Alberta Health Care Insurance Plan

AHCIPClaim Submission Seminar

HematologyJeffrey P Schaefer, MD

Jan 18, 2010

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 comprehensive consultation– 03.03D hospital visit– 02.82A transesophageal echocardiogram– 03.01AA providing care in hospital after hrs

Modifiers• Modifiers:

• changes the value of the service• changes the rules for claiming the service

– Implicit Modifier• pre-entered or derived by the Claim Submitter

– Explicit Modifiers• must be entered with each claim• up to 3 with any HSC may be submitted

Implicit Modifier Categoriesprogrammed into the billing software

• LEVL (level)– INMDH1, INMDH2, GASTH1, GASTH2

• SKLL– HEM– E.g. INMD, CARD…

Relevant Explicit Modifier Categoriesmust 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

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

03.08Acomprehensive

consultation

Possible Surcharges for the 03.08A(from the Price List)

• After Hours Time Premium 03.01AA– this is a Health Service Code– hospital care provided outside of regular hours (08-17 M-F)– requires a SURT modifier (e.g. TEV, TNTP, TNTA, TWK, TST)– claim by the call (unit); each call is 15 min or portion thereof– claim must be for individual patients

Hospital Consultation• You are consulted by the Emerg Dept MD

on a patient with pancytopenia.• You receive the call at 21:50, initiate the

consult at 22:15, and finish at 22:55 (40 min).

• You perform a bone marrow biopsy and aspiration that night, this takes 30 minutes.

• The patient’s BMI is 36.• What is your claim?

Hospital Consultation with Procedure• 03.08A $ 183.86

– NTPM $ 107.22– CMXC30 $ 28.70

• 03.01AA– TNTP x 5 calls ($41.00 x 5) $ 205.00

• 53.81A $ 53.24– BMIANT (+25%) $ NA

• 53.81B $ 52.97– BMIANT (+25%) $ NA

• Total $ 630.99

BMI• BMISRG most applicable for medicine

– check Price List to determine HSC– BMI 35+

Bone Marrow Aspiration & Bx

Minor or Repeat Consultations03.07A03.07B

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

Transfers of Care• 03.03D + TOC• 03.03AO: hem, gim, medonc, endo…

Emergency Detention per 15 minbedside attendance

• needs supporting text… e.g. patient in respiratory failure / distress.

Office / Clinic Visits• 03.03F

– Repeat office or scheduled outpatient visit in a regional facility, referred cases only

HEM: 15, 30, eligible

Don’t forget the Modifiers!!!Office / Clinic Visit Modifiers

Office / Clinic Visit Modifiers

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

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)

d

ev

pm

am

wk

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.

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

Team Conference Family Conference

$42 / 15 min = typical of all

Advice to Allied Health Care Workers

d

ev/wk

pm/am

Chemotherapy• Not my area but… I expected an intra-thecal administration code?

Certification

Residents….• Claims may be submitted by a physician

who is present and supervising a resident or intern during the provision of a service.

ARP Codes

Audits...

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

Category Codes

Summary• email me:

– codes you use– questions / concerns– tips