Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar

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Alberta Health Care Insurance PlanAHCIPClaim
Submission Seminar

• Nephrology
• Jeffrey P Schaefer, MD
• April 17, 2009

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Objective

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

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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

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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

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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

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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

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Relevant Explicit Modifier Categoriesmust 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

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Implicit Modifier Categoriesprogrammed 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

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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

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03.08Acomprehensiveconsultation
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Surcharges consults procedures
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Consultations in the HospitalAfter 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)

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

• You are consulted to see a patient concerning
  hyperkalemia. You are called at 2150, initiate
  the consultation at 2215 and finish at 2255.
  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

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Minor or Repeat Consultations

• 03.07A
• 03.07B

Rules about consultations no limitation of
quantity but caution ensure that a valid
referral was made!
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Hospital Visits

• 03.03D . . . . . . . . . . . . . . . . . . .
  56.54
• Hospital Visit
• Modifier COMX (20 minutes) add 36.90
• Modifier TOC (receiving)

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CARE (COMX)

• 36.90

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Emergency Detention per 15 minbedside attendance
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Office / Clinic Visits

• 03.03F
• Repeat office or scheduled outpatient visit in a
  regional facility, referred cases only

NEPHRO 15, 30, 35 eligible
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Nephrology CMXV
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Nephrology CMXV35
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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

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Ref-dRef-ev/wkRef-a/pCon-dCon-ev/wkCon-a/p
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CallbacksTypically 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)

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devpmamwk
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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

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

• similar to inpatients
• billing.healthlearner.com

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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

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Team Conference Family Conference42 / 15 min
typical of all
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Advice to Allied Health Care Workers
dev/wkpm/am
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Dialysis
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Certification
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Residents.

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

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Audits...
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Diagnostic Codes

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

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Procedures (old prices)

• 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...)
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Procedures (surcharges apply)
Consider BMI SURC LVP 03.01AA SURT
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Category Codes
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Summary

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