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Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar GI Group Jeffrey P Schaefer, MD January 25, 2012.

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Presentation on theme: "Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar GI Group Jeffrey P Schaefer, MD January 25, 2012."— Presentation transcript:

1 Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar GI Group Jeffrey P Schaefer, MD January 25, 2012

2 Objective Know the anatomy of an AHCIP claim Know the common situations 1.Comprehensive Consultation 2.Minor and Repeat Consultation 3.Hospital Visits 4.Emergency Detention 5.After Hours Time Premiums 6.Conferences 7.Office Visits 8.Telephone Consultations 9.Telephone Calls from Allied Health Care 10.Procedures

3 Sources of Truth - 5 documents to download –Medical Governing Rules –Medical Benefits Procedure List –Medical Benefits Price List –Fee Modifier Definitions –Explanatory Code List

4 What's Needed? Demographics –AHCIP  AHW requires the PHN only –OOP  requires everything –College  requires complete billing records Location –Facility and Functional Centre Diagnosis Code –ICD-9 Referring Physician for some Services –PRACID if in Alberta (not required otherwise) Health Service Code –implicit modifier –explicit modifier

5 HSC and Modifiers HSC Health Service Code –refers to the service rendered –03.08A comprehensive consultation –03.03D hospital visit –03.03Foffice / clinic visit –02.82A transesophageal echocardiogram –03.01AA providing care in hospital after hrs

6 Modifiers Modifiers: changes the value of the service changes the rules for claiming the service –Implicit Modifier pre-entered or derived by the Claim Submitter –Explicit Modifiers must be entered with each claim (you write this in) up to 3 with any HSC may be submitted

7 Implicit Modifier Categories LEVL (level.... relates to admission date) –INMDH1, INMDH2... SKLL (programmed into software once) –INMD, GAST, OBGY, HEME AGE (calculated from PHN or DOB) –G75 (age surcharge)

8 Relevant Explicit Modifier Categories MD must supply these CARE (complex patient care) –COMX, CMXC30, CMXV15, CMXV20 SURC (services unscheduled) –EV, NTPM, NTAM, WK SURT (after hours premium: 03.01AA) –TDES, TEV, TNTP, TNTA, TWK, TST BMISRG (body mass index > 35) LVP (repeat procedures): LVP75, LVP 50, ADD, ADD2 TELE (telehealth): TELES

9 procedure list price list

10 Comprehensive Consultations

11 Comprehensive Consultation HSC = 03.08A –Possible Explicit Modifiers: SURC: EV or NTPM or NTPM or WKTEV CARE: CMXC30 TELE: TELES Rules about consultations… 1 per 180 days per patient AHW and College rules apply


13 Governing Rules… sample


15 Unscheduled Service (SURC)

16 03.08I Prolonged Consult 30’+

17 Minor / Repeat Consults


19 Hospital Visits



22 After Hours Time Premium –this is a Health Service Code per 15 min or major portion thereof –hospital care provided outside of regular hours (08-17 M-F) –requires a SURT modifier (e.g. TDES, TEV, TNTP, TNTA, TWK, TST)

23 After Hours Time Premium 03.01AA + explicit modifier x number of 'calls'


25 Test your skills…

26 Claims Consulted for obese (BMI 36) pt with GIB –ED MD called at 2145 –saw pt at 2230 - 2315 (45 min) –gastroscopy 2345 - 0045 (1 hr) –banding x 3 esophageal varices

27 Services? Comprehensive Consultation Endoscopy Banding of 4 esophageal varices After hours time premium

28 03.08A 03.08I x 2 01.14 $156.08 Claim? $115.40+25% $35.35 x 3 = $250.03 $42.84 x 8=$390.72 $1,211.70

29 Transfers of Care

30 Transfers of Care Not for GI... whose your AMA rep?

31 Emergency Detention per 15 min - series of codes here… resuscitation needs supporting text… e.g. patient in respiratory failure / distress.


33 Office Visits

34 INMD: 15, 30, eligible

35 Prolonged Office Visit Not for GI… yet

36 MD to MD Advice

37 Physician to Physician Consultation Referring Physician –03.01LG (M-F 7-17) –03.01LH (M-F 17-22, Sat-Sun 7-22) –03.01LI (22-7 anyday) Consultant –03.01LJ (M-F 7-17) –03.01LK (M-F 17-22, Sat-Sun 7-22) –03.01LL (22-7 anyday) –Lots of rules, not for expediting referrals <24h

38 Ref-d Ref-ev/wk Ref-a/p Con-d Con-ev/wk Con-a/p

39 Callbacks Typically used for patients you attend on. Pays less than new or repeat consultation Inpatient Callbacks –03.05N (M-F 0700 - 1700 hours) –03.05P (M-F 1700 - 2200 hours) –03.05QA (All 2200-2400 hours) –03.05QB (All 2400-0700 hours) –03.05R (Sat, Sun, Stat 0700-2200 hours)

40 d ev pm am wk

41 Callback Rules 1. May only be claimed when a special call for attendance is made on the patient's behalf. 2. The physician responds to such a call from outside the hospital, on an unscheduled basis. 3. The patient is attended on a priority basis. 4. There is direct attendance by the physician. 5. Second or subsequent patients seen during the same callback are not eligible for benefits under 03.05N, 03.05P, 03.05QA, 03.05QB or 03.05R but time spent may be claimed using the AFTER HOURS TIME PREMIUM modifier. 6. May not be claimed in association with any health service code except 03.01AA. Refer to GR 15.8

42 Callbacks and Emergency Visits: Emergency Depts, Outpatient Departments, Auxillary Hospitals, Nursing Homes similar to inpatients

43 Family / Team Conference $42 Team Conference (per 15 min) –03.05JA Family Conference (per 15 min) –03.05JB (?) or 03.05JC (Acute Care, In-pt) Palliative Care Family or Team (per 15) –03.05T first call, 03.05U next calls Chronic Pain Team Conference –03.05V first call, 03.05W next calls Chronic Pain Family Conference (/15 min) –03.05X

44 Team Conference Family Conference $42 / 15 min = typical of all

45 Advice to Allied Health Care Workers d ev/wk pm/am

46 Certification

47 Residents…. Claims may be submitted by a physician who is present and supervising a resident or intern during the provision of a service.

48 ARP Codes Codes paid at $0 A couple might be useful…

49 Audits...

50 Diagnostic Codes ICD-9 codes see

51 Category Codes


53 Summary email me: –codes you use –questions / concerns –tips

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