Alberta Health Care
Insurance Plan
AHCIP
Claim Submission Seminar
GI Group
Jeffrey P Schaefer, MD
January 25, 2012
Objective
• Know the anatomy of an AHCIP claim
• Know the common situations
1. Comprehensive Consultation
2. Minor and Repeat Consultation
3. Hospital Visits
4. Emergency Detention
5. After Hours Time Premiums
6. Conferences
7. Office Visits
8. Telephone Consultations
9. Telephone Calls from Allied Health Care
10. Procedures
billing.schaeferville.com
• Sources of Truth - 5 documents to download
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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
What's Needed?
• 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 for some Services
– 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
– 03.03F office / clinic 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 (you write this in)
• up to 3 with any HSC may be submitted
Implicit Modifier Categories
• LEVL (level.... relates to admission date)
– INMDH1, INMDH2...
• SKLL (programmed into software once)
– INMD, GAST, OBGY, HEME
• AGE (calculated from PHN or DOB)
– G75 (age surcharge)
Relevant Explicit Modifier Categories
MD must supply these
• CARE (complex patient care)
– COMX, CMXC30, CMXV15, CMXV20
• SURC (services unscheduled)
– EV, NTPM, NTAM, WK
• SURT (after hours premium: 03.01AA)
– TDES, TEV, TNTP, TNTA, TWK, TST
• BMISRG (body mass index > 35)
• LVP (repeat procedures): LVP75, LVP 50, ADD, ADD2
• TELE (telehealth): TELES
procedure list
price list
Comprehensive Consultations
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
Governing Rules… sample
Unscheduled Service (SURC)
03.08I Prolonged Consult 30’+
Minor / Repeat Consults
Hospital Visits
COMX
After Hours Time Premium
– this is a Health Service Code per 15 min or major portion thereof
– hospital care provided outside of regular hours (08-17 M-F)
– requires a SURT modifier (e.g. TDES, TEV, TNTP, TNTA, TWK, TST)
After Hours Time Premium
03.01AA + explicit modifier x number of 'calls'
Test your skills…
Claims
• Consulted for obese (BMI 36) pt with GIB
– ED MD called at 2145
– saw pt at 2230 - 2315 (45 min)
– gastroscopy 2345 - 0045 (1 hr)
– banding x 3 esophageal varices
Services?
•
•
•
•
Comprehensive Consultation
Endoscopy
Banding of 4 esophageal varices
After hours time premium
Claim?
• 03.08A
• 03.08I x 2
• 01.14
•
$156.08
$115.40+25%
$35.35 x 3
= $250.03
$42.84 x
$1,211.70
Transfers of Care
Transfers of Care
Not for GI... whose your AMA rep?
Emergency Detention per 15 min
- series of codes here… resuscitation
• needs supporting text… e.g. patient in
respiratory failure / distress.
Office Visits
INMD: 15, 30, eligible
Prolonged Office Visit
Not for GI… yet
MD to MD Advice
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.
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: jpschaef@ucalgary.ca
– codes you use
– questions / concerns
– tips