Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29,...
-
Upload
willis-haynes -
Category
Documents
-
view
225 -
download
7
Transcript of Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29,...
![Page 1: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/1.jpg)
Alberta Health Care Insurance Plan
AHCIPClaim Submission Seminar
Jeffrey P Schaefer, MD
June 29, 2006
![Page 2: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/2.jpg)
Objective• Appropriate claim submission is in
everyone’s interest– members– alternative relationship plan– billing clerks– patients– payers– society
![Page 3: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/3.jpg)
Rules for Today• Individual physicians are ultimately
responsible for their claims.
• My qualifications– Vice-president – AMA section of Int Med– Chair, ARP Management Committee– Chaired: two billing seminars– 11 years of Specialist Practice in Alberta
• There will be areas I do not know… let me find out rather than get stuck on a point.
![Page 4: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/4.jpg)
Website
billing.healthlearner.com
![Page 5: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/5.jpg)
Elements of an Int Med 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
![Page 6: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/6.jpg)
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
![Page 7: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/7.jpg)
Modifiers
• Modifiers– change the value of the service– change the rules associated with the service
• Explicit Modifiers– must be entered with each claim (eg COMX)
• Implicit Modifier– pre-entered or derived by the Claim Submitter
(eg LEVL HEMH1 (HAEMATOLOGY HD1)
![Page 8: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/8.jpg)
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
![Page 9: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/9.jpg)
Implicit Modifier Categories• Implicit Modifiers are programmed into the
billing software by the Claim Submitter
• LEVL (level)– INMDH1, INMDH2, HEMH1, skillcodeH(1or2)
• SKLL (skill)– CARD, DERM, INMD, HEME, E/M, etc– *SKLL can be explicit if not using your default– e.g. GAST bill 03.03D under INMD
![Page 10: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/10.jpg)
![Page 11: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/11.jpg)
Sources of Truth
• Medical Governing Rules• Medical Benefits Procedure List• Medical Benefits Price List• Fee Modifier Definitions• Explanatory Code List
• All available in pdf format from AHW
www.health.gov.ab.ca/professionals/somb.html
![Page 12: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/12.jpg)
Consultations• 03.08A
– Comprehensive Consultation – Modifier: SURC (EV, NTPM, NTPM, WKTEV)– Modifier: CMXC30– Modifier: TELE (TELES)
• 03.01AA– Modifier: SURT (TEV, TNTP, TNTA, TWK,TST)
• Rules about consultations…• 1 / 180 days• done according to peer• College• AHW
![Page 13: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/13.jpg)
![Page 14: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/14.jpg)
22-07 asthma attack...$172.65+$28+$176.70+$14 = $391.35
![Page 15: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/15.jpg)
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
![Page 16: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/16.jpg)
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
![Page 17: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/17.jpg)
$38.09 +
$36.00
$74.09
INMDH1INMDH2
![Page 18: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/18.jpg)
Emergency Detention per 15 min
![Page 19: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/19.jpg)
Office / Clinic Visits• 03.03F
– Repeat office or scheduled outpatient visit in a regional facility, referred cases only
– Modifiers: CMXV15, CMXV20
– Consider 03.03Z for age > 75 years if geri
![Page 20: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/20.jpg)
![Page 21: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/21.jpg)
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
![Page 22: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/22.jpg)
Ref-d
Ref-ev/wk
Ref-a/p
Con-d
Con-ev/wk
Con-a/p
![Page 23: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/23.jpg)
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
![Page 24: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/24.jpg)
d
ev
pm
am
wk
![Page 25: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/25.jpg)
Callback Rules1. 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
![Page 26: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/26.jpg)
Callbacks and Emergency Visits:Emergency Depts, Outpatient Departments,
Auxillary Hospitals, Nursing Homes
• similar to inpatients
• billing.healthlearner.com
![Page 27: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/27.jpg)
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
![Page 28: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/28.jpg)
Team Conference Family Conference
$32 / 15 min = typical of all
![Page 29: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/29.jpg)
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 can’t initiate, 2/day, your location...
![Page 30: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/30.jpg)
Inpatient Advice
d
ev/wk
pm/am
![Page 31: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/31.jpg)
Procedures53.81A 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
![Page 32: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/32.jpg)
Residents….
• Claims may be submitted by a physician who is present and supervising a resident or intern during the provision of a service.
![Page 33: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/33.jpg)
Audits...
![Page 34: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/34.jpg)
Diagnostic Codes• ICD-9 codes
• see billing.healthlearner.com
![Page 35: Alberta Health Care Insurance Plan AHCIP Claim Submission Seminar Jeffrey P Schaefer, MD June 29, 2006.](https://reader031.fdocuments.in/reader031/viewer/2022020106/56649efe5503460f94c1306f/html5/thumbnails/35.jpg)
Summary• email me:
– codes you use– questions / concerns– tips