Alberta Health Care
Insurance Plan
AHCIP
Claim Submission Seminar
New Members
Jeffrey P Schaefer, MD
July 14, 2010
Objective
• Know the anatomy of an AHCIP claim
• Know the common situations
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Comprehensive Consultation
Minor and Repeat Consultation
Hospital Visits
Emergency Detention
After Hours Time Premiums
Conferences
Office Visits
Telephone Consultations
Telephone Calls from Allied Health Care
billing.healthlearner.com
• Sources of Truth
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Medical Governing Rules
Medical Benefits Procedure List
Medical Benefits Price List
Fee Modifier Definitions
Explanatory Code List
http://www.health.alberta.ca/professionals/somb.html
http://www.health.alberta.ca/professionals/fees.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
– 03.03F
– 02.82A
– 03.01AA
comprehensive consultation
hospital visit
office / clinic visit
transesophageal echocardiogram
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 (you write this in)
• up to 3 with any HSC may be submitted
Implicit Modifier Categories
programmed into the billing software
establish your SKLL code (once)
• LEVL (level)
– INMDH1, INMDH2…
• SKLL
– INMD
• AGE
– G75 e.g. 03.03A
Relevant Explicit Modifier Categories
physician must supply these
• CARE (complex patient care)
– COMX, CMXC30, CMXV15, CMXV20
• SURC (services unscheduled)
– EV, NTPM, NTAM, WK
• SURT (after hours premium: 03.01AA)
– TEV, TNTP, TNTA, TWK, TST
• TELE (telehealth)
– TELES
• There are several others relating mostly to procedures…
Comprehensive Consultation
• HSC = 03.08A
– Possible 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
Procedures List
Price List
Possible Surcharges for the 03.08A
(from the Price List)
Minor Consultation or
Repeat Consultation (< 180 d)
(same price)
Comprehensive Geriatric Assessment
03.08A + CMXC30 + 03.08I vs 03.04K
1.5 hours is break point
less  03.08A more  03.04K
• 2 hour consultation
– 03.08A + CMXC30
– 03.08I x 4 (max)
$183.86 + $28.70
42.94/15min = $171.76
Total = $384.32
– 03.04K + COMGER
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$300 + (2 x $50)
Total = $400
Hospital Visits
• 03.03D . . . . . . . . . . . . . . . . . . . $51.25
– Hospital Visit
– Modifier: COMX (20 minutes) add $36.90
CARE (COMX)
$36.90
Transfers of Care
• 03.03D + TOC
• 03.03AO: hem, gim, medonc, endo…
Emergency Detention per 15 min
bedside attendance
• needs supporting text… e.g. patient in
respiratory failure / distress.
• After Hours Time Premium 03.01AA
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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
Office / Clinic Visits
• 03.03F
– Repeat office or scheduled outpatient visit in a
regional facility, referred cases only
INMD: 15, 30, eligible
Prolonged Office Visit
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
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
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.
ARP Codes
• Codes paid at $0
• A couple might be useful…
Audits...
Diagnostic Codes
• ICD-9 codes
• see billing.healthlearner.com
Category Codes
Summary
• email me:
– codes you use
– questions / concerns
– tips