Transcript Alberta Health Care Insurance Plan AHCIP Claim Submission

Alberta Health Care
Insurance Plan
AHCIP
Claim Submission Seminar
Cardiology
Jeffrey P Schaefer, MD
June 16, 2009
Objective
• AHCIP is complex
• Correct claim submission is in everyone’s interest
– ARP and FFS member time and effort
– AHCIP benefits by fewer admin reviews
– ICD-9 codes helps to target health funding
• e.g. the prevalence of heart failure is inferred from claims
billing.healthlearner.com
• Sources of Truth
–
–
–
–
–
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
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
• Referring Physician
– PRACID if in Alberta (not required otherwise)
• Health Service Code
– implicit modifier
– explicit modifier
HSC and Modifiers
• HSC (health service code)
– refers to the service rendered
– 03.08A
– 03.03D
– 02.82A
– 03.01AA
comprehensive consultation
hospital visit
transesophageal echocardiogram
providing care in hospital after hrs
Modifiers
• Modifiers:
• two categories: explicit and implicit
• change the value of the service
• change the rules for claiming the service
• Explicit Modifiers
– must be entered with each claim
– up to 3 with any HSC may be submitted
• Implicit Modifier
– pre-entered or derived by the Claim Submitter
Relevant Explicit Modifier Categories
must be provided by physician
• BMI (body mass index)
– BMISRG
• 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)
– TEV, TNTP, TNTA, TWK, TST
• TELE (telehealth)
– TELES, STFO
Implicit Modifier Categories
programmed into the billing software
• LEVL (level)
– INMDH1, INMDH2, GASTH1, GASTH2
• SKLL (CARD)
– CARD
Comprehensive Consultation
• HSC = 03.08A
– Available 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
03.08A
comprehensive
consultation
Possible Surcharges for the 03.08A
(from the Price List)
After Hours Time Premium (hospital only)
• 03.01AA
–
–
–
–
After hours time premium (other than 8-17 M-F)
Modifiers: SURT (TEV, TNTP, TNTA, TWK, TST)
one ‘call’ (unit) = 15 minutes
claim must be for individual patients
BMI
• BMISRG most applicable for medicine
– check Price List to determine HSC
– BMI 35+
Hospital Consultation
• You are consulted to see a patient concerning
chest pain. Your skill code is CARD.
• You are called at 21:50, initiate the consultation
at 22:15 and finish at 22:55 (40 min).
• You implant a pacemaker at 23:30 that takes 45
minutes.
• The patient’s BMI is 35.
• What is your claim?
Hospital Consultation with Procedure
• 03.08A
– NTPM
– CMXC30
$ 167.79
$ 107.22
$ 28.70
• 03.01AA
– TNTP x 5 calls ($41.00 x 3)
$ 205.00
• 02.82A TEE
– + 25%
$ 135.92
$ 33.98
• Total
$ 678.61
Minor or Repeat Consultations
03.07A
03.07B
Rules about consultations… no limitation of quantity but
caution… ensure that a valid referral was made!
Hospital Visits
• 03.03D . . . . . . . . . . . . . . . . . . . $51.25
– Hospital Visit
– Modifier: COMX (20 minutes) add $36.90
– Modifier: TOC (receiving)
CARE (COMX)
$36.90
Emergency Detention per 15 min
bedside attendance
Office / Clinic Visits
• 03.03F
– Repeat office or scheduled outpatient visit in a
regional facility, referred cases only
CARD:
15, 30, 35 eligible
CARD: CMXV
CARD: CMXV35
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
Ref-d
Ref-ev/wk
Ref-a/p
Con-d
Con-ev/wk
Con-a/p
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)
d
ev
pm
am
wk
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
Callbacks and Emergency Visits:
Emergency Depts, Outpatient Departments,
Auxillary Hospitals, Nursing Homes
• similar to inpatients
• billing.healthlearner.com
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
Team Conference
Family Conference
$42 / 15 min = typical of all
Advice to Allied Health Care Workers
d
ev/wk
pm/am
Certification
Residents….
• Claims may be submitted by a physician
who is present and supervising a resident
or intern during the provision of a service.
Audits...
Diagnostic Codes
• ICD-9 codes
• see billing.healthlearner.com
Category Codes
Summary
• email me:
– codes you use
– questions / concerns
– tips