1. Intro to Medical Billing for a County Health Program
Diane E. Zucker, M.Ed., CCS-P
Health Care Consultant
1033 Wagar Road, Rocky River, Ohio 44116

2. Agenda for this morning…
A basic overview of how health care is paid – and where a Health Department may fit in
Credentialing of providers – who, how, why and the process
Immunizations – coding, billing and the process
Collection of money from patients – and how this works with insurance
Resources..

3. Reimbursement process…
Payment for health care is based on several basic concepts
Valid independent provider – providing the service
Patient authorization to bill for services (insurance card, completed form, etc.)
Documentation of the service provided in a “medical record”
Correct coding of the service provided with both CPT and ICD codes
Submission of claims, collection of money and billing patients for their portion of services

4. Valid provider… Valid providers include… Physicians – MD or DO
Advance practice nurses – APN, CNP, nurse midwife, CNS*
Physician Assistant*
Mental health providers – LISW, psychologists, etc.
Facilities and institutions that are identified to provide certain types of facility services – immunization clinics staffed by nurses but with a medical director

5. Providers…
Provider types are not interchangeable – what this means is that Dr. A is Dr. A and cannot be coded and billed as Dr B
Insurance programs credential the provider not the degree and not the position
Mid level providers are not interchangeable with physicians for supervision of some services

6. A word about mid level providers
The State of Ohio has two distinct types of mid level providers
Advance practice nurses – APN, NP, FNP, CNS, CNM – these people practice advanced nursing; have a collaborative plan and can be credentialed independent of a physician
Physician assistants are governed by the state medical board and must practice only with their identified physicians based on their written plan of care

7. MLP…
Can see new patients and new problems based on their relationship with their supervising physicians
Are paid 85% of the physician fee schedule (except in some primary care settings they are paid the same)
May or may not be recognized by all insurance plans as independent providers

8. What is “incident to”
The concept of “incident to billing” means that a practice (or setting like yours) codes and bills for services under a physician (or APN or PA) but that person is not actually providing the service
That person must be on site when this is done
That person must sign off on certain types of procedures and services
That person takes responsibility for the insurance (or Medicare/Medicaid) for the services billed under their name and provider status

9. MLP and incident to…
If a mid level provider is billing under the physician the care must be…
An established patient established problem
The physician must be in the agency
The physician must either sign off on the note or be referenced in the note as supervising
Must be part of the initial care plan and process
There is no way to identify this activity on a claim form, the form looks like the physician did the work!

10. What can nurses do? In a clinic setting they care provide..
Immunizations
TB and other lab testing by an order or identified process
Blood draw (36415)
Nurse visits (99211) if there is a physician on site to supervise and sign off on care – and this care must be a continuation of a prior plan and process
Some select services based on contracts with insurance programs

11. Patient authorization…
The is the form the patient completes providing you with …
Name
Address
Birth date
Insurance information
A signed statement authorizing you to bill their insurance/Medicare/Medicaid
May include a self pay clause or statement about responsibility for balances, co-pays and deductibles

12. Medical record…
This is a unique record per patient that includes the key components needed to provide care for the patient
Name, birth date,
Date of care
Service received (lot #, date of expiration, drug)
Who provided the service
Forms related to services (vaccine information)
This record is maintained based on Ohio medical records requirements

13. Coding…
Coding is the use of alpha numeric characters to assign a procedure (CPT) and a diagnoses (ICD) to all services provided
CPT codes are used to identify the “what you did” and are specific to vaccines, nurse visits, physician visits, TB testing…
ICD 9 codes are the diagnoses that identifies “why you did what you did” that are specific to immunizations, exposure, conditions, history and…

14. Standardization of coding…
Because of HIPAA all CPT and ICD coding done in your setting must be based on the standard rules and process – no made up codes
ICD codes change every October (but now not until October 2014)
CPT codes change every January
HCPCs codes change every January

15. What is a HCPCs code…
These are the codes CMS creates for services that default to the ..
99070 Supplies and materials (except spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)
Drugs, biological and supplies are in this section (the G and Q codes for Medicare flu vaccine administration and supply)

16. A couple examples of procedure codes…
90658 Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use
90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
86580 Skin test; tuberculosis, intradermal

17. A few ICD 9 codes…
V04.81 Need for prophylactic vaccination and inoculation, Influenza
V01.1 Contact with or exposure to tuberculosis
V74.5 Screening examination for venereal disease
098.0 Gonococcal infection (acute) of lower genitourinary tract

18. A word about ICD 10
If you are an entity that is submitting claims to insurance, Medicare, Medicaid then on October 1, 2014 there is a change in ICD coding from ICD 9 to ICD 10
This change is major and will require education of staff/providers; a computer system to manage this process (for claims) and the ability to convert current coding to future coding
14,000 codes to 70,000 codes

19. Money for care provided
Once you begin involving a third party (insurance) into this process many rules you work under change
Patients have co-payments, deductibles and services paid based on a “contract” not your current methods
The rules of the third party supersede what you may want to do (there is no “take what insurance pays”

20. Insurance programs require…
The providers who are billing for services be the providers that are rendering care (one cannot substitute provider A for provider B)
The documentation supports the services billed under the identified provider
Certain policies about coverage for services
Claims are submitted electronically and payment accepted electronically

21. As part of the insurance world…
You become just like a doctors office or facility
Verification of patient status (yes this may mean a photo ID)
Collection of a co-pay at the time of care
Advance notification of non covered services (which you may be expected to know)
Balance billing for services applied to a deductible, co- insurance or denied as non covered

22. A side not about “agency issues”
Depending on how your agency does business and coordinates your part of the “county” you may need to consider…
A DBA tax identification number to keep your business and practice clean from the rest of the county
A lock box or unique bank account that can handle direct deposits and not co-mingle with general funds for tracking purposes for AR management
A reporting system to your county finance department that may include the ability to refund patients or insurance if mistakes are made….

23. Claim forms…
As a “practice” you would submit your claims on a CMS form
This is “red” but 99% of the forms go via the internet… so
Billing service or system to submit electronically
Ability to receive remittance electronically
HIPAA 5010 compliant

25. The completion of the form..
Requires accurate data of…
Name
DOB
Address
SS#
CPT and ICD codes
Provider numbers, location codes,
NPI numbers

26. Credentialing
This process is the examination and review of the credentials of individuals meeting a set of educational or occupational criteria and therefore being licensed in their field. Strict credentialing is required by both hospital and managed care accreditation bodies. The process is conducted periodically because of the responsibility of the organization for any claims of malpractice by its staff

27. For an agency…
This means that you must have the professional level of staff to meet the requirements to credential to become a provider MD DO
APN
PA with the identified supervisory physician

28. Part of credentialing…
The standard process for identified providers is the CAQH format
This web site has information about how this process works on both the provider side and insurance side
Medicare and Medicaid still need their own Applications

29. Medicare via CGS (Cigna)
You MUST have a National Provider Identifier (NPI). An NPI is required for a change of information or to apply for a new Medicare number. Your application will be delayed if you fail to provide an NPI with your original submission. See below for additional details.
You MUST agree to accept Electronic Payment. This federally- mandated requirement applies to established providers submitting a change of information that are not already set up for electronic payment, as well as all new enrollees. An Electronic Funds Transfer Authorization Agreement (EFT) form must be included with your application request. Your application will be delayed if you fail to include a completed EFT Agreement with your original submission. See below for additional details.

30. Medicaid… through ODJFS
Effective 8/2/2011: The Ohio Department of Job and Family Services (ODJFS) has implemented the new Medicaid Information Technology System (MITS). Please click here to enroll as a new Medicaid Provider, click here to check enrollment status or click here to login to the secure MITS portal to update demographic information as an existing provider

31. Medicaid provider unit…
For additional information please contact us: . Provider Enrollment Unit P.O. Box Columbus, Ohio
Please listen to the entire message before making your selection Telephone: , select option 3, then option 1, then option 1 again, then option 4
Monday through Friday, 8:00 a.m. to 4:30 p.m

32. Medicaid managed care…
Will not enroll you until you have a valid Medicaid provider number
May have different rules and process from traditional Medicaid (and vice versa)
They all have links on the internet…

33. Medicaid plans…
CareSource -
Buckeye -
Molina
home.aspx
Amerigroup
io.aspx

34. Credentialing… Requires time and patience
About 6 months from start to provider status (in the best case)
Requires diligence in maintaining contact information, update status and monitoring of process
Are there places that do this for you? Yes

35. Immunizations… The rules differ for children and adults
The Vaccine for children is only until age 18 (you know that!)
For adults insurance plans may or may not cover this services
The codes for administration are based on method…

36. 90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)
90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)
90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)
90474 Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

37. But Medicare has … G0008 Administration of influenza virus vaccine
G0009 Administration of pneumococcal vaccine
G0010 Administration of hepatitis B vaccine

38. And then the actual vaccine…
90632 Hepatitis A vaccine, adult dosage, for intramuscular use
90650 Human Papilloma virus (HPV) vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use
90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use
90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use

39. What if…
The insurance does not pay us the cost of the immunization or drug…
Can we balance bill the patient? NO
Can we collect at the time of service? NO
Can we collect the difference between the payment and the cost? NO
Do we have to submit to insurance if we are contracted if we know they do not pay enough to cover the cost? (yes)

40. Patient verification process
This is the process that before a patient is provided service you..
Validate who they are
What their coverage is
What the co-pay may be
If the service is considered self pay
Works for scheduled patient but walk ins…

41. What is compliance…
This is the process of following identified rules and regulations as they relate billing (submission of claims) to insurance, Medicare, Medicaid..
The service was provided – by who it is billed under
The service is documented and coded and then submitted as provided
Collection of balances is based on claims processed
Write off, adjustments and billing are consistent with standards in the industry

42. Compliance requires… Staff understand the rules and change in process
Follow the rules and do not make exceptions
Monitor themselves and others to assure that the care provided is the care billed is the care collected

43. Fee schedules… Can a setting have more than one fee schedule?
Yes, but it must be based on set criteria
Can we have a sliding fee schedule based on income
Yes as long as it is consistent and documented how the fee schedule was determined for a patient and that it is monitored on a regular basis

44. How to set the fee schedule…
Many settings use the Medicare fee schedule as the basis for all services they provide and bill because it is on the internet, and the basis for how you are paid by commercial insurance plans
The rate of payment from insurance plans ranges from 85% to 150% of the Medicare fee schedule
Use of the Medicaid fee schedule – an option but you may leave $ on the table

45. Who can use CPT codes… The CPT code book is updated every year
The Codes in the book are specific to providers who are “eligible” to provide and receive payment by Medicare or insurance plans alone
What this means is – that just because a “nurse” provides a high level of assessment in your setting does not mean they can use these CPT codes

46. CPT codes…
Each CPT code has an identified relative value (RVU) that is based on CMS guidelines and process
The diagnoses does not change the payment for a CPT code or service – it either validates the care or not
Are 5 numbers long and…

47. CPT codes are broken down into various “types”
Are codes that have “5” digits which have a unique order and type
E&M services that start with “99xxx”
Procedure codes start with 1, 2, 3, 4, 5, 6
Codes that end in “f” are PQRI (and some G codes as well)
Radiology services start with 7 – and requires “17 and 17A
Lab services start with 8 – and requires 17 and 17A
Additional “medical services” start with 9xxx
Injections and supplies or HCPCs codes (alpha numeric codes)

48. Resources for “stuff”
Where do you begin to educate yourself on this process and regulations..
This depends on the services you provide
Medicare and the CGS web site is a good place to begin for all things Medicare
ODJFS is the place for Medicaid

49. Other programs… Credentialing can be programs can be found..
Decision Health -
AHIMA – for coding and general programs
aspx
Many on line resources

50. Other types of programs..
Ohio State Medical Association – OSMA.org
Community colleges and trade schools
Medical billing programs – TRI C in Cleveland, St. Clair in Dayton, Capitol in Columbus
Boot camps and one day programs – but check to make sure they are “Ohio” based

51. The road begins!