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The Principles of Billing

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Presentation on theme: "The Principles of Billing"— 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 #. The above case example is extremely common. Many teaching programs are on alternate relationship plans and the teaching staff are on salary. The physician/faculty staff person may or may not have worked in the community in the past and their familiarity with the fee schedule and the intricacies of billing are often rusty. Furthermore, most programs hope or assume that the resident will be introduced to the specifics of billing from the community preceptors during the resident’s community rotations. However, these community preceptors have usually not been given specific direction from the program as to what billing instruction is expected from them. In summary: Billing has often not been included in the ongoing teaching of the resident. Dr. New Entrant has a lot to learn if s/he wants to know how to bill appropriately and effectively when s/he starts his/her locums or practice in 5 months.

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 Most physicians in Canada are still independent contractors rather than salaried employees. Physicians receive a majority of their income by billing their respective provincial ministry of health on a piecework basis, i.e., fee-for-service. The CMA’s 2000 Physician Resource Questionnaire results indicate that 62% of Canadian physicians received at least 90% of their clinical income from fee-for-service. Physicians who receive other forms of compensation are still likely to have some fee-for service billings. Close to 90% of physicians report receiving some fee-for-service income. A proprietor is the owner of the business. Physicians are in fact owners of their solo or group practices unless they function in a fully employed status.

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 HCP = Health Care Plan run by the Provincial Ministry of Health (MOH) WCB = Workers Compensation Board

5 Areas to be Addressed (cont’d)
Third Party Billing Uninsured/Noninsured Services Alternate Billing Options NEVER FORGET TO....!! Common Mistakes Uninsured and noninsured services are terms used in different provinces that refer to services or procedures not covered by a provincial HCP.

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 The process of applying for a provincial billing number is essentially the same in each province. What differs are the requirements regarding place of medical school and residency training, certification exams, and language requirements. New entrant restrictions also vary. Some provinces offer restricted and unrestricted billing #’’s. The barriers to practice in the different Canadian provinces are available by calling the PM Hotline at or the Canadian Medical Association. Before you can apply for a billing number you will need an Independent Practitioner License that is granted by the provincial licensing body (College of Physicians & Surgeons -Edmonton or toll free ) . The Registration Department sends new registrants the “Requirements for a Certificate of Registration for Independent Practice” which must be completed before processing.

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.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) The physician information kit you will receive from AH&W includes all the information required for you to carry on your daily interaction with the Ministry/Department of Health. If you have questions they can be directed to the AH&W’s customer service area, Edmonton – or toll free and at the prompt key in (780)

9 Staff Training Office policies Alberta Health Billing
Billing for Uninsured services Alberta Health Billing Submission Reconciliation Resubmission Not all services are billable - varies from province to province Supervised services Reciprocal Billing Always make sure staff have been advised and have access to your policies in relation to uninsured services.. Read the provincial schedule of fees and preamble/rules closely to verify what you can charge for. Always check for notes associated with specific items as they will also provide guidance as to when and how the particular item may be billed. For example: In Ontario you can bill a urinalysis fee for using a urine chemstrip and charge for an immunization shot. In Quebec, you cannot charge for administering the immunization. These procedures may have a small fee of $1 - 2, BUT these services/procedures can generate significant income and cover the costs of staff and supplies, etc. In Alberta minor procedures provided at the same time as a visit, in general, may only be charged if the diagnoses are different as outlined in GR 6.1. 6.1 If a physician performs a minor procedure and provides a service warranting a claim for an office visit or a home visit on the same day, benefits for both may be claimed only if the services and diagnoses are unrelated. Exceptions are the surgical diagnostic procedures (M+) which may be billed in addition to the visit or consultation irrespective of the diagnosis . Or some items have a note attached indicating that a visit or consultation is payable in addition

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

11 Verifying AH Coverage IVR 1-888-422-6257 Netcare Opted out
Good Faith Claims Invalid AHC Numbers Office Bill patient Hospital Patient Name, address, phone number, ULI, DOS, DOB, claim number To receive your payment for services rendered, you must properly submit your bill to the Ministry/Department. Billing errors or incomplete information regarding the billing will result in a delay of payment or no payment at all. Always verify the patients health care number prior to providing the service Interactive voice response (IVR) If the number is invalid you have two options. Either bill the patient directly or, if you are confident that the patient is eligible for health care coverage in Alberta, submit the claim as a good faith claim. Good faith claims must be the first claim submitted and submitted within 30 days of the date of service. Opted out Some patients elect to not participate in the AHCIP. Patients in this category must be billed directly. You WILL NOT be eligible for payment from AH&W. Hospital patients – Submit the following details to the AMA. (You can fax details to the attention of Krista Knutson at 780‑482‑5445 Patient’s name, address, telephone number, date of birth, date of service, registration number that you had, 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 When the HCP sends payment for the previous weeks’ billings, the computer software may do a remittance reconciliation to verify if all bills were paid and to isolate unpaid bills, reductions, etc. It is estimated that upwards of 3 –5% of billings remain unpaid as physicians fail to follow up and resubmit. Make sure, prior to submitting you billings that you verify submissions against your appointment log. Verify discrepancies – was a billing missed or was the patient a non show or a third party billing.

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 Always review refusals and reductions in payments to ensure that they are correct and in accordance with the rules. If you are not in agreement with the explanatory code assigned question the refusal/reduction. DO NOT JUST ACCEPT. Remember the Ministry can make errors just like everyone else. In those situations where it is clear that the refusal /reduction is due to either missing or incorrect information ensure that the claim is resubmitted with the updated information. The average doctor may have 3-5% of all bills to the MOH/DOH not paid for various reasons. Failure to follow-up on these accounts results in a significant loss of income. Remember it is the physician’s responsibility to ensure that claims are submitted accurately and in accordance with the rules. While you may delegate this responsibility to staff you are ULTIMATELY responsible.

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) The provincial HCP will be responsible for payment of most services rendered. In Alberta Workers’ Compensation Board claims are submitted directly to WCB including the form fee. In most other provinces, Workers’ Compensation Board can be billed via the provincial health care plan by just changing the responsible party to WCB instead of the HCP. With the exception of Alberta the fee for the completion of the WCB form may have to be billed separately to WCB. For example, in Quebec, the service and the form completion fee is paid via the HCP. In Ontario, WCB pays the physician directly for form completion, but pays for the service via the HCP. For third-party billing and uninsured services requested by patients or by a third party, e.g. Alberta Human Resources and Employment, insurance companies, the physician will bill this party directly. A separate billing record must be kept for third-party billing and accounts receivable reviewed on a regular basis. Your computer system can do this for you if you have the software.

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 Always bill the WCB when the patient’s medical complaint is work related. The WCB assigns a registration # to physicians for accounting purposes. This can be obtained by phoning WCB (Edmonton , or or toll free ), and they will then send you a Physician Information Kit outlining procedures for billing, fees schedules, form completion, etc. In Alberta WCB uses the AH&W schedule & rules for billing with the exception that the visit is unbundled from the procedure and may be billed in addition, inclusive care periods do not apply. Billing the HCP for WCB services will negatively affect global caps which not only hurt you, but other physicians. You will also usually be paid more by WCB because you are paid for form completion. It is important to verify at the patient’s presentation who the responsible party is. Claw backs do not apply to WCB billing. In Alberta, if it is a WCB case and the patient requests that you not notify the WCB you have no option but to submit the claim to WCB. Under the WCB Act you must notify WCB and bill WCB.

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) Your computer billing software should be set up to do reciprocal billing. All that is required is the patient’s provincial health card information and recovery code (province). The rest of the billing is done using your own service and diagnostic codes. As each province/territory has slightly different health care coverage or specific rules for some services there is a list of services which are excluded under the Medical Reciprocal Program. A list of these services can be found in the Physician’s Resource Guide. In the case of excluded services you simply send the claim directly to the provincial plan. In the case of the patient not presenting a valid card, the patient should be billed directly and an Out of Province Claim for physicians services provided to the patient for reimbursement by the patient’s home province. Quebec patients should be billed directly. If the patient pays and submits the claim to the Quebec Plan they will receive payment at the rate they paid you. If you submit to Quebec you will receive considerably less than requested.

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. Alberta Health & Wellness provides payment to physicians on a weekly basis. Many other provinces are every 2 weeks. It is important to submit your bills often (ideally daily) so that mistakes can be sent back to you by the HCP for correction within that billing period. This will help to reduce accounts receivable. Not all provinces (e.g., BC and AB) mandate modem billing referred to as Electronic Data Transfer (EDT) which makes the turnaround time for remittance reconciliation much faster, as is payment. EDT allows for a 24 hour turnaround time to verify if the previous days’ submissions are accepted. If not, the physician can make the correction within the same billing period and thus reduce the outstanding accounts receivable. Please note, each province has a claim submission deadline of either 3 or 6 months. If you do not submit a correct claim to the HCP within that time frame you WILL NOT be paid for that service.

18 The Components of a Bill
Calls Diagnostic code Encounter number Modifiers if applicable Facility number Functional centre Responsible party Recovery code Service provider PRACID Skill Code Recipient ULI Date of service Location of service Referral PRACID if applicable Health service code Patient identification (ULI) = HCP # with correct name, date of birth (address is not required) Doctor identification (PRACID) = doctor’s name and billing number Skill code (physician specialty) Date of service = the date the service was provided Diagnostic code = numerical code designating the diagnosis (see diagnostic code listing (ICD 9) for codes) Health service code = alpha/numerical code designating the service rendered. Calls = the number of services/units must be designated. Location of service = home or other Facility number = in Alberta all physicians’ offices, hospitals, long term care facilities are provided with a unique number Functional centre = location in hospital (MED, EMRG etc) Modifiers, if any = special codes which allow extra payment. Responsible party = HCP, WCB, third-party or the patient. Recovery code = reciprocal provincial plan.

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 The Ministry of Health can randomly request copies of the patient record to verify that what you billed was justifiable. Your record must stand alone to verify appropriate billing (without your interpretation) just as it must as an indicator of good record keeping and patient care if reviewed by the College of Physicians and Surgeons of Alberta (CPSA) In regards to the retention of records the Alberta Health Care Insurance Regulation Part 3, Claims, Section 15 (2) states: "If a practitioner provides goods or services to a resident of Alberta, the practitioner must retain the original documentation relating to the goods or services provided for a period of not less than 6 years and must, on request, make the documentation available to the Minister"

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 The HCP schedule of fees/benefits may not be printed on a yearly basis. However, the Ministry/Department will regularly send out bulletins updating doctors on changes and new restrictions. It is imperative that you always read these bulletins and provide billing staff with copies. Ignorance leads to lost income or inappropriate billing for which you will be liable. Claims for Benefits Regulation (204/81) Stipulates that claims must be signed by the practitioner or an authorized person If latter “the practitioner is responsible and liable for information required to be shown on it.” The above regulation is of particular importance if billing has been delegated to someone else. In the case of an audit by AH&W whereby it is determined that claims were submitted inappropriately and recovery of funds results, the physician is responsible and AH&W does not accept the excuse “I didn’t know this was happening”.

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” It is beyond the scope of this presentation to review the bread and butter codes of all specialties. Residents are encouraged to arrange for “ billing workshops” to learn the common billing codes of their specialty. A list of common codes is included with your package.

22 Bread and Butter Codes:
03.03A Limited visit not requiring complete history and evaluation $35.92 -75 years and older 03.03A + 20% 03.03B Prenatal visit $35.78 03.04A Comprehensive visit $98.78 CMGP Complex patient visit modifier/unit $15.56 J, 03.03A, 03.03B, 03.03C, 03.03N, 03.03P, 03.03Q, 03.07A, 03.07B In general/family practice there are often 5-6 most commonly used service codes. Many specialties will, similarly, have 5-6 most common service codes. 1. Comprehensive visit (03.04A) is defined as: An in-depth evaluation of a patient. This service includes a complete history and performing a complete physical examination appropriate to the physician’s specialty, an appropriate record and advice to the patient. It may include the ordering of appropriate diagnostic tests and procedures as well as discussion with the patient. For family practice appropriate examination is all body systems. Comprehensive visits are payable not more often than once every 180 days per patient, per physician. 2. Prenatal visits (03.03B) are payable up to and including the day of delivery 3. Limited visit 75 years of age or over submit as 03.03A and automatic increase of 20%. CMGP Complex patient visit requiring that the physician spend a full15 and then a full10 minute increments to maximum of 6 units on management of the patients care. Must be full 15 and full 10 in order to bill. Does not have to be face to face for the entire time. Includes chart review, diagnostic information review, charting and actual patient visit time must be on the same day that you saw the patient.

23 Bread and Butter Codes cont’d:
CMXC30 Complex visit/consultation modifier $30.56 A, 03.04B, 03.04C, 03.04D 03.04M, 03.08A 08.19G Direct contact with a patient for psychiatric treatment, per 15 minute $44.90 98.12A Excisional biopsy, skin $41.25 03.04M Pre op history & physical $98.78 Psychotherapy ( 08.19G) - Direct contact with an individual patient for psychiatric treatment (including medical psychotherapy and medication prescription), psychiatric reassessment, patient education and/or general psychiatric counseling. May only be billed by a non psychiatrist when a physician assessment has established that the patient is suffering from a psychiatric disorder. Look at options when billing 1 unit of 08.19G (15 minutes). It is better to bill using 03.03A with CMGP01 modifier ($ $15.56 – Total of $51.48 vs $44.90) Do not forget to bill the visit in addition as 98.12A is a “M+” so may be billed in addition to a visit with same diagnostic code 03.04M Preoperative history & physical is eligible for the CMXC30 modifier when 30 minutes or more is spent.

24 Comprehensive care plan
03.04JDevelopment, documentation & administration of a comprehensive annual care plan for patient with complex needs $215.52 - 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

25 Comprehensive care plan cont’d
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)

26 Comprehensive care plan cont’d
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

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????? For office based patients if the IVR or Netcare has not been used AH&W will not assist with finding a valid number as it is the physician’s responsibility to establish eligibility. For hospital based patients with invalid registration numbers, demographic details of the claim may be submitted to the AMA who will advocate on your behalf . Fax (780) Services, excluding consultations, provided to the same patient, on the same date of service by two different doctors require text to justify the claims. In the case of the emergency department the DSCH modifier must be added to the claim to indicate that the patient was seen previously in the ER, discharged and returned for a second visit. Another example is concurrent care which would require text. Payment of a submission will only be made if the MOH receives all information required and the claim is correctly submitted. Periodic MOH bulletins will update physicians on fee increases, reductions and eliminations. Failure to stay up to date with these leads to lost income. All fees not paid lead to either lost or delayed payment and more paperwork for you and your staff.

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 At least % of a physicians’gross billings can be justifiably generated by discretionary billing for uninsured services. Historically, physicians have been very poor at billing for uninsured services due to an embarrassment of giving the patient a “bill”. With cutbacks and clawbacks physicians can no longer afford not to bill for these services. A clawback occurs when the provincial government garnishees a percentage of gross billings submitted to the provincial HCP. For example, a 10% clawback would mean that instead of receiving 100% payment, you could receive 90% on reconciled submissions.

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. Create PR problems - Any change in practice (office hours, appointment policies, hospital affiliations etc.) can create PR problems. Fair and reasonable policies with clear explanations and proper notice can diffuse most problems of this type. Create administrative problems - As above, any change can create office problems if poorly planned or administered. Again, planning and implementation are the solutions. Not financially worth it - Possibly, though this is usually an opinion, not an answer supported by fact. There are very few practices that cannot considerably raise revenues with little or no additional administrative cost. I’ve never done it before - Inertia is a force to be reckoned with, and the longer you’ve been in practice, the harder it is to change course. But this answer is no more acceptable in practice management than when faced with changes in approach to clinical management. The only one in town - Difficult to address, but only applies if you are not as busy as you would like to be, or if you are sufficiently busy but know that your area is becoming over-doctored. I don’t know how - If you managed to get into and through medical school and can handle clinical management, you can certainly manage the challenges of planning and implementing uninsured services. Furthermore, later in this talk we are going to tell you much of what you need to know.

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 If done properly, the following, more favorable outcomes, are more likely. Patients will recognize that ALL of my time is valuable - they know that your time is valuable, and explaining the time value of uninsured services will generally put any debate to rest. Your services may garner more respect if patients understand their financial worth. I will accept that ALL my time is valuable - to the relief of your accountant, your family and any other personal obligations. Due to the nature of the work you do, there will always be unremunerated work (research on a case, CME, etc.) I will get paid for things I do for free - Discretion should always be used when real hardship will be created. My revenues increase - Who could argue otherwise, and who could possibly protest? I can work less for same income. My overhead rate will decrease - Which will take pressure off finding cost efficiencies in staffing, office space, etc.

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 The patient must always be informed in advance that the service they have requested is not paid for by the HCP. They should be advised of the fee in advance. Payment upon completion of the service is an appropriate expectation of the physician. The use of patient information sheets regarding office policies and proactive staff can help to avoid patient discontent and arguments. Uninsured service fee schedules should be posted in the waiting room and exam rooms. Always use discretion and be prepared to discuss it with the patient. Many patient complaints received by provincial colleges are a consequence of poor communication between the doctor and the patient. This holds true especially when it applies to the billing of uninsured services. Many patients assume that ALL services are covered. It is therefore very important to proactively educate the patient. Finally - don’t leave the “dirty work” to your staff. The physician should take ownership for all office policies, especially the billing of 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 Each provincial medical association usually provides members with a suggested fee schedule for uninsured services. Remember the listed rates by in large are guidelines. Special reports requested by others (e.g., lawyers) should be billed at an appropriate hourly rate. However, always remember if you are requesting a fee you also have an obligation to provide the report in a timely manner.

37 Uninsured Service Fees
Most provincial medical associations provide recommended rates for uninsured services Contact your provincial medical association for more information Most provincial medical associations are now providing their members with guidelines for billing for uninsured services which are updated on a regular basis.

38 Alberta Medical Association Recommended Fees
Medical - legal services Report on patient attended $ /hr Review & interpretation of file $450 – 625/hr Phone Rx renewal $55 -75 Sick note - note only $50 - exam & note $ The above rates are recommended by the Alberta Medical Association. These rates are recommendations only and the physician may bill less or more. If you are charging above the recommended rate you must be prepared to detail to the paying agency the rationale for the higher rate. Always negotiate the fee before providing the service. Stay up to date with your provincial medical association for their most recent recommended uninsured fee schedule rates.

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) Chart transfer at patient request and covered under HIA Total fee: 1. Basic $25. Plus 2. Fee for severing, plus 3. Material costs Basic fee includes one or more of the following: receiving and clarifying the request Obtaining consent Locating and retrieving records Preparing the record for copying, includes removal of staples and paper clips Preparing response letter Packaging copies for shipping or faxing or both Postage and faxing costs Photocopying a record (first 20 pages, i.e. up to a value of $5 – calculated at $0.25/page Regulations state that the request will not be processes until: 1. Applicant agrees to pay the fee 2. Applicant makes a deposit of at least 50%

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 The impact that appropriate billing for non-insured services can have is often underestimated. In this example one could also calculate that the gross earnings from billing for these sick notes is the equivalent to the gross income earned over 3 full clinic or office days. Therefore, you have just allowed yourself to have 3 more holidays per year. Remember you are medical legally responsible for everything you sign. You are in fact providing an opinion. You should be paid for that opinion and the risk you take in offering this service. If you devalue your service and time so will your patients. Patients routinely assume you get paid for everything you do. They also assume that you get paid a lot more for your services than you actually receive from the MOH. Patients are very receptive and understanding when they are educated in this way.

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 The failure to bill for many of the minor daily procedures adds up to a lot of lost income. 03.05I (Palliative care) is a per 15 minute service and can be billed in office, hospital or home. Always look at options as many times opting to use the time based code provides greater remuneration. 03.01J (AHC/WCB) may be claimed to AHW if the patient is seen for a WCB injury and an unrelated health care service. CMGP eligible CMGP modifier physician spends a full 15, 25, 35, 45, 55, 65 etc minutes or more managing patients care includes chart review, exam & history taking as well as charting, basically anything the physician does on SDOS in relation to that patient. CMXC30 modifier - physician spends 30 minutes or more managing patients care includes chart review, exam & history taking as well as charting COINPT modifier – physician spends 20 minutes or more managing a complex inpatient with multisystem disease, or LTC patetin with an intercurrent illness whose comorbidities complicate or increase the care required – includes assessment of patient, discussion with nurse, other physicians review of diagnostic data charting anything physician does relating to patient care.

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 Mental Health home care advice (03.01B, BA, BB): Must be initiated by worker who is working in program administered by AHS Phone or other telecommunication methods, must be documented Max 2/day/patient/physician, payable with visit SDOS Patient care advice (03.01NG, NH, NI) Advice to paramedic (pre hospital patch), assisted living/designated living & lodge staff, active treatment facility worker, LTC worker, nurse practitioner or home care worker Must be initiated by worker, phone or other telecommunication methods Max 2/day/patient/physician, payable with visit SDOS, must be documented Physician must be outside facility for LTC and active treatment facility Physician to Physician advice (03.01LG, LH, ) Claimable if consultant provides recommendation for pt Rx &/or management & pt remains in care of physician Not claimable for transfer or expedited consult that occurs within 24 hour, (unless pt transferred from outside facility and advice give, arrange, discuss or inform of DI or lab INR (03.01N) Max 2/month/patient

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 Following the above rules will pay big dividends by eliminating lost income. The key is to set up strict office protocols to address these issues. The physician must take ownership of assuring that both he/she and staff complete the billing loop so that all services are billed for and paid. Match appointment schedule to claims submissions and investigate discrepancies. WCB billings are to be clarified by the physician because the staff may not know that it is a WCB case when the appointment is made. Completing the billing protocol loop is essential. Failure to do so is the number 1 practice management mistake made by physicians and their staff. Supervised services : In Alberta the SOMB applies to physician services with only three exceptions (AHC Bulletin - Med 97): Technical services - e.g. ECG, x-rays, etc. Explicitly delegated service - There is only one such service in Alberta 13.42A (Injection of allergy serum) or flu shot (13.59A) Services provided by a physician trainee if the preceptor remains in a position to monitor the patient to the exclusion of all others.

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 It is essential for all doctors to read the bulletins that are routinely sent to them by the MOH. These bulletins will often have updates to the fee schedule that will have a direct effect on them. The individual physician is responsible, with the assistance of their medical billing software supplier, to update fees on their billing system so that the new fees are submitted. This is important for reconciliations as well as identifying accounts receivable. In Alberta you do not have to enter the fee unless you wish to be paid at a lower rate. The fee code along with number of calls and applicable modifiers will automatically generate the appropriate payment. In other provinces this may not necessarily be true and unless the physician submits the appropriate amount amount payment may not be accurate. Ignorance of changes leads to lost income and more work in reconciling accounts receivable. Billing the MOH for a non-insured service is fraudulent and can result in legal action. Provincial ministries of health are becoming more vigilant in doing reviews of physician billings. It is the responsibility of all physicians to bill honestly and appropriately. Furthermore, the fees received for non-insured services are greater than the provincial fee schedule. Bottom Line: Always bill appropriately but ensure that you get paid for the services you provide. Suggestion: Ask your faculty preceptors to assist you in arranging for a comprehensive billing examples workshop that is specific to your specialty.

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 This workshop will concentrate on the main components of the physician’s claim to the provincial health care plan. These are: health service codes, diagnostic codes, modifiers and identification elements. It very important to realize that there are significant differences from province to province. The new physician must study the appropriate provincial fee schedule and especially the general rules to learn what services can and cannot be billed and under what circumstances. Much of this information will differ from province to province. A failure to familiarize ones self with the provincial fee schedule will lead to lost income or inappropriate billing that could lead to disciplinary action. Ignorance is not a defence.

47 Billing Examples: Alberta 2011
Q1. A thorough office visit for a URI with an IM (flu) shot given? 03.03A $35.92 Possible CMGP01 (modifier ) $15.56 13.59A V $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 $98.78 Possible CMXC30 (modifier) $30.56 Q1 A 66 year old male presents with a 7 day history of cough, occasional yellow phlegm, no fever, increased cough with exercise. He is a smoker. Functional inquiry is negative. Past history is non-contributory . Your HEENT, adenopathy exam and chest exam is essentially normal.. You elect to defer antibiotics and reassess if no improvement in 3-5 days. The patient's flu shot is due and you offer the shot to save him the inconvenience of coming back. What service, procedural and diagnostic codes are appropriate ? A1 Limited exam (03.03A), IM shot (13.59A), diagnostic code for URI and diagnostic code for influenza immunization V If total time managing patient (review of chart, DI & lab, talking to & examining patient, charting) excluding time for flu shot was 15 min add CMGP01 modifier Q2 A 55 year old female presents with a complicated history of chest pain and occasional abdominal pain. A complete history and examination is indicated. A urinalysis is done. A2 Complete assessment (03.04A) In Alberta you are unable to bill for laboratory services. Diagnostic code (chest pain) Possible CMXC30 modifier if 30 minutes spent managing patients care. Urinalysis not billable on fee for service in Alberta.

48 Billing Examples Q3. Office visit for BP follow-up?
Q4. 25 minutes assessing an anxious patient? 03.03A CMGP ( ) $ or G (44.90 x 2) $89.80 Q3 A 56 year female requires a renewal for her BP medications. Her BP is 140/85 and she has no other questions or concerns. You renew her prescription for 1 year and offer to see her in the interim if needed. A3 Minor exam (03.02A), diagnostic code 401 (essential hypertension not specified as malignant or benign) Q4 A 33 year old single mom requests a same day appointment for assessment of headaches. You enter the exam room at 14:07. Her history reveals that she has just lost her job and that her estranged husband is not keeping up with child support. She is anxious and tearful but not suicidal. You offer crisis insight orientated and supportive psychotherapy and offer to see her again within a week. You leave the exam room at 14:31 A4 Limited office visit (03.03A), diagnostic code 300 (neurotic disorders) or Psychotherapy (08.19G) x 2 (08.19G is billed for each 15 minutes or portion thereof may only be billed by a non psychiatrist if an assessment has determined that the patient is suffering from a psychiatric disorder. Note: All billings involving time units require documentation of the “time in” and “time out” on the chart.

49 Billing Examples Q5. Complete assessment 74 year old febrile male one week post-operative discharge. 03.04A $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 $ 35.92 01.24B (+ tray) ( ) $112.63 ($148.55) Q5 A 74 year old man presents with a fever NYD. He was discharged from your service having been admitted for abdominal pain that ultimately revealed a para colic abscess secondary to diverticulitis. You do a complete history and physical exam due to vagueness of his complaints. A5 Comprehensive visit (03.04A). Text required as service was in the post operative period – Complication pay as per GR 6.8.1c) Note : In some provinces (i.e. Quebec, Sask.) there is a different service code for patients over 70 with a higher fee paid. In Alberta there is a 20% increase for 75 and over at the limited visit rate (03.03A) Also as this is a complication it will be paid in addition to the surgery. In Alberta the post operative inclusive care period is 14 days for major surgery. However, visits related to complications may be billed in addition. CMXC30 may be applicable if 30 minutes spent managing patients care adds an additional $28.70 Q6 A 35 year male presents with abdominal pain and intermittent blood and mucous in stool for 3 weeks. Your appropriate history and exam indicates possible ulcerative colitis. Your sigmoidoscopy reveals an inflamed rectosigmoid mucosa with traces of blood. Appropriate lab and consults are made. A6 Flexible sigmoidoscopy (01.24B), tray , limited exam (03.03A) diagnostic code 556 (abscess of anal and rectal regions). The sigmoidoscopy is a “+”procedure and therefore an office visit (03.03A) is payable in addition. If a complete history & physical were performed and the patient had not had a comprehensive visit in the previous 180 days then 03.04A could be claimed in lieu of the 03.03A. Note: In Alberta the tray service component is automatically paid if the location code is office.

50 Billing Examples Q7. Emergency house call, 3pm,weekday, first patient seen, breast cancer, 25 minutes? 03.03N CMGP ( ) $ or 03.05I x $98.18 Q8. Same visit, spouse seen and NSAIDs re-ordered for osteoarthritis? 03.03P 715 $ 29.93 Possibly CMGP01 (if 15 minutes spent) $15.56 Q7 You are called out of your afternoon office by the VON to urgently assess a palliative patient with breast cancer. A7 Housecall visit first patient seen (03.03N), diagnostic code 174 (breast cancer). The billing code takes into account the time of the house call. Or if the patient is a palliative care patient receiving ongoing multidisciplinary team care and the time spent with the patient was at least 25 minutes, bill direct contact with a patient for palliative care (03.05I) on a per 15 minute basis. Q8 While there the spouse asks you to review his medications and write a renewal for his NSAIDS. A8 Subsequent/additional patient seen (03.03P), diagnosis osteoarthritis 715. Note: A premium can only be billed for the first patient seen at the same location.

51 Billing Examples Q9. Weekday evening (2100 H) ER visit, complete assessment, 55 year old, chest pain NYD? 03.03LA $107.76 03.04A $ 98.78 Possible CMXC30 (modifier) $ 30.56 03.01AA TEV $ ($ if no modifier $ if modifier applicable) Q9 You are on call and called in to assess your colleagues patient who has new onset chest pain. It is The nature of the presentation requires a complete assessment. A9 Special call to the emergency department ( ) (03.03LA) plus 03.04A for complete assessment, diagnostic code ( chest pain). The billing code takes into account the premium for the trip to the emergency because you are not onsite. If the patient is admitted, the 03.03LA & 03.04A codes would not be used. An admission code (03.04C) with a time modifier would be used if the patient was admitted. 03.01AA with modifier TEV 02 used as physician spent total of 30 minutes with patient

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 ( ) $545.91 03.01AA TNTA03 (43.65x 3) $ ($676.86) Q10 / A10 - Vaginal delivery is 87.98A, the augmentation is not payable. The premium for the delivery is paid when the NTPM modifier is added to the 87.98A code. Diagnostic code 650 (delivery in a completely normal state). Note : If the GP attends the labour and delivery but requires obstetrical help with the delivery (i.e., forceps rotation with delivery by the obstetrician) then the GP bills 87.98B, management of labor and attempted delivery (same fee as 87.98A). The obstetrician will bill for the delivery. In some provinces the GP will not be able to bill this attendance code and lose significant income even though he /she was in attendance all along. In Alberta augmentation of labor is not payable. Medical induction (85.5A) is only payable if the physician has assessed the patient prior to the induction and monitors the patient’s progress subsequent to the induction. There is a maximum of 2 per 24 hours to 4 per pregnancy. Post natal hospital care is included in the delivery fee (7 day post delivery inclusive care period).

53 Billing Examples Q11. New-born care in hospital, circumcision?
03.05G (first day) V $ 70.33 03.05GA (subsequent days/day) $ 40.58 In Alberta, the circumcision is uninsured. Q11 & A11 Care of healthy newborn is a single service fee for all visits occurring during that hospitalization. Care of healthy newborn (03.05G), diagnostic code V30.0 (well baby). If the baby is ill and requires daily visit then daily hospital care (03.03D) may be claimed. If special visits are requested by the nursing staff and the physician responds to such a call from outside the hospital, i.e. to assess the baby for jaundice or breathing problems, then special callbacks(03.5N, 03.05P, 03.05QA, 03.05QB, 03.05R DF) may be claimed as appropriate to the time of day. Circumcisions are non-insured and the physician and hospital fee will vary from province to province. The patient must be advised of the fee prior to the procedure. In Alberta, if the circumcision is done in the hospital there will be a hospital tray fee that the parents are responsible for in addition to the doctor’s fee. Therefore, it is cheaper for the procedure to be done by the doctor in his/her office.

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 ( ) $265.60 03.01AA TNTP (21.83 x 2) $ 43.66 03.03D x (40.58 x 5) $202.90 03.05R (2100) $ 03.03DF $ 03.01AA TWK01 $ Use encounter 2 for Sat. callback ($682.33) Q12 You are called at 11 pm by the emergency physician to admit your patient who is in heart failure. The emergency physician has sent the patient to the floor on your verbal request. You see the patient an the floor and do your admission exam and documentation. The patient is seen for 5 regular hospital visits. You are also called in on the evening of the 4th day of admission at 9 PM to re-evaluate the patient who was noted by the nursing staff to be more dyspneic. A12 Admission to hospital (03.04C) with modifier HANTPM plus time premium (03.01AA with modifier TMTP02 to indicate two 15 minute time periods) assumed the admission took 30 minutes. The 5 regular hospital visits are 03.03D billed with calls set at 5. The weekend evening callback may be billed as 03.05R DF with encounter number 2 and time premium (03.01AA with modifier TEV01) assumed time was 15 minutes and assumed the physician responded from outside the hospital and attends on a priority basis. The diagnostic code is 428 (heart failure). Note: Always remember to add modifiers where appropriate to obtain payment for after hours services and always claim the time premium with the appropriate modifier as this is payable for both scheduled and unscheduled services and applies to any service provided in the after hours period.

55 Billing Examples Q13. Office visit, shave biopsy / desiccation of basal cell Ca < 1 cm, on the face? 03.03A $35.92 98.81B (Punch biopsy) $29.60 ($65.52) Note: 98.81B does not have a tray fee Q13 You have noted a probable basal cancer on a patient during a check-up and ask them to return for the procedure. A13 Punch biopsy (98.81B) does not have an associated tray fee B is a “+” procedure and thus an office visit (03.03A) may be claimed in addition with either the same or different diagnosis. Diagnosis Skin Cancer 173. Note: You do not need a pathology report on the chart proving the diagnosis to bill for a cancer removal.

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 $ ($114.88) Should this billing be put on hold? Q14 A patient has noted that a mole has changed colour. You verify that it is indeed a nevus and advise the patient that for reassurance a biopsy is in order due to the possibility of dysplasia. You have time to do the procedure then. A14 A limited office visit (03.03A) is not payable as the 98.12M is category M and visit and category M are only payable if diagnoses are unrelated, removal of pigmented begin nevus excluding face 98.12M. The tray fee will be automatically paid with the billing submission. Diagnosis begin neoplasms of the skin – other sites (216.8) If unsure if it is benign then bill as excisional biopsy A as 98.12A is a surgical diagnostic procedure. Note: The billing is not dependent on the pathology report (unlike other provinces). Treatment of moles, warts and keratosis are uninsured in Alberta with the exception of genital warts, planter warts, precancerous skin lesions, warts in the immuno-deficient patient or immuno-suppressed patient or molluscum contagiosum.

57 Billing Examples Q15. A patient presents with a plantar wart and liquid nitrogen is applied? 98.12L $20.45 03.03A $ 35.92 ($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? Q15 & A15 The HSC is 98.12L (non-surgical treatment) and is payable in addition to a visit. A tray fee is not paid by AHW and the patient is responsible for the N2 cost Q16 & A16 In Alberta wart treatment is only covered if the wart is plantar or genital, the patient is immunosuppressed or immunodepressed exceptions are listed in AHC bulletin Med 18. All other warts are uninsured and must be billed directly to the patient. The same rules applies to benign moles. It is important to review the fee schedule and all HCP update memos to stay abreast of the increasing number of procedures that are being de-insured The provincial medical association will publish recommended fees for non-insured services as well as non-insured procedures.

58 Billing Examples Q17. Regular visit, diabetes and BP assessment, unanticipated crisis supportive psychotherapy for additional 22 minutes, marital strife? 03.03A CMGP ( ) $ 67.04 or 08.19G x $89.80 Note: Assessment must have determined that patient is suffering from a psychiatric disorder Q17 & A17 If you evaluate a patient for a routine follow-up regarding their BP and diabetes it would be appropriate to bill a 03.03A. You cannot bill for the chemstrip in Alberta. In addition to this, the patient then advises that his/her sugars have been adversely affected due to an acute marital crisis and you then offer crisis insight oriented psychotherapy for an additional 22 minutes. Don’t forget to add the CMGP modifier for first 15 minutes and then in 10 minute increments to a maximum of 6 units. You can only bill for the psychotherapy as a non-psychiatrist if an assessment has determined that the patient is suffering from a psychiatric disorder. The psychotherapy code would be 08.19G x 2 with a diagnostic code of 300 (neurotic disorders). Note: You must document the interventional time you spent with the patient on the chart.

59 Billing Examples Q18. Attendance at labour, assistance at C.S. which took 1 hour, finished at 10 pm? 87.98B EV ( ) $475.63 86.9C SA $143.95 03.01AA TEV08 $ ($794.22) Q19. Assisting at elective hernia repair, 1 hour time, 10 am? 65.01A SA $143.95 Q18 You are the GP obstetrician whose patient develops fetal distress requiring an emergency C.Section which you assist at. The time of the section is 9-10 pm. A18 Management of labour and attempted delivery (87.98B ) with EV modifier, diagnostic code (fetal distress). The C-section assist is billed as 86.0 with SA modifier and encounter number 2. GR outlines the conditions associated with 87.98B. Assumed attendance at labor was 1 hour therefore billed 8 units of time premium. May be claimed when the referring physician intended to conduct the delivery, provided the following conditions are met: a) the referring physician attended the patient during labour and has provided assessment of the progress of the labour, both initial and ongoing; b)there is documented complication warranting the referral, such as fetal distress or dysfunctional labour (failure to progress) and c)the referring physician remains in attendance and assist the consultant; or d) the physician must transfer the patient to another facility because of either fetal or maternal distress and delivery occurs within 24 hours of transfer The surgical assist fee is $ for the first hour and $35.35 for every subsequent 15 minute block or portion thereof. Only one surcharge modifier is payable. Q19 You regularly assist your surgeon colleague on Wednesdays and assist with a routine hernia repair which lasts 1 hour. A19 See A18. The procedure code is 65.01A with role modifier SA. No diagnostic code is required with a surgical assist.

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 $ 96.43 Possibility CMXC30 modifier (30.56) ($ if modifier applicable) ($183.73) Q20 & A20 There are special fees for the doctor who is doing rotation duty shift in the emergency rather than being on call and called in specially to the E.R. Codes 03.05CR,, DR & ER are eligible for the CMXV20/35 modifier. Don’t forget to add the time premium payment modifier. The fee schedule will clarify this. Different fees apply to different times. In this case the fee code is 03.05ER with a diagnostic code of (abdominal pain) or if the conditions for a comprehensive visit are met it could be 03.04H In depth evaluation of patient with new or existing medical condition Complete history & physical examination Ordering & reviewing of appropriate diagnostic tests Initiation of appropriate therapy Or for patients whose illness' or injury require prolonged observation, continuous therapy & or multiple reassessments

61 Billing Examples Q21. Regular registered nursing home visit to assess a patient with dementia. 03.03E $ 26.94 Q21 & A21 If you do routine visits to a nursing home there are no special visit premiums. There are limitations to the number of routine visits you can make per month, per patient, i.e.,1 per week. If you are called in to do a special visit and you attend from outside the nursing home, then the special call back codes may be applicable (03.03KA 03.03LA, 03.03MC or 03.03MD EA). For nursing home patients who develop an intercurrent illness or are palliative care requiring daily care the regular daily hospital visits (03.03D) apply. If you are visiting after 5PM on weekdays or anytime on weekends do not forget the 03.01AA time premium.

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 Q22 & A22 In Alberta there is not a separate code for counseling unless it is related to a patient suffering from a psychiatric disorder in which case the claim would be submitted under 08.19G on a per 15 minute basis. The code is 03.03A (limited visit) and the diagnostic code is 272 (disorders of lipid metabolism).

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. 03.03A $35.92 80.83B (+tray) ( ) $55.16 ($91.08) Q23 & A23 After doing an appropriate history and exam you obtain consent and do an endometrial aspirate biopsy in the office. You can bill for the examination as well as for the procedure and tray fee. Often the lab will supply the sampling material for you free. Limited office visit is 03.03A, endometrial biopsy is 80.83B and the tray service is automatically paid if the location code is office. Diagnostic code (postmenopausal bleeding)

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 ) 03.03A $35.92 ($80.02) Q24 & A24 After doing an appropriate exam to verify that the only problem is the boil you freeze the area and incise, drain and pack the wound. 98.03A is I & D of subcutaneous abscess. Diagnostic code (carbuncle and furuncle – other specified site). The tray fee is automatically paid if the location of service is office. This fee code has a note attached to it that allows for billing of a consult or visit for same diagnostic code at same encounter If the abscess is deep you would claim 98.03B which is a by assessment code. When claiming by assessment codes you must set you own fee and provide text to indicate how you determined the fee. Include as much detail as possible.

65 Billing Examples Q25. A patient receives their regular allergy shot from the nurse. 13.42A V $10.99 (Allergy injection) Q25 & A25 Patients receiving allergy injections often do not have to see the doctor. In this case a procedure fee for the shot and observation by the nurse is billed as a 13.42A as well as the diagnostic code of V07.1 (desensitization to allergens) A maximum of one office visit per month may be claimed for reassessment of the patient in lieu of a claim for the desensitization. The benefit includes all materials except the allergy serum. If the patient has a chest cold and your nurse requests that you see the patient to clear them for their injection you bill for the 03.03A or 03.02A, diagnostic code 460 (acute pharyngitis) as well as the injection using 13.42A with diagnostic code V07.1.

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 $35.92 97.81 (+tray) ( ) $56.06 (Needle biopsy breast) ($91.98) How will bill differ if needle biopsy? No difference as above Q26 & A26 In this case, a limited exam is appropriate to rule out adenopathy, hepatoslenomegaly etc.. There is no specific code for breast aspiration, AH&W advises the physician to bill as a needle biopsy (97.81) which is a “+” procedure, and if provided in the office 03.03A as well as the tray component are payable. Diagnostic code (solitary cyst of breast). As the needle biopsy code is used there is no difference in billing for a needle biopsy.

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. 03.03A $35.92 95.96A ( for tray) $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 Q27 & A27 95.96A (Other bursae, tendon sheaths, ganglion of wrist or ankle, aspiration/injection) does not allow the claiming of an office visit in addition unless the visit was for a different purpose i.e., unrelated diagnosis. (GR 6) Diagnostic code 727 (other disorders of synovium, tendon and bursa) Don’t forget to bill the patient for the cortisone that you had to supply. As this will not pay with a visit and the visit is greater you bill both services. AHW will pay the tray portion only for the injection.

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 Q28 & A28 03.01N Management of anticoagulant therapy to include ordering necessary blood tests, interpreting results, adjusting the anticoagulant dosage as required $ 16.95 NOTE: 1. May be claimed twice per calendar month, per patient regardless of whether the same or different physician provides the service. 2. May only be claimed in months where advice has been given regarding dosage. 3. May be claimed in addition to visits or other services provided on the same day by the same physician. 4. May not be claimed for hospital inpatients or hospital outpatients 5. Documentation of the communication must be recorded.

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) 03.03A $ 35.92 ($125.98) Q29 & A29 The removal of a benign sebaceous cyst is deemed, by most provinces, as cosmetic and is thus, not covered. In Alberta this is still an insured service and billed as 98.12C. A tray service is payable if the service is provided in the office. Diagnostic code (sebaceous cyst). 98.12C is one of the codes that is an exception to GR 6 and has a note indicating a visit or consultation is payable in addition. In provinces where the service is uninsured the fee for the procedure would be set by the physician based on the time involved, expertise and the cost of the materials needed. Physicians are encouraged to consult colleagues about what they are charging for the same procedure. Always advise the patient in advance of the procedure that they are responsible for the payment of the procedure.

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 $35.92 CMGP01 if 15 m excluding report $15.56 Disability report - initial medical report &/or Reassessment medical report $ (patient responsibility) Q30 & A30 Follow up visit is billed to Alberta Health 03.03A (limited visit), diagnostic code (hemiplegia unspecified). Disability report is billed to the patient or the Insurance company. Be very clear on your charting that one service was insured and one was third party. Uninsured Services guidelines: Form only $ Examination & form completion $

71 Billing Examples Q31.You have a flu shot clinic where 20 patients see your nurse for a flu shot. 13.59A V $9.58 (Note to bill this a physician must supervise) Total 20 patients $191.60 Q31 & A31 In Alberta the SOMB codes are only claimable for physician provided services and may not be claimed for services provided by nursing staff. In Alberta there are two exceptions allergy injections (13.42A) & flu shots (13.59A) this is outlined in AHC Bulletin Med 97 & 147). If the patient is seen for an unrelated condition in addition to the flu shot an office visit (03.03A) may be claimed as well. In some provinces this may be an example where your nurse can generate income without you seeing the patients. The government will supply the flu vaccine free.

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 Billing of WCB services vary from province to province in some the professional services is billed to the Ministry and the form to WCB. In Alberta the service and the form are billed to WCB. Make sure to follow up and track payments to ensure that both service and report were paid. Legislation in Alberta specifies that WCB MUST be billed if it is a work related injury to a worker covered by WCB. Employers will often times pressure employees to not report the injury as work related thus the need to question the patient and review with them that it is fraudulent to bill AH&W if the injury is work related. But more importantly reporting the injury as work related protects the patient in the event that the injury results in complications at a later date which hampers the patients ability to work. If the original injury was not reported to WCB the complications will not be covered by WCB nor will the lost wages. It may be different in other provinces so always verify the rules prior to submitting.

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 Answers: The initial visit would be claimed as a limited visit (03.03A). In the past a first visit was always billed as a comprehensive (03.04A). However, the WCB contract stipulates that AHW rules apply unless otherwise stated. Comprehensive visit under AHW is an all organ system examination. Add CMGP if management of the patient took 15 minutes and then in 10 minute increments after excluding time to complete the report Effective April 1, 2010 all submissions to WCB must be electronic. BCP (business cost program) 1 unit for every visit service provided in the office.

75 WCB Billing Example Follow-up visit in 4 weeks, patient has form to fill in, steroid injection indicated 0303A $35.92 95.96A $12.57 MINT (tray) $ ($61.23) Progress report (C051) $35.28 BCP 01/02 x 1 Follow up visit would be charged as a limited visit (03.03A) and the injection (95.96A) and a tray fee. Tray fees are not automatically paid by WCB and must be billed in addition to the procedure. The recent agreement with WCB has allowed for “unbundling” which allows for payment of the procedure in addition to the visit. [Note: If this were not a WCB claim only the visit or the injection would be payable but not both.] The report would be claimed as an progress report (C051).

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 $127.01 Additional 15 minute increments $49.41 Photocopying (RF08) $0.43 per page Answers: If a detailed report is requested by WCB then billing is done on a time basis. Make sure to add the number of time units in the calls field e.g. 1 hour at the rate of $ for first 30 minutes and $48.20 for each additional 15 minute increments. Photocopying $0.42 per page. In Alberta specialist are paid at a different rate than general practitioners.

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 CCP Disability Physicians may charge patients the difference between what CCP will pay for the report and their normal fee for the service, if applicable.

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 $ Answers: Tonsillitis with sick note If the service is medically required then 03.03A may be billed to the health care plan. If the sole purpose of the visit was to obtain a sick note then both the form completion and the visit are to be billed to the patient. Sick note only $43 Note & examination $ Be very cautious as to the information you provide on the form. If you attend the patient while they are still ill you can record that the patient is ill. However, if the patient has recovered and is requesting a form for the days when s/he was off ill. Make sure your note indicates that the patient advised you that s/he was ill and they have now recovered. You are legally liable for all the information you record and provide so only report the patient was ill if you attended them when they were ill otherwise simply report that they advised you that they were ill. 2. MOT exam The recommended fee for examination and form completion is $246 - $418

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 Answers: Phone script renewal ~ recommended fee is $ Non-insured visit for removal of 7 skin tags The AMA does not have a recommended rate and suggests that the physician set their own fee by taking into consideration time, expertise, supplies, etc.. Travel advice is not insured. The AMA does not have a recommended rate for travel advice.

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 The AMA recommended rate for general practitioner for report on patient attended is $213for the first 30 minutes and $85 for each additional 15 minute increment. Photo copies are charged at $25 first 20 pages, then $0.25/page The charge would be $553for the report prep and chart review and $25 for the additional photo copies Note: Submit an estimate to lawyers in advance so that they can approve and agree to payment on receipt of the report rather than at the settlement of the claim. Please refer to the 2011 AMA Guidelines to Billing Uninsured Services.


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