1. Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Nephrology Jeffrey P Schaefer, MD April 17, 2009

2. Objective Appropriate claim submission is in everyone’s interest –members –alternative relationship plan –billing clerks –patients –payers –society

3. billing.healthlearner.com Medical Governing Rules Medical Benefits Procedure List Medical Benefits Price List Fee Modifier Definitions Explanatory Code List www.health.gov.ab.ca/professionals/somb.html

4. Elements of an AHW Claim Demographics –AHCIP  AHW requires the PHN only –OOP  requires everything –College  requires complete billing records Location –Facility and Functional Centre Diagnosis Code –ICD-9 (up to 3… 4.6%-2, 1.3%-3 of 6mil-op) Referring Physician –PRACID Health Service Code –implicit modifier –explicit modifier

5. HSC and Modifiers HSC –refers to the service rendered –03.08A comprehensive consultation –03.03D hospital visit –01.09 bronchoscopy –03.01AA providing care in hospital after hrs

6. Modifiers –change the value of the service –change the rules associated with the service Explicit Modifiers –must be entered with each claim Implicit Modifier –pre-entered or derived by the Claim Submitter

7. Relevant Explicit Modifier Categories must be provided by you CARE (complex patient care) –COMX, CMXC30, CMXV15, CMXV20 LMTS (limits) –TOC… LVP (lesser value, additional procedure) –LVP50, LVP75, ADD, ADD2 SURC (services unscheduled) –EV, NTPM, NTAM, WK SURT (after hours premium: 03.01AA, 03.01BA) –TEV, TNTP, TNTA, TWK, TST TELE (telehealth) –TELES, STFO

8. Implicit Modifier Categories programmed into the billing software LEVL (level) –INMDH1, INMDH2, GASTH1, GASTH2 SKLL (skill) –GAST, INMD –*SKLL can be explicit if not using your default –e.g. GAST  bill 03.03D under INMD

9. Comprehensive Consultations 03.08A –Comprehensive Consultation –Modifier: SURC (EV, NTPM, NTPM, WKTEV) –Modifier: CARE (CMXC30 –Modifier: TELE (TELES) Rules about consultations… 1 / 180 days done according to peer College has rules AHW has rules CHR has rules

10. 03.08A comprehensive consultation

11. Surcharges: consults & procedures

12. Consultations in the Hospital After Hours Time Premium 03.08A –Comprehensive Consultation –Modifier: SURC (EV, NTPM, NTPM, WKTEV) –Modifier: CARE (CMXC30 –Modifier: TELE (TELES) 03.01AA –After hours time premium (other than 8-17 M-F) –Modifier: SURT (TEV, TNTP, TNTA, TWK, TST)

13. 03.01AA after hour time premium Health Service Code - for services in an acute care facility after hours. - attributable to individual patients. - 1 call (service) = 15 min (or portion thereof)

14. Hospital Consultation You are consulted to see a patient concerning hyperkalemia. You are called at 21:50, initiate the consultation at 22:15 and finish at 22:55. Your skill code is NEPH. HSC = 03.08A$ 188.57 –Explicit Modifier = NTPM$ 107.22 –Explicit Modifier = CMXC30$ 28.70 HSC = 03.01AA –Explicit Modifier 1 = TNTP ($10.50/15min) –Number of calls = 3 ($41.00 x 3)$ 123.00 Total$ 447.49

15. Minor or Repeat Consultations 03.07A 03.07B Rules about consultations… no limitation of quantity but caution… ensure that a valid referral was made!

16. Hospital Visits 03.03D................... $56.54 –Hospital Visit –Modifier: COMX (20 minutes) add $36.90 –Modifier: TOC (receiving)

17. CARE (COMX) $36.90

18. Emergency Detention per 15 min bedside attendance

20. Office / Clinic Visits 03.03F –Repeat office or scheduled outpatient visit in a regional facility, referred cases only NEPHRO: 15, 30, 35 eligible

21. Nephrology: CMXV

22. Nephrology: CMXV35

23. 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

24. Ref-d Ref-ev/wk Ref-a/p Con-d Con-ev/wk Con-a/p

25. 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)

26. d ev pm am wk

27. 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

28. Callbacks and Emergency Visits: Emergency Depts, Outpatient Departments, Auxillary Hospitals, Nursing Homes similar to inpatients billing.healthlearner.com

29. 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

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

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

32. Dialysis

34. Certification

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

36. Audits...

37. Diagnostic Codes ICD-9 codes see billing.healthlearner.com

38. Procedures (old prices) 53.81Abone marrow aspiration (SURC)$ 52 53.81Bbone marrow biopsy(SURC)$ 52 16.81Aspinal tap(SURC)$ 75 66.91Aabdominal paracentesis(SURC)$ 46 46.91thoracentesis(SURC)$ 54 46.84Apleural biopsy(SURC)$ 58 01.22colonoscopy(SURC,LVP)$144 57.21Acolonic polypectomy$ 67 01.14gastroscopy(SURC,LVP)$111 13.99Adialysis, unstable pt(SURC)$113 13.99Bdialysis, stable pt(SURC)$ 52 61.03excision perianal skin tag(SURC)$ 44 98.12Aexcisional skin biopsy (TRAY, SURC...)$ 40

39. Procedures (surcharges apply) Consider: BMI SURC LVP 03.01AA SURT

40. Category Codes

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