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The Principles of Billing. Case Study  Dr. New Entrant (NE) completes his/her FM residency in 5 months. To date, she only fills in a patient encounter.

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Presentation on theme: "The Principles of Billing. Case Study  Dr. New Entrant (NE) completes his/her FM residency in 5 months. To date, she only fills in a patient encounter."— Presentation transcript:

1 The Principles of Billing

2 Case Study  Dr. New Entrant (NE) completes his/her FM residency in 5 months. To date, she only fills in a patient encounter form which the unit manager will use to do the billing. Her preceptor is on salary with the teaching program funded by a ARP. There has been no specific instruction in billing. The program encourages the resident to learn this during their community rotations. NE doesn’t know how to bill or how to obtain her billing #.

3 Introduction  Most physicians are self-employed vs salaried  As a professional, you provide a service  Your income is received upon billing and receipt of payment for services rendered  You are now a proprietor in the Service Industry called Medicine

4 Areas to be Addressed  Registering with the provincial HCP  When, how and who to bill  Staff Training  Where to go for Help  Monitoring  The components of a bill to provincial Health Care Plans (HCP) or WCB  The “bread & butter” of billing

5 Areas to be Addressed (cont’d)  Third Party Billing  Uninsured/Noninsured Services  Alternate Billing Options  NEVER FORGET TO....!!  Common Mistakes

6 Registering with Your HCP  Provincial registration variations & exclusion criteria  Contact provincial licensing college  application for Independent Practice License  Contact HCP for “Application for Billing Number”  Billing # restrictions may apply!  Register with WCB

7 Choosing a Billing Package  List of approved submitters  (780)  AMA Web site (www.albertadoctors.org)  computerized office  Physician office system program  3 approved vendors (Med Access, Telus Health Solutions (Practice Solutions), Telus Health Solutions - Wolf Medical System)  Practitioners in Similar practices  Service Bureau’s VS Direct Submission  Cost, support, availability of software

8 HCP Physician Information Kit  HCP Schedule of Benefits (www. albertadoctors.org, fees and negotiation, billing advice)  General Rules  Procedure list  Fee modifier list  Price list  Explanatory codes  Diagnostic code manual  AHW Web site (http://www.health.alberta.ca/documents/Diagnostic-Code- ICD-9.pdfhttp://www.health.alberta.ca/documents/Diagnostic-Code- ICD-9.pdf  A Physicians Resource Guide /AH&W Bulletins  AHW Web site (http://www.health.alberta.ca/documents/Physician- Resource-Guide-2014.pdf)  Facility Listing  AH Web site (http://www.health.alberta.ca/documents/Facility-Listing pdf)

9 Staff Training  Office policies  Billing for Uninsured services  Alberta Health Billing  Submission  Reconciliation  Resubmission  Not all services are billable - varies from province to province  Supervised services  Reciprocal Billing

10 Where to go for Help  Physician Resource Guide  Alberta Health  (780)  AMA - Physician Advocacy  (780) 

11 Verifying AH Coverage  IVR  Netcare  Opted out  Good Faith Claims  Invalid AHC Numbers  Office  Bill patient  Hospital Patient  Name, address, phone number, ULI, DOS, DOB, claim number

12 Remittance Review & Reconciliation  The weekly process of reviewing if you have received 100% payment for the services you have rendered to date  Unpaid or partially paid accounts should be reviewed, corrected & resubmitted to the responsible party

13 Monitoring  Verify assessment results  Is explanatory code acceptable  Paid does not equate to assessment is correct  Few edits in place  Physicians responsibility to ensure that assessment is correct

14 Responsible Party  The Responsible Party remits payment to the physician for services rendered  Provincial HCP  WCB  Third parties (uninsured services)  insurance companies  employers  lawyers  government agency  Patient (insured or uninsured)

15 Worker’s Compensation  Obtaining a Registration (billing) number  Edmonton or toll free  Always verify if the patient is covered by WCB when assessing all work related medical complaints.  Knowingly billing the Provincial HCP for WCB services is…fraudulent  WCB pays for form completion  Claims submission must be electronic

16 Reciprocal Billing  All provinces & territories, except Quebec, have mutual arrangements that allow the physician to bill the patient’s “home province” for services rendered  Payment is rendered at the rates of the “host province”  Some exceptions/exclusions  Physician’s Resource Guide (section 4)

17 Billing Period  AHW provides weekly payments  Accounts receivable = weeks  AHW claim submission deadlines are 180 days from service date or 180 from last communication  Note AH has indicated to AMA they want to move to 90 days.

18 The Components of a Bill  Service provider PRACID  Skill Code  Recipient ULI  Date of service  Location of service  Referral PRACID if applicable  Health service code  Calls  Diagnostic code  Encounter number  Modifiers if applicable  Facility number  Functional centre  Responsible party  Recovery code

19 Billing Documentation  Billing Day sheet  Computer record  Patient record must be able to stand alone as an indicator of what services and procedures were provided without your interpretation!!!  AHC legislation  Records must be kept minimum of 6 years

20 Know Your Fee Schedule  Provincial HCP’s “Schedule of Benefits” dictate the fees you receive  Fees change - READ ALL BULLETINS  Stay up-to-date  Request new SOMB fax (780)   Review the schedule - general rules, procedure list and associated notes, modifiers  PHYSICIAN DECIDES ON CODE TO SUBMIT  IGNORANCE leads to LOST INCOME

21 The “Bread & Butter” of Billing  In general, most specialties use 5-6 service codes more often than any others  Learn what criteria must be met before using these codes  Each code is explained in the procedure list of the HCP “Schedule of Medical Benefits”

22 Bread and Butter Codes: 03.03A Limited visit not requiring complete history and evaluation$ years and older 03.03A + 20% 03.03B Prenatal visit $ A Comprehensive visit $98.78 CMGP Complex patient visit modifier/unit$ J, 03.03A, 03.03B, 03.03C, 03.03N, 03.03P, 03.03Q, 03.07A, 03.07B

23 CMXC30Complex visit/consultation modifier $ A, 03.04B, 03.04C, 03.04D 03.04M, 03.08A 08.19GDirect contact with a patient for psychiatric treatment, per 15 minute$ A Excisional biopsy, skin$ MPre op history & physical$98.78 Bread and Butter Codes cont’d:

24 03.04JDevelopment, documentation & administration of a comprehensive annual care plan for patient with complex needs$ Family physician most responsible - One/patient/year with ongoing communication - Not payable within 345 days of previous 03.04J - May be claimed in addition to 03.03A, 03.03N, 03.04A - Complex – patient with multiple complex health needs including chronic disease and other complications - Two or more diagnosis from group A & B Comprehensive care plan

25 Group A - Hypertensive disease (401) - Diabetes Mellitus (250) - COPD (496) - Asthma 493) - Heart Failure (428) -Ischemic Heart Disease ( ) -Chronic renal failure (585) -(2 different GFR readings, >3 mon apart. Values must be accompanied by urine or imaging abnormalities) Group B - Mental Health Issues (290 – 319) - Obesity (Adult + BMI 35, Child = BMI 97 percentile) (278) - Addictions (303 – 304) - Tobacco (305.1) Comprehensive care plan cont’d

26 Care plan includes: - Direct contact with patient - Clearly defined goals - Detailed review of chart, current therapies and problem list - Demographic information that may affect patient health &/or treatment - Incorporate patient values and personal goals - Expected outcome - Identification of other health care professionals that may be involved - Physician & patient sign and each keep copy Comprehensive care plan cont’d

27 Most Common Rejected Claims  Patient coverage problems  Duplicate services  Patient seen twice in one day  Missing information on claim  Reductions by the Ministry  What does this cost you every Month/Year?????

28 Primary Care Networks  Objectives of PCN include  Increase access to primary care  Manage 24/7 access to appropriate care  Increase emphasis on promotion and prevention  Greater use of multi-disciplinary teams  Better coordination and integration between the components of the health system

29 Primary Care Initiative cont’d  Local Primary Care Networks (LPCN)  Arrangement between group(s) and a regional health authority (shared leadership)  Local flexibility to address local needs  Manages the comprehensive care of a population  Patient population defined through formal or informal enrolment  Funding follows the patient

30 AMA Practice Management Program To provide high quality change management products and services primarily to physicians entering Local Primary care Networks (LPCN’s)

31 Third-Party Billing & Uninsured Services  Services not covered by provincial HCP or WCB  Physician bills the responsible party (insurance company, employer, lawyer, government agency or directly to the patient)  Not subject to clawbacks

32 Non-insured Services Why Physicians Don’t Bill  It will create public relations problems  It will create administrative problems  It’s not financially worth it  I’ve never done it before  I don’t want to be the first in town to do it  I don’t know how  My patient’s won’t like me.

33 Is Bill a 4-letter word?

34 What will really happen  My patients will recognize that ALL my time is valuable  I will accept that ALL my time is valuable  I will get paid for things that I now do for free  My revenues will increase  Overhead ratio will decrease  My practice remains viable  Able to take time off

35 Billing for Un-insured Services is... EXTREMELY IMPORTANT  Be proactive - start from day one!  Be consistent  Use discretion  Inform patients of their responsibility for payment prior to the delivery of the service  Don’t feel guilty for billing appropriately for uninsured services

36 Common Uninsured Services  Sick notes and medical certificates  Employment insurance forms  Phone call prescription renewals  Chart transfer charges  Missed appointments  Insurance reports  Cosmetic procedures

37 Uninsured Service Fees  Most provincial medical associations provide recommended rates for uninsured services  Contact your provincial medical association for more information

38 Alberta Medical Association Recommended Fees  Medical - legal services  Report on patient attended$ /hr  Review & interpretation of file$450 – 625/hr  Phone Rx renewal $  Sick note - note only $50 - exam & note $

39 Alberta Medical Association Recommended Fees  Driver’s Exam (<74.5 years) form only$75 – 150  Exam and form $  EI / Maternity$  CPP Disability  short narrative, 1 page (15 – 20 min)$50  full narrative, 2 pages (40 – 45 min)$100  Detailed narrative, 3 or more pages (60 min)$150  Insurance Disability  Form completion only$  Examination & form$  Chart Transfer patient request$25  + photocopying $0.25/page (HIA)

40 Remember!  Billing for 1 sick note at $50 for every office day generates ~ $14,000/year... office medical supplies cost < $3,000 per year  Can you afford not to bill for these services?  If you undervalue your services, so will your patients

41 Commonly Missed Services  Palliative care (03.05I)  Unrelated AHC service with WCB (03.01J)  Visit with non surgical treatment of warts (98.12L)  Visit with IUD insertion (81.8)/removal (11.71A)  CMGP modifier (03.01J, 03.03A, 03.03B, 03.03C, 03.03N, 03.03P, 03.03Q, 03.07A)  CMXC30 modifier (03.04A, 03.04B, 03.04C, 03.04D, 03.04M)  Complex inpatient modifier (COINPT) (03.03D, 03.03AR)  03.01AATime premium

42 Commonly Missed services  Telephone advice (03.01B, BA, BB; 03.01NG, NH, NI, 03.01LM, LN, LO, 03.01NM)  Physician to physician advice (03.01LG, LH, LI, LJ, LK, LL)  Periodic Pap smear (13.99BA)  INR Management (03.01N)  REVIEW ALL premiums and modifier codes in Schedule of Fees

43 NEVER FORGET TO !!!!!!!!  Complete all components of the bill!  Always verify who is the responsible party!  Bill for daily minor procedures  Bill WCB whenever appropriate

44 NEVER FORGET TO !!!!!!!  Stay up-to-date with the fee schedule  Never bill the HCP for uninsured services  Bill for uninsured services when appropriate

45 Common AHC Billing Examples

46 Introduction  The key billing components billed to the Ministry of Health are:  health service codes  diagnostic codes  modifiers  physician and patient identification  Code definitions and #’s vary by province

47 Billing Examples: Alberta 2011  Q1. A thorough office visit for a URI with an IM (flu) shot given?  03.03A 465.9$35.92  Possible CMGP01 (modifier )$15.56  13.59A V04.8 $9.58 ($45.50 if modifier not applicable or $61.06 if applicable)  Q2. Complete office assessment of 85 year old for chest pain, urinalysis done?  03.04A 786.5$98.78  Possible CMXC30 (modifier)$30.56

48 Billing Examples  Q3. Office visit for BP follow-up?  03.02A 401.9$20.94  Q4. 25 minutes assessing an anxious patient?  03.03A CMGP ( ) $67.04 or  G 300(44.90 x 2)$89.80

49 Billing Examples  Q5. Complete assessment 74 year old febrile male one week post-operative discharge.  03.04A 780$98.78 Note: CMXC30 may be applicable if 30 minutes spent adds an additional $30.56  Q6. Detailed office assessment, suspected ulcerative colitis, flexible sigmoidoscopy?  03.03A 556 $  01.24B (+ tray) 556 ( ) $ ($148.55)

50 Billing Examples  Q7. Emergency house call, 3pm,weekday, first patient seen, breast cancer, 25 minutes?  03.03N CMGP ( )$ or  03.05I x 2 174$98.18  Q8. Same visit, spouse seen and NSAIDs re- ordered for osteoarthritis?  03.03P 715$ Possibly CMGP01 (if 15 minutes spent) $15.56

51 Billing Examples  Q9. Weekday evening (2100 H) ER visit, complete assessment, 55 year old, chest pain NYD?  03.03LA 786.5$  03.04A786.5$  Possible CMXC30 (modifier) $  03.01AA TEV 02$ ($ if no modifier $ if modifier applicable)

52 Billing Examples  Q10. You do a delivery at 1 AM having augmented the patient. You do post-natal care visits in the hospital?  87.98A NTAM 650 ( ) $  03.01AA TNTA03 (43.65x 3) $ ($676.86)

53 Billing Examples  Q11. New-born care in hospital, circumcision?  03.05G(first day) V30.0$  03.05GA(subsequent days/day)$  In Alberta, the circumcision is uninsured.

54 Billing Examples  Q12. Evening admission on 2/11/10 at 2330, 72 year old, Dx CHF, 5 regular hospital visits, special evening (2100) special callback Sat 6/11/10 to reassess dyspnea.  03.04C HANTPM 428 ( ) $  03.01AA TNTP02 (21.83 x 2) $  03.03D x 5428 (40.58 x 5) $  03.05R (2100)428$  03.03DF428$  03.01AA TWK01$  Use encounter 2 for Sat. callback ($682.33)

55 Billing Examples  Q13. Office visit, shave biopsy / desiccation of basal cell Ca < 1 cm, on the face?  03.03A 173$35.92  98.81B173 (Punch biopsy) $29.60 ($65.52)  Note: 98.81B does not have a tray fee

56 Billing Examples  Q14. Office visit, patient concerned regarding a changing mole, excisional biopsy.  98.12M (+ tray) ( ) $71.94 (Removal of pigmented benign nevus) or If unsure and decide to do excisional biopsy  98.12A (+ tray) ( ) $78.96  03.03A$35.92 ($114.88)  Should this billing be put on hold?

57 Billing Examples  Q15. A patient presents with a plantar wart and liquid nitrogen is applied?  98.12L078.1$20.45  03.03A 078.1$ ($56.37)  Don’t forget to bill the patient for the N2  Q16. A patient requests a visit for N2 treatment of a wart on their finger  Can you bill the HCP for this?  What should you bill?

58  Q17. Regular visit, diabetes and BP assessment, unanticipated crisis supportive psychotherapy for additional 22 minutes, marital strife?  03.03A CMGP ( ) $ or  08.19G x2 300$89.80 Note: Assessment must have determined that patient is suffering from a psychiatric disorder Billing Examples

59  Q18. Attendance at labour, assistance at C.S. which took 1 hour, finished at 10 pm?  87.98B EV ( ) $  86.9C SA $  03.01AA TEV08$ ($794.22)  Q19. Assisting at elective hernia repair, 1 hour time, 10 am?  65.01A SA$143.95

60 Billing Examples  Q20. Dr. on duty in ER, multiple systems assessment, 1 am, abdominal pain, NYD?  03.05ER CMXV ( ) $43.70  03.01AA TNTA02$87.30 ($131.00) or  03.04H $ Possibility CMXC30 modifier (30.56) ($ if modifier applicable)  03.01AA TNTA02$87.30 ($183.73)

61 Billing Examples  Q21. Regular registered nursing home visit to assess a patient with dementia.  03.03E 290$ 26.94

62 Billing Examples  Q22. During a periodic health exam you order a lipid profile. The patient’s lab has returned and is abnormal. You request a follow-up visit and spend 25 minutes educating the patient regarding their risk of ASHD and the treatment options for their abnormal lipid profile.  O3.03A CMGP ( )$ 67.04

63 Billing Examples  Q23. A postmenopausal woman who has been on continuous HRT for 4 years presents with breakthrough bleeding. You do an endometrial aspirate biopsy.  03.03A627.1$35.92  80.83B (+tray) 627.1( )$55.16 ($91.08)

64 Billing Examples  Q24. A 44 year old male presents with a painful 2cm boil in the left axilla which you incise and drain.  98.03A (+tray) ( )$44.10 (I & D subcutaneous abscess )  03.03A680.8$35.92 ($80.02)

65 Billing Examples  Q25. A patient receives their regular allergy shot from the nurse.  13.42A V07.1$10.99  (Allergy injection)

66 Billing Examples  Q26. A 35 year female patient presents with a newly discovered breast lump. You do an appropriate exam and aspirate 3cc of clear fluid that is sent off for cytology.  03.03A 610.0$35.92  (+tray)610.0( )$56.06 (Needle biopsy breast) ($91.98)  How will bill differ if needle biopsy?  No difference as above

67 Billing Examples  Q27. A patient with tennis elbow unresponsive to NSAIDS and physiotherapy is seen for follow-up and you decide to inject with cortisone.  03.03A727$35.92  95.96A ( for tray) 727$12.74 ($48.66) Note 95.96A does not allow for visit in addition but need to bill to get the tray fee (95.96A rate = $12.57) (Who pays for the cortisone?)  Patient is billed ~$10-15 separately

68 Billing Examples  Q28. You receive the bi-weekly INR results of a patient and instruct your nurse to call the patient to modify their coumadin dosage.  Can you bill for phone call advice?  03.01N$16.46  Management of anticoagulant therapy, two per month per patient

69 Billing Examples  Q29. A patient has seen you before and decides to return for the elective removal of a sebaceous cyst.  Is this an insured service?  98.12C (+tray) ( ) $90.06 (Removal of sebaceous cyst)  03.03A706.2$ ($125.98)

70 Billing Examples  Q30. A disabled hemiplegic patient with multiple concerns is seen in follow-up. You also complete a Disability benefit report for an Insurance company on their request.  03.03A 342.9$35.92 CMGP01 if 15 m excluding report$15.56  Disability report - initial medical report &/or Reassessment medical report$ (patient responsibility)

71 Billing Examples  Q31.You have a flu shot clinic where 20 patients see your nurse for a flu shot.  13.59A V04.8$9.58  (Note to bill this a physician must supervise)  Total20 patients$191.60

72 Third Party Billing

73 Billing WCB  Verify if work related problem  Verify if patient is covered  Bill WCB for professional service & form completion  It is fraudulent to bill AHW for WCB service

74 WCB Billing Examples  33 year old typist with evidence of lateral epicondylitis from RSI.  03.03A CMGP01 ( )$51.48  Initial report, (C050) (electronic)$58.07  BCP 01/02 X2  BCP01 All of Alberta except Calgary & Airdrie$2.82/unit  BCP02 Calgary & Airdrie$3.33/unit

75 WCB Billing Example  Follow-up visit in 4 weeks, patient has form to fill in, steroid injection indicated  0303A$ A $12.57 MINT (tray)$12.74 ($61.23)  Progress report (C051)$35.28  BCP 01/02 x 1

76 WCB Billing Examples  WCB requests a detailed report and copies of all consults, exams, investigations.  Summary of medical information, without opinion requested by WCB (RF05):  First 30 minutes$  Additional 15 minute increments$49.41  Photocopying (RF08)$0.43 per page

77 Canada Pension Plan - CPP  56 year old with severe RA applying for CPP brings in forms. You later spend 40 minutes preparing a 2 page medical summary. What should you bill CPP?  Form / report completion $100  What are the CPP billing criteria?  Based on time spent

78 CPP Billing Guidelines  Photocopied info and / or short report  time spent < 15 minutes $25  Chart Review & Short typed narrative report 1-2 pages  time spent minutes$50  Full typed narrative, 2 or more pages  time spent minutes$100  Detailed typed narrative, 3 or more pages  time spent 60 minutes $150

79 Non-insured Billing  33 year old seen for tonsilitis & requests sick note for 2 days  03.03A (AHW)$35.92  Form completion$50  Pilot seen for MOT exam  Examination & form completion $

80 Non-insured Billing  14 year old seen for camp physical with form completion  Form only$50  Examination and form $130  22 year old requests N2 for wart on hand  Non surgical treatment$  Surgical removal $95 – 210

81 Non-insured billing  Phone request for prescription renewal  $  Request for removal of 7 skin tags  individually set  Travel advice and Hepatitis A shot  individually set

82 Medical Legal Reports  1.5 hours for chart review, report dictation and review, inclusion of 20 photocopies from chart  Report $450 – 625/hour  Photocopies (HIA)$25  Completion of Insurance Company Medical summary  Report & examination$260 - $450


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