is sent home and re-admitted for non-

surgical care• for complications not related to the surgery

• From day 15 onward visits can be billed

In Hospital - Post-operative billing

Surgery for a complication requiring return to the OR

bill the new surgical procedure at full the hospital stay is reset for the new surgical

date

An emergency basis - a service that must be performed without delay because of the medical condition of the patient.35% (US=PREM) 50% (US=PR50) not less than 18 units for patient specific services

Premium Fees

Time Period Payment Rate

• Monday to Friday 17:00 - 23:59 US=PREM (35%) • Tuesday to Saturday 00:00 - 07:59 US=PR50 (50%) • Saturday 08:00 - 16:59 US=PREM (35%) • Saturday to Monday 17:00 - 07:59 US=PR50 (50%) • Recognized Holidays 08:00 - 23:59 US=PR50 (50%)

Premium Fees

Claiming procedures that are a necessary part of an over-arching procedure

Common Surgical Billing Errors

Common Surgical Billing Errors

• EC claims based upon total time in the OR rather than just the surgical time

• Billing EC claims along with a specific procedure code

• Two collaborating surgeons billing 100% for same procedure

• Billing as assistant for procedures done by a colleague (two surgical teams in OR doing different procedures)

Common Billing Errors

Claiming for procedures that are not done:• Drainage of abscess• Code claimed is for more extensive surgery than

that performed • omental biopsy vs omentectomy• hysteropexy vs vaginal vault suspension

• Look alike codes are used when there is not an appropriate code• 46.2 – excision or destruction of mediastinal lesion

Common Surgical Billing Errors

Instead of using a single over-arching code, the procedure is broken into components and

multiple codes are used

60.55 Hartmann resection

60.52 Other anterior

resection

58.11 Colostomy

Stacking Errors – Type 1

The overarching procedure code is billed as well as some of the procedure components:46.2 - excision or destruction of lesion or tissue of mediastinum Submitted Billings :46.2 – excision or destruction mediastinum20.71 - Thymectomy80.4 - Vaginal hysterectomy Submitted Billings: 80.4 – vaginal hysterectomy82.7 – obliteration of vaginal vault enterocele

Stacking Errors – Type II

Endoscopy

Depth of insertion is basis for payment01.24B – proctoscopy ( 5 u)01.24C – sigmoidoscopy ( 15 u)01.24A – proctosigmoidoscopy – under 16 years ( 25 u)

Colonoscopy01.22C – descending colon (40 u)01.22D – descending and transverse colon (70 u)01.22E – descending , transverse and ascending colon(100)

Operative colonoscopy codes01.22A – biopsies01.22B - polypectomies

MSI Website

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How to contact us

• [email protected]

Physician’s Manual on-line at:• www.medavie.bluecross.ca/msiprograms• www.doctorsns.com

• MSI Assessment (902)496-7011• Fax (902)490-2275 • Toll Free 1-866-553-0585

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MSI Billing Education Session

Thank You!

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