Medical Services Insurance
Program Billing Information
Session
General Surgery May 25, 2015
Relationships
• DHW
Sets health policy
• DNS
Negotiates fees with DHW via Fee
Schedule Advisory Committee
• Medavie Blue Cross
Medavie is subcontracted by DHW to
administer the MSI program; physicians
submit claims to MSI through Medavie
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Agenda
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General MSI overview
Visits
Common visit billing errors
Hospital admission and surgery
Review of premium fees
Procedure claiming processes
Common surgical billing errors
Overview of Claims
• Medavie Blue Cross has administered MSI since 1969
• More than 8M claims submitted annually - Physician
payments approximately $651M per annum
• Approximately 700,000 claims submitted per month - 5,900
to 8,600 of the total claims submitted are manually assessed
each month
• Approximately 80 calls per day
• Bi-weekly payments to physicians, optometrists, ancillary
providers and OOP/OOC claims submitted by
physicians/patients
• Support DHW and Doctors NS business initiatives i.e.
physician billing seminars, column in member magazine
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Important Documents
• Physician’s Manual:
- Billing rules in the section labelled “Preamble”
- Explanatory Codes
- Miscellaneous
- Health Service Codes (HSC) and fees
-Information on claims submission process
- Merged with Billing Instructions Manual September 2014
• Physicians’ Bulletins:
– MSI Administrative updates that indicate/clarifies
changes
– Master Agreement incentive program update
– provides pertinent information on assessment, fee codes,
billing guidelines, etc.
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Timing of Claims Submissions
• 90 days from the date of service to submit claims
• Exceptions can be made to allow submission beyond that
timeframe in exceptional circumstances
• 185 days to resubmit from the date of service
• Reversals can also be submitted as long as the original claim is
available in the production database (MSI keeps 3 years of data)
• Service to residents of other provinces must be submitted within 1
year of date of service
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Requests for OR Reports & Time Sheets
• When a claim has been paid at zero with error code
NR072 asking for an OR report, the original claim
itself also has to be resubmitted with an action code
of “R” for reassessment.
• Resubmit as per NR072 – ( R )
• Rebilling ( A ) always refuses as a duplicate claim
• OR reports without a resubmit results in the claim
being permanently ‘ held ’ and will not be paid.
• Same for time sheet requests GN052
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Methods of Claims Submission
Electronic :
FFS and Shadow claims are submitted electronically and
must be in accordance with the rules defined in the
Preamble section of the Physician’s Manual.
Manual:
OOP/OOC claims are submitted manually and are keyed
into the system in our office to generate payments.
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Methods of Claims Submission
Importance of Shadow Claim submission and timeliness:
• Data integrity:
in the interests of maintaining appropriate and
comprehensive records, you are encouraged to submit
these services in a timely fashion.
• Incentive and top up payments.
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Accurate Billing
• MSI data is used to capture services eligible for
incentives
• Reduces the risk of rejected claims
• Maximizes billings
• Reduces the risk of poor audit results
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Basics of Billing
03.03 A LO=OFFC
Health Service Code (HSC): The health service performed (may or may not be a
defined Canadian Classification of Procedures (CCP)
Qualifier:An alpha character appended to some HSCs to subdivide the code and
distinguish differences specific to the procedure.
Modifier: MSI adjudication system uses them to determine the payment amount of a
service encounter. They can affect payment by:
• Adding or subtracting an amount from basic fee
• Replacing the basic fee with a different amount
• Indicating role, time, method, age
Service Encounter: A transaction which describes the health service performed by the
provider to the patient.
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Visits
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Visits
• Evaluation of a patient either as a sole
service or in association with one or more
procedures
• Umbrella term: includes consultations,
directive or continuing care, ICU services, for
example
• Common set of rules, some specific rules
related to location, etc.
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Comprehensive vs Limited Visit
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Limited Visit
• Limited visit = limited assessment for
diagnosis and treatment of a patient’s
condition.
• Includes a history of the presenting problem
and an evaluation of relevant body systems
• Un-referred limited visit = 03.03
• Referred limited visit = limited consultation
03.07
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Comprehensive Visit
• In-depth evaluation of the patient
necessitated by seriousness, complexity or
obscurity of patient complaint or medical
condition.
• Requires complete history and physical
examination relevant to specialty and
working diagnosis
• E.g. family history, medications, allergies, ROS
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Comprehensive Visit
• Referred comprehensive visit = 03.08
• Un-referred comprehensive visit = 03.04
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Comprehensive Visit – Specific Situations
Office (03.04)
-for diagnosis of a new condition or
complications of an existing condition
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Consultations
• Requires a referral from a physician, nurse
practitioner, midwife, dentist or optometrist
• Comprehensive (03.08) v. limited (03.07)
• Requires a written report to the referring
provider
• Follow-up visits are claimed as continuing or
directive care
• Repeat Consultation – re-referral for same
problem within 30 days
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General Visit Rules
• When a visit is requested in one time period
and performed in another, it must be claimed
using the lesser of the two rates
• If the sole purpose of the visit is to provide a
procedure or injection then only the
procedure or injection may be claimed
• If the patient has never had a referral, claim
using GP rates
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Transferral of Care
• If care is transferred temporarily or
permanently from one specialist to another
neither a consultation nor a comprehensive
visit may be claimed
• Exception – medical necessity e.g. general
surgeon transferring care to a thoracic
surgeon
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Detention Time
• Commences 30 minutes after physician is
first in attendance for visit and after 60
minutes for consultations
• Claimed in 15 minute increments
• May claim either detention or other services
such as procedures during the time spent
with the patient, but not both
• For active, urgent medical treatment
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Detention time
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Many exclusions including:
Discussions with family
Waiting time
Time spent reviewing or completing charts
Office visits
ICU Care
More than one patient at a time
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Urgent Visit
• May be claimed when a physician travels at
the request of hospital staff to see a patient.
• Reminder – movement within a hospital does
not qualify as travel
• Location office – if the physician travels to
his/her office outside of 0800-1700h M-F at
the request of the patient. Cannot be billed
during scheduled office hours
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Case Management Conference Fee (HSC 03.03D)
A time based code that may be claimed for formal multi-disciplinary health
team meeting
• Meeting must be called by an employee of the Nova Scotia Health
Authority (or a Director of Nursing/Director of Care at a Long Term Care
Facility )to address a specific health concern for a specific patient
• Clinical record must include start and finish times and a list of all
physician participants
• Cannot be used for regularly scheduled rounds e.g. stroke rounds,
tumour rounds, M &M rounds, etc.
• Use for ad hoc situations e.g. complex discharge planning issue
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Billing for Services of Medical Trainees
• May claim for services of medical students
and residents provided the physician claiming
the service is present or immediately
available
• If services provided to separate patients
concurrently bill for one or the other but not
both
• May not claim for services provided by
nurses or nurse practitioners
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Common Visit Billing Errors
• No documentation
• Claiming a visit when the sole purpose of the
encounter was to provide a procedure
• Claiming a comprehensive visit/consultation for
limited and non-complex problem e.g. ingrown
toenail
• No physical examination – a required element of both
limited and comprehensive consultations and
comprehensive visits
• Both procedure and visit code claimed with no visit
documentation
Common Visit Billing Errors
• Claiming a consultation when there has been
no referral
• Claiming a new consultation for follow-up
visits
• Claiming a new consultation in transferral of
care situations
• Post-op hospital visits claimed by designated
covering physician
Hospital admission
and surgery
Pre-operative Care
• Surgical fee includes hospital admission and
pre-op care for two days prior to the surgery
• May bill daily visit fee if patient is in hospital
for more than two days
Intraoperative Billing
Method of surgical exposure may not be
claimed except for laparotomy & laparoscopy:
• When no other
procedure is performed
• When one surgeon
provides exposure so
that another can perform
a procedure
Multiple Procedure Rules
Multiple procedures – same physician
Through same incision or on one organ
• Principal procedure 100%
• Additional procedure 50%
Through multiple incisions or sites
• Principal procedure 100%
• Additional procedure 65%
Multiple Procedure Rules
• Laparoscopy considered
single incision
• Incidental procedures
(Appendectomy) performed
with another abdominal
procedure must be
supported by a pathology
report.
Multiple Procedure Rules
The bilateral procedure is claimed at 50% of
unilateral procedure
Bilateral Procedures - Same Physician
Bilateral procedures performed subsequent to a
different major procedure through the same
incision should be billed at 50% and 25%
Aortic aneurysm repair
100%
Right common iliac
endarterectomy
50%
Left external iliac
Endarterectomy
25%
Bilateral Procedures – Same Physician
Bilateral procedures performed after a
different major procedure through a different
incision should be claimed at 65% and 32.5%
Multiple Procedures- Different Physicians
Surgeon #1
Surgeon #2
Morbid obesity – BMI > 50
• May be claimed once per patient per
physician for major procedures
• Neck and hip surgery done by incision
• The trunk by laparotomy or laparoscopy
Cancelled Surgical Procedures
If a surgical procedure is cancelled
before it started
- claim regular visit fee
If a surgical procedure is cancelled after it
started
– claim for intended procedure (applies to both
surgeon and assistant)
Miscellaneous Billing Rules
• Add-on procedures – never performed
alone, paid at full fee
• Surgeries should not be unbundled
• Anaesthesia is not payable in addition to
the surgical fee
EC/IC Claims
Reasons for making these claims:
– Physician performs a service with no code
– Existing code does not compensate for the work
done in a specific circumstance
Compensation for these claims
– Rate of 100 units/ hour
– Exceptions - 130u/hr
– total abdominal wall reconstruction
– Laparoscopic sacral colpopexy
What to do if you don’t have a HSC to bill for a
procedure…
The Fee Schedule Advisory Committee (FSAC) is the only
standing committee of the Master Agreement Steering
Committee (MASG). The FSAC is responsible for making
recommendations to the MASG on matters pertaining to the
fee schedule.
• Applications for a new fee and fee adjustment are available on line
through the Doctors NS website
• Applications are accepted at any time of the year
• When an application is submitted, DNS will review the application to
ensure it is complete before it is forwarded to the FSAC
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First Surgical Assists
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Some major surgical procedures do not
allow for assist fees (Appendix E of MSI
Physician’s Manual)
• The surgical assistant is compensated at 33.8% of
the total surgical fee.
• The health service codes claimed for surgical
assistant services are expected to align with those
submitted by the primary surgeon.
Second Surgical Assists
• There are a few codes that have a
second assist modifier.
• Second assistants are compensated at
50% of fee paid to the first assist
• a letter from the surgeon is needed to
support second assist claim
In Patient Hospital – Post op billing
• Post op care for the first 14 days is included in the
surgical and assistant fee
• Neither the surgeon nor a designated covering
physician can claim visits
• Exceptions
• If the patient is sent home and re-admitted for nonsurgical care
• for complications not related to the surgery
• From day 15 onward visits can be billed
In Hospital - Post-operative billing
Surgery for a complication
requiring return to the OR
bill the new surgical procedure at full
the hospital stay is reset for the new surgical date
Premium Fees
An emergency basis - a service that must be
performed without delay because of the
medical condition of the patient.
35% (US=PREM)
50% (US=PR50)
not less than 18 units for patient specific
services
Premium Fees
Time Period Payment Rate
• Monday to Friday 17:00 - 23:59 US=PREM (35%)
• Tuesday to Saturday 00:00 - 07:59 US=PR50 (50%)
• Saturday 08:00 - 16:59 US=PREM (35%)
• Saturday to Monday 17:00 - 07:59 US=PR50 (50%)
• Recognized Holidays 08:00 - 23:59 US=PR50 (50%)
Common Surgical Billing Errors
Claiming procedures that are a necessary part of
an over-arching procedure
Common Surgical Billing Errors
• EC claims based upon total time in the OR
rather than just the surgical time
• Billing EC claims along with a specific
procedure code
Common Billing Errors
• Two collaborating
surgeons billing 100% for
same procedure
• Billing as assistant for
procedures done by a
colleague (two surgical teams
in OR doing different
procedures)
Common Surgical Billing Errors
Claiming for procedures that are not done:
• Drainage of abscess
• Code claimed is for more extensive surgery than
that performed
• omental biopsy vs omentectomy
• hysteropexy vs vaginal vault suspension
• Look alike codes are used when there is not an
appropriate code
• 46.2 – excision or destruction of mediastinal lesion
Stacking Errors – Type 1
Instead of using a single over-arching code, the
procedure is broken into components and
multiple codes are used
60.55
Hartmann
resection
60.52
Other anterior
resection
58.11
Colostomy
Stacking Errors – Type II
The overarching procedure code is billed as well as some of
the procedure components:
46.2 - excision or destruction of lesion or tissue of mediastinum
Submitted Billings :
46.2 – excision or destruction mediastinum
20.71 - Thymectomy
80.4 - Vaginal hysterectomy
Submitted Billings:
80.4 – vaginal hysterectomy
82.7 – obliteration of vaginal vault enterocele
Endoscopy
Depth of insertion is basis for payment
01.24B – proctoscopy ( 5 u)
01.24C – sigmoidoscopy ( 15 u)
01.24A – proctosigmoidoscopy – under 16 years ( 25 u)
Colonoscopy
01.22C – descending colon (40 u)
01.22D – descending and transverse colon (70 u)
01.22E – descending , transverse and ascending colon(100)
Operative colonoscopy codes
01.22A – biopsies
01.22B - polypectomies
MSI Website
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How to contact us
• MSI_Assessment@medavie.bluecross.ca
Physician’s Manual on-line at:
• www.medavie.bluecross.ca/msiprograms
• www.doctorsns.com
• MSI Assessment (902)496-7011
• Fax
(902)490-2275
• Toll Free
1-866-553-0585
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MSI Billing Education Session
Thank You!
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