The Principles of Billing

Case Study

Dr. New Entrant (NE) completes his/her FM residency in 5 months. To date, she only fills in a patient encounter form which the unit manager will use to do the billing. Her preceptor is on salary with the teaching program funded by a ARP. There has been no specific instruction in billing. The program encourages the resident to learn this during their community rotations. NE doesn’t know how to bill or how to obtain her billing #.

Introduction

Most physicians are self-employed vs salaried

As a professional, you provide a service Your income is received upon billing and receipt

of payment for services rendered

You are now a proprietor in the Service Industry called Medicine

Areas to be Addressed

Registering with the provincial HCP When, how and who to bill Staff Training Where to go for Help Monitoring The components of a bill to provincial Health

Care Plans (HCP) or WCB The “bread & butter” of billing

Areas to be Addressed (cont’d)

Third Party Billing Uninsured/Noninsured Services Alternate Billing Options NEVER FORGET TO....!! Common Mistakes

Registering with Your HCP

Provincial registration variations & exclusion criteria

Contact provincial licensing college application for Independent Practice License

Contact HCP for “Application for Billing Number”

Billing # restrictions may apply! Register with WCB

Choosing a Billing Package

List of approved submitters 310-000 (780) 422-0069

AMA Web site (www.albertadoctors.org) computerized office

Physician office system program 3 approved vendors (Med Access, Telus Health

Solutions (Practice Solutions), Telus Health Solutions - Wolf Medical System)

Practitioners in Similar practices Service Bureau’s VS Direct Submission

Cost, support, availability of software

HCP Physician Information Kit

HCP Schedule of Benefits (www. albertadoctors.org, fees and negotiation, billing advice) General Rules Procedure list Fee modifier list Price list Explanatory codes

Diagnostic code manual AHW Web site (

http://www.health.alberta.ca/documents/Diagnostic-Code-ICD-9.pdf

A Physicians Resource Guide /AH&W Bulletins AHW Web site

(http://www.health.alberta.ca/documents/Physician-Resource-Guide-2014.pdf)

Facility Listing AH Web site (http://www.health.alberta.ca/documents/Facility-

Listing-2014-04.pdf)

Staff Training

Office policies Billing for Uninsured services

Alberta Health Billing Submission Reconciliation Resubmission Not all services are billable - varies from province

to province Supervised services

Reciprocal Billing

Where to go for Help

Physician Resource Guide Alberta Health

310-0000 (780) 427-1432

AMA - Physician Advocacy 1-800-272-9680 (780) 482-2626 e-mail

marilyn.kroon@albertadoctors.orgdarcy.shade@albertadoctors.orgmarisa.bonuccelli@albertadoctors.org billingadvice@albertadoctors.org

Verifying AH Coverage

IVR 1-888-422-6257 Netcare Opted out Good Faith Claims Invalid AHC Numbers

Office Bill patient

Hospital Patient Name, address, phone number, ULI,

DOS, DOB, claim number

Remittance Review & Reconciliation

The weekly process of reviewing if you have received 100% payment for the services you have rendered to date

Unpaid or partially paid accounts should be reviewed, corrected & resubmitted to the responsible party

Monitoring

Verify assessment results Is explanatory code acceptable

Paid does not equate to assessment is correct Few edits in place Physicians responsibility to ensure that

assessment is correct

Responsible Party

The Responsible Party remits payment to the physician for services rendered Provincial HCP WCB Third parties (uninsured services)

insurance companies employers lawyers government agency

Patient (insured or uninsured)

Worker’s Compensation

Obtaining a Registration (billing) number Edmonton 780 498-4316 or toll free 1-866-922-

9221

Always verify if the patient is covered by WCB when assessing all work related medical complaints.

Knowingly billing the Provincial HCP for WCB services is…fraudulent

WCB pays for form completion Claims submission must be electronic

Reciprocal Billing

All provinces & territories, except Quebec, have mutual arrangements that allow the physician to bill the patient’s “home province” for services rendered

Payment is rendered at the rates of the “host province”

Some exceptions/exclusions Physician’s Resource Guide (section 4)

Billing Period

AHW provides weekly payments Accounts receivable = 2 - 4 weeks AHW claim submission deadlines are 180

days from service date or 180 from last communication Note AH has indicated to AMA they want to move

to 90 days.

The Components of a Bill

Service provider PRACID Skill Code Recipient ULI Date of service Location of service Referral PRACID if

applicable Health service code

Calls Diagnostic code Encounter number Modifiers if applicable Facility number Functional centre Responsible party Recovery code

Billing Documentation

Billing Day sheet Computer record Patient record must be able to stand alone

as an indicator of what services and procedures were provided without your interpretation!!!

AHC legislation Records must be kept minimum of 6 years

Know Your Fee Schedule

Provincial HCP’s “Schedule of Benefits” dictate the fees you receive

Fees change - READ ALL BULLETINS Stay up-to-date

Request new SOMB fax (780) 427-1093 http://www.health.alberta.ca/professionals/

SOMB.html Review the schedule - general rules, procedure list

and associated notes, modifiers

PHYSICIAN DECIDES ON CODE TO SUBMIT IGNORANCE leads to LOST INCOME

The “Bread & Butter” of Billing

In general, most specialties use 5-6 service codes more often than any others

Learn what criteria must be met before using these codes

Each code is explained in the procedure list of the HCP “Schedule of Medical Benefits”

Bread and Butter Codes:

03.03A Limited visit not requiring complete history and evaluation $35.92

-75 years and older 03.03A + 20%

03.03B Prenatal visit $35.7803.04A Comprehensive visit $98.78CMGP01 - 10 Complex patient visit modifier/unit

$15.56- 03.01J, 03.03A, 03.03B, 03.03C, 03.03N, 03.03P, 03.03Q, 03.07A, 03.07B

CMXC30 Complex visit/consultation modifier $30.56- 03.04A, 03.04B, 03.04C, 03.04D 03.04M, 03.08A

08.19G Direct contact with a patient for psychiatric treatment, per 15 minute

$44.9098.12A Excisional biopsy, skin $41.2503.04M Pre op history & physical $98.78

Bread and Butter Codes cont’d:

03.04JDevelopment, documentation & administration of a comprehensive annual care plan for patient with complex needs

$215.52- Family physician most responsible

- One/patient/year with ongoing communication- Not payable within 345 days of previous 03.04J

- May be claimed in addition to 03.03A, 03.03N, 03.04A - Complex – patient with multiple complex health needs including chronic disease and other complications

- Two or more diagnosis from group A & B

Comprehensive care plan

Group A- Hypertensive disease (401)- Diabetes Mellitus (250)- COPD (496)- Asthma 493)- Heart Failure (428)- Ischemic Heart Disease (413 - 414)- Chronic renal failure (585)

- (2 different GFR readings, >3 mon apart. Values 60-89 must be accompanied by urine or imaging abnormalities)

Group B- Mental Health Issues (290 – 319)- Obesity (Adult + BMI 35, Child = BMI 97 percentile) (278)- Addictions (303 – 304)- Tobacco (305.1)

Comprehensive care plan cont’d

Care plan includes:- Direct contact with patient

- Clearly defined goals- Detailed review of chart, current therapies and problem list- Demographic information that may affect patient health &/or treatment- Incorporate patient values and personal goals- Expected outcome- Identification of other health care professionals that may be involved- Physician & patient sign and each keep copy

Comprehensive care plan cont’d

Most Common Rejected Claims

Patient coverage problems Duplicate services Patient seen twice in one day Missing information on claim Reductions by the Ministry What does this cost you every

Month/Year?????

Primary Care Networks

Objectives of PCN include Increase access to primary care Manage 24/7 access to appropriate care Increase emphasis on promotion and prevention Greater use of multi-disciplinary teams Better coordination and integration between the

components of the health system

Primary Care Initiative cont’d

Local Primary Care Networks (LPCN) Arrangement between group(s) and a regional

health authority (shared leadership) Local flexibility to address local needs Manages the comprehensive care of a population Patient population defined through formal or

informal enrolment Funding follows the patient

AMA Practice Management Program

To provide high quality change management products and services primarily to physicians entering Local Primary care Networks (LPCN’s)

Third-Party Billing & Uninsured Services

Services not covered by provincial HCP or WCB

Physician bills the responsible party (insurance company, employer, lawyer, government agency or directly to the patient)

Not subject to clawbacks

Non-insured Services Why Physicians Don’t Bill

It will create public relations problems It will create administrative problems It’s not financially worth it I’ve never done it before I don’t want to be the first in town to do it I don’t know how My patient’s won’t like me.

Is Bill a 4-letter word?

What will really happen

My patients will recognize that ALL my time is valuable

I will accept that ALL my time is valuable I will get paid for things that I now do for free My revenues will increase

Overhead ratio will decrease My practice remains viable Able to take time off

Billing for Un-insured Services is... EXTREMELY IMPORTANT

Be proactive - start from day one! Be consistent Use discretion Inform patients of their responsibility for

payment prior to the delivery of the service Don’t feel guilty for billing appropriately for

uninsured services

Common Uninsured Services

Sick notes and medical certificates Employment insurance forms Phone call prescription renewals Chart transfer charges Missed appointments Insurance reports Cosmetic procedures

Uninsured Service Fees

Most provincial medical associations provide recommended rates for uninsured services

Contact your provincial medical association for more information

Alberta Medical Association Recommended Fees

Medical - legal services Report on patient attended $500 - 700/hr Review & interpretation of file $450 – 625/hr

Phone Rx renewal $55 -75

Sick note - note only $50 - exam & note $90 - 135

Alberta Medical Association Recommended Fees

Driver’s Exam (<74.5 years) form only $75 – 150 Exam and form $150 -275

EI / Maternity $55 - 95 CPP Disability

short narrative, 1 page (15 – 20 min) $50 full narrative, 2 pages (40 – 45 min) $100 Detailed narrative, 3 or more pages (60 min) $150

Insurance Disability Form completion only $60 - 125 Examination & form $145 - 230

Chart Transfer patient request $25 + photocopying $0.25/page (HIA)

Remember!

Billing for 1 sick note at $50 for every office day generates ~ $14,000/year... office medical supplies cost < $3,000 per year

Can you afford not to bill for these services? If you undervalue your services, so will your

patients

Commonly Missed Services Palliative care (03.05I) Unrelated AHC service with WCB (03.01J) Visit with non surgical treatment of warts

(98.12L) Visit with IUD insertion (81.8)/removal

(11.71A) CMGP modifier (03.01J, 03.03A, 03.03B,

03.03C, 03.03N, 03.03P, 03.03Q, 03.07A) CMXC30 modifier (03.04A, 03.04B, 03.04C,

03.04D, 03.04M) Complex inpatient modifier (COINPT)

(03.03D, 03.03AR) 03.01AATime premium

Commonly Missed services

Telephone advice (03.01B, BA, BB; 03.01NG, NH, NI, 03.01LM, LN, LO, 03.01NM)

Physician to physician advice (03.01LG, LH, LI, LJ, LK, LL)

Periodic Pap smear (13.99BA) INR Management (03.01N) REVIEW ALL premiums and modifier

codes in Schedule of Fees

NEVER FORGET TO !!!!!!!!

Complete all components of the bill! Always verify who is the responsible party! Bill for daily minor procedures Bill WCB whenever appropriate

NEVER FORGET TO !!!!!!!

Stay up-to-date with the fee schedule Never bill the HCP for uninsured services Bill for uninsured services when appropriate

Common AHC Billing Examples

Introduction

The key billing components billed to the Ministry of Health are: health service codes diagnostic codes modifiers physician and patient identification

Code definitions and #’s vary by province

Billing Examples: Alberta 2011

Q1. A thorough office visit for a URI with an IM (flu) shot given? 03.03A 465.9 $35.92 Possible CMGP01 (modifier )

$15.56 13.59A V04.8 $9.58

($45.50 if modifier not applicable or $61.06 if applicable)

Q2. Complete office assessment of 85 year old for chest pain, urinalysis done? 03.04A 786.5$98.78 Possible CMXC30 (modifier) $30.56

Billing Examples

Q3. Office visit for BP follow-up? 03.02A 401.9 $20.94

Q4. 25 minutes assessing an anxious patient? 03.03A CMGP02 300 (35.92+15.56+15.56)

$67.04 or 2 - 08.19G 300 (44.90 x 2) $89.80

Billing Examples

Q5. Complete assessment 74 year old febrile male one week post-operative discharge. 03.04A 780 $98.78

Note: CMXC30 may be applicable if 30 minutes spent adds an additional $30.56

Q6. Detailed office assessment, suspected ulcerative colitis, flexible sigmoidoscopy? 03.03A 556 $ 35.92 01.24B (+ tray) 556 (74.92 +37.71)

$112.63

($148.55)

Billing Examples

Q7. Emergency house call, 3pm,weekday, first patient seen, breast cancer, 25 minutes? 03.03N CMGP02 174 (79.35 + 31.12)$

110.47 or 03.05I x 2 174 $98.18

Q8. Same visit, spouse seen and NSAIDs re-ordered for osteoarthritis? 03.03P 715 $ 29.93 Possibly CMGP01 (if 15 minutes spent) $15.56

Billing Examples

Q9. Weekday evening (2100 H) ER visit, complete assessment, 55 year old, chest pain NYD? 03.03LA 786.5 $107.76 03.04A 786.5 $ 98.78 Possible CMXC30 (modifier) $ 30.56 03.01AA TEV 02 $ 43.66

($250.20 if no modifier $280.76 if modifier applicable)

Billing Examples

Q10. You do a delivery at 1 AM having augmented the patient. You do post-natal care visits in the hospital?

87.98A NTAM 650 (431.74 + 114.17) $545.91

03.01AA TNTA03 (43.65x 3)$130.95($676.86)

Billing Examples

Q11. New-born care in hospital, circumcision? 03.05G (first day) V30.0 $

70.33 03.05GA (subsequent days/day)

$ 40.58

In Alberta, the circumcision is uninsured.

Billing Examples

Q12. Evening admission on 2/11/10 at 2330, 72 year old, Dx CHF, 5 regular hospital visits, special evening (2100) special callback Sat 6/11/10 to reassess dyspnea. 03.04C HANTPM 428 (122.72 + 142.88) $265.60 03.01AA TNTP02 (21.83 x 2) $ 43.66 03.03D x 5 428 (40.58 x 5) $202.90 03.05R (2100) 428 $ 107.76 03.03DF 428 $ 40.58 03.01AA TWK01 $ 21.83 Use encounter 2 for Sat. callback ($682.33)

Billing Examples

Q13. Office visit, shave biopsy / desiccation of basal cell Ca < 1 cm, on the face? 03.03A 173

$35.92 98.81B 173 (Punch biopsy) $29.60

($65.52)

Note: 98.81B does not have a tray fee

Billing Examples

Q14. Office visit, patient concerned regarding a changing mole, excisional biopsy. 98.12M (+ tray) 216.8 (34.23 + 37.71)

$71.94(Removal of pigmented benign nevus) or

If unsure and decide to do excisional biopsy 98.12A (+ tray) (41.25 +37.71)

$78.96 03.03A $35.92

($114.88)

Should this billing be put on hold?

Billing Examples

Q15. A patient presents with a plantar wart and liquid nitrogen is applied? 98.12L 078.1 $20.45 03.03A 078.1 $ 35.92

($56.37) Don’t forget to bill the patient for the N2

Q16. A patient requests a visit for N2 treatment of a wart on their finger Can you bill the HCP for this? What should you bill?

Q17. Regular visit, diabetes and BP assessment, unanticipated crisis supportive psychotherapy for additional 22 minutes, marital strife? 03.03A CMGP02 250 (35.92 + 31.12) $ 67.04

or 08.19G x2 300 $89.80

Note: Assessment must have determined that patient is suffering from a psychiatric disorder

Billing Examples

Billing Examples

Q18. Attendance at labour, assistance at C.S. which took 1 hour, finished at 10 pm? 87.98B EV 656.3 (428.04 + 47.59)

$475.63 86.9C SA

$143.95 03.01AA TEV08

$174.64($794.22)

Q19. Assisting at elective hernia repair, 1 hour time, 10 am? 65.01A SA

$143.95

Billing Examples

Q20. Dr. on duty in ER, multiple systems assessment, 1 am, abdominal pain, NYD?

03.05ER CMXV20 789.0 (28.43 + 15.27) $43.7003.01AA TNTA02 $87.30

($131.00) or03.04H 789.0 $ 96.43Possibility CMXC30 modifier (30.56)

($126.99 if modifier applicable) 03.01AA TNTA02 $87.30

($183.73)

Billing Examples

Q21. Regular registered nursing home visit to assess a patient with dementia.

03.03E 290 $ 26.94

Billing Examples

Q22. During a periodic health exam you order a lipid profile. The patient’s lab has returned and is abnormal. You request a follow-up visit and spend 25 minutes educating the patient regarding their risk of ASHD and the treatment options for their abnormal lipid profile. O3.03A CMGP02 272 (35.92+ 31.12) $

67.04

Billing Examples

Q23. A postmenopausal woman who has been on continuous HRT for 4 years presents with breakthrough bleeding. You do an endometrial aspirate biopsy.

03.03A 627.1 $35.92 80.83B (+tray) 627.1(42.42 + 12.74)

$55.16

($91.08)

Billing Examples

Q24. A 44 year old male presents with a painful 2cm boil in the left axilla which you incise and drain.

98.03A (+tray) 680.8 (31.36 + 12.74)$44.10(I & D subcutaneous abscess )

03.03A 680.8 $35.92

($80.02)

Billing Examples

Q25. A patient receives their regular allergy shot from the nurse.

13.42A V07.1 $10.99 (Allergy injection)

Billing Examples

Q26. A 35 year female patient presents with a newly discovered breast lump. You do an appropriate exam and aspirate 3cc of clear fluid that is sent off for cytology.

03.03A 610.0 $35.92 97.81 (+tray) 610.0 (43.32 + 12.74) $56.06

(Needle biopsy breast) ($91.98)

How will bill differ if needle biopsy? No difference as above

Billing Examples

Q27. A patient with tennis elbow unresponsive to NSAIDS and physiotherapy is seen for follow-up and you decide to inject with cortisone.

03.03A 727 $35.92 95.96A ( for tray) 727 $12.74

($48.66)

Note 95.96A does not allow for visit in addition but need to bill to get the tray fee

(95.96A rate = $12.57)(Who pays for the cortisone?)

Patient is billed ~$10-15 separately

Billing Examples

Q28. You receive the bi-weekly INR results of a patient and instruct your nurse to call the patient to modify their coumadin dosage.

Can you bill for phone call advice? 03.01N $16.46

Management of anticoagulant therapy, two per month per patient

Billing Examples

Q29. A patient has seen you before and decides to return for the elective removal of a sebaceous cyst.

Is this an insured service?

98.12C (+tray) 706.2 (52.35 + 37.71) $90.06 (Removal of sebaceous cyst)

03.03A 706.2 $ 35.92

($125.98)

Billing Examples

Q30. A disabled hemiplegic patient with multiple concerns is seen in follow-up. You also complete a Disability benefit report for an Insurance company on their request. 03.03A 342.9 $35.92

CMGP01 if 15 m excluding report $15.56 Disability report - initial medical report &/or

Reassessment medical report$60 - 125 (patient responsibility)

Billing Examples

Q31.You have a flu shot clinic where 20 patients see your nurse for a flu shot.

13.59A V04.8 $9.58 (Note to bill this a physician must supervise) Total 20 patients $191.60

Third Party Billing

Billing WCB

Verify if work related problem Verify if patient is covered Bill WCB for professional service & form

completion It is fraudulent to bill AHW for WCB service

WCB Billing Examples

33 year old typist with evidence of lateral epicondylitis from RSI. 03.03A CMGP01 (35.92 + 15.56) $51.48 Initial report, (C050) (electronic) $58.07 BCP 01/02 X2

BCP01 All of Alberta except Calgary & Airdrie $2.82/unit BCP02 Calgary & Airdrie $3.33/unit

WCB Billing Example

Follow-up visit in 4 weeks, patient has form to fill in, steroid injection indicated 0303A $35.92• 95.96A $12.57• MINT (tray) $12.74

($61.23) Progress report (C051) $35.28 BCP 01/02 x 1

WCB Billing Examples

WCB requests a detailed report and copies of all consults, exams, investigations.

Summary of medical information, without opinion requested by WCB (RF05):

First 30 minutes

$127.01 Additional 15 minute increments

$49.41 Photocopying (RF08)

$0.43 per page

Canada Pension Plan - CPP

56 year old with severe RA applying for CPP brings in forms. You later spend 40 minutes preparing a 2 page medical summary. What should you bill CPP? Form / report completion $100

What are the CPP billing criteria? Based on time spent

CPP Billing Guidelines

Photocopied info and / or short report time spent < 15 minutes $25

Chart Review & Short typed narrative report 1-2 pages time spent 15-20 minutes $50

Full typed narrative, 2 or more pages time spent 40-45 minutes $100

Detailed typed narrative, 3 or more pages time spent 60 minutes $150

Non-insured Billing

33 year old seen for tonsilitis & requests sick note for 2 days 03.03A (AHW) $35.92 Form completion $50

Pilot seen for MOT exam Examination & form completion $260 - 450

Non-insured Billing

14 year old seen for camp physical with form completion Form only $50 Examination and form $130

22 year old requests N2 for wart on hand Non surgical treatment $55 -

100 Surgical removal $95 –

210

Non-insured billing

Phone request for prescription renewal $55 - 75

Request for removal of 7 skin tags individually set

Travel advice and Hepatitis A shot individually set

Medical Legal Reports

1.5 hours for chart review, report dictation and review, inclusion of 20 photocopies from chart Report $450 –

625/hour Photocopies (HIA) $25

Completion of Insurance Company Medical summary Report & examination $260 - $450