Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar

1
Alberta Health Care Insurance PlanAHCIPClaim
Submission Seminar

• Jeffrey P Schaefer, MD
• March 27, 2007

2
Objective

• Appropriate claim submission is in everyones
  interest
• members
• alternative relationship plan
• billing clerks
• patients
• payers
• society

3
billing.healthlearner.com

• All Links are on my Website
• 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
• 01.22 colonoscopy
• 03.01AA providing care in hospital after hrs

6
Modifiers

• 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
Explicit Modifier Categories

• 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

• Implicit Modifiers are programmed into the
  billing software by the Claim Submitter
• 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
Consultations

• 03.08A
• Comprehensive Consultation
• Modifier SURC (EV, NTPM, NTPM, WKTEV)
• Modifier CMXC30
• Modifier TELE (TELES)
• 03.01AA for being in the hospital
• Modifier SURT (TEV, TNTP, TNTA, TWK,TST)
• Rules about consultations
• 1 / 180 days
• done according to peer
• College has rules
• AHW has rules
• CHR has rules

10
03.08Acomprehensiveconsultation
11
After-hours Surchargesconsults procedures
12
03.01AAaftehour time premium
13
2130 ?call to see GI Bleed

• 2201 to 2246 (initiate 2201 45 min)
• Consult 03.08A 165.09
• SURC NTPM 176.70
• CARE CMXC30 28.00
• 03.01AA .00
• SURT TNTP x 3 31.50
• Gastroscopy 01.14 110.74
• Total ? 512.03
• surc with gastro not permitted (only 1 surc per
  patient encounter, this is one encounter)

14

• Consults, Procedures ? SURC Modifiers

• 03.01AA ? SURT Modifiers

• 03.01AA ? SURT Modifiers

15
Gastroscopy
16
(No Transcript)
17
Minor or Repeat Consultations

• 03.07A, 03.07B
• Limited or Repeat Consultation
• Modifier SURC (EV, NTPM, NTPM, WKTEV)
• Modifier TELE (TELES)
• 03.01AA
• Modifier SURT (TEV, TNTP, TNTA, TWK,TST)
• Rules about consultations
• no limitation of quantity but caution
• ensure that a valid referral was made!
• AHW Governing Rules

18
Hospital Visits

• 03.03D
• Hospital Visit
• Modifier COMX (20 minutes)
• Modifier TOC (receiving)
• 03.03AO
• transfer of care receiving for some divisions
• Rules
• one per day per physician unless supporting txt
• use call backs for subsequent visits
• 13.99J - emergency detention time / 15

19
Hospital Visit Code Jan 2007
27.03 36.00 63.03
20
Emergency Detention per 15 min
21
Office / Clinic Visits

• 03.03F
• Repeat office or scheduled outpatient visit in a
  regional facility, referred cases only
• Modifiers CMXV20 available to GI
• CMXV15 available to INMD

30.35 14.00 44.35
22
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 lt24h

23
Ref-dRef-ev/wkRef-a/pCon-dCon-ev/wkCon-a/p
24
Callbacks

• 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).
• 03.05BA
• Second and subsequent patient seen after initial
  after-hours callback to hospital inpatient
• Use SURT TEV, TNTP, TNTA, TWK, TST

25
devpmamwk
26
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 with 03.05BA.
• 6. May not be claimed in association with any
  health service code except 03.01AA. Refer to GR
  15.8

27
Callbacks and Emergency VisitsEmergency Depts,
Outpatient Departments, Auxillary Hospitals,
Nursing Homes

• similar to inpatients
• billing.healthlearner.com

28
Family / Team Conference

• 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

29
Team Conference Family Conference32 / 15 min
typical of all
30
Advice to Allied Health Care Workers

• Home Care
• 03.01A (M-F 7-17)
• 03.01AB (M-F 17-22, S-S-S 7-22)
• 03.01AC (anyday 22-7)
• Long Term Care
• 03.01M, 03.01MN, 03.01MO
• Active Treatment Facility
• 03.01ND, 03.01NE, 03.01NF
• Rules
• you cant initiate, 2/day, your location...

31
Inpatient Advice
dev/wkpm/am
32
Procedures

• 53.81A bone marrow aspiration (SURC) 52
• 53.81B bone marrow biopsy (SURC) 52
• 16.81A spinal tap (SURC) 75
• 66.91A abdominal paracentesis (SURC) 46
• 46.91 thoracentesis (SURC) 54
• 46.84A pleural biopsy (SURC) 58
• 01.22 colonoscopy (SURC,LVP) 144
• 57.21A colonic polypectomy 67
• 01.14 gastroscopy (SURC,LVP) 111
• 13.99A dialysis, unstable pt (SURC) 113
• 13.99B dialysis, stable pt (SURC) 52
• 61.03 excision perianal skin tag (SURC) 44
• 98.12A excisional skin biopsy (TRAY, SURC...)
  40

33
Residents.

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

34
Audits...
35
Diagnostic Codes

• ICD-9 codes
• see billing.healthlearner.com

36
Summary

• email me
• codes you use
• questions / concerns
• tips