Tricky Hospitalist Billing Scenarios

There are some common, yet unclear billing scenarios all physicians are due to encounter during their career. Here are some tricky hospitalists billing scenarios we have come across:

Assessment billing codes vs. consult billing codes

If the physician is called upon to see a patient because the most responsible physician (MRP) has stepped out then you should use your assessment billing codes (usually A007A) with the special visit premium. If the physician has a written referral to see a patient then you should use your consult billing codes (usually A005A) with the special visit premium. Any billing codes relating to consults can only be used if the physician has a written referral from another physician; otherwise it is considered an assessment.

Awaiting long term care (ALC) patient status

When a patient’s status is changed to ALC you should not bill for discharge (C124A), you should only bill for discharge if the patient is physically leaving the facility. On the last day the physician sees the patient and changes their status to ALC you should bill for a subsequent visit (C002A). If a patient with status ALC becomes sick and the physician begins to treat them again you should continue to bill for subsequent visit (C002A). When the patient physically leaves the facility to go to a nursing home then you should bill for discharge (C124A).

Multiple weekly visits (past 5 week stay)

If a patient  has been in the hospital for more than 5 weeks you should bill for subsequent visits using C007A (instead of C002A) which can be used to a maximum of 3 times per week. If the patient becomes very ill and the physician needs to see them more than 3 times per week then the physician can; but they will not get paid for more than 3 subsequent visits in a week. However, if the patient becomes ill with something other than what the physician was initially treating them for then you can bill for intercurrent illness (C121A) and there is no maximum limit on that code.

Patient passing

If a patient passes the MRP can bill for discharge (C124A). If a physician has pronounced a patient dead for which he is not the MRP you should bill for pronouncement of death (C777A).  This may include filling out the death certificate and visiting with the patient's family but are not required to bill for pronouncement of death. If another physician pronounced the patient dead and the physician only fills out the death certificate then you bill for certification of death (C771A). You cannot bill C777A or C771A with other billing codes.

Breaking down the common family practice billing codes

The Section on General & Family Practice of Ontario (SGFP) release an up to date document of Common Family Practice Codes (2011 version) each year. Sometimes the descriptions on this document aren’t enough for physicians and medical staff to decipher which billing code to use. The purpose of this blog entry is to break down the Common Family Practice Billing Codes so it can be better understood. Download the document as I will be referring to it in this blog, so hang in there and follow along closely.

The first four codes on the document are A001, A007, A003 and A004; these are your office visit codes. Typically for most office visits you would use A007. Note that A003, a full assessment, can only be billed twice per year per patient, each time with a different diagnostic code.

The next following four codes, K130, K131, K132 and K017 are your periodic health visit codes encompassing educational discussions.

A008 is the billing code which is supposed to be billed with WSIB claims. For example, if you are examining the patient for an injury which occurred on the job but they also happen to have another unrelated health concern which you examine at the same time, you can bill A008.

A888 can be billed (instead of the typical A007) when you see a patient during weekends/holidays whether it is scheduled or unscheduled. Note that this code can be used for weekday visits from Christmas to New Years, which you should take advantage of as the pay is higher! Immediately after A888, you have E080 which is a premium you can bill if you are seeing a patient that has been discharged from the hospital within the past two weeks.

After there is a block of K billing codes, K005, K002, K007, K013, K033, K623; these are your counseling codes. There isn’t a great distinction between K005 and K007, where you provide less formal listening and support. K002 is what you bill if you are talking with an authorized individual regarding directives for the patient. K013 is what you bill if you are building a therapeutic relationship with the patient by providing educational dialogue. K013 can only be billed 3 times in a year (max) per patient, after three times of using this code start billing K033.

Following there is another group of K codes, K050-K056, which are your form codes. These are the billing codes you use to fill out various different forms for patients.

A901 and A902 are your house call billing codes. K070-K072 are your homecare billing codes.

I won't be covering hospitalist billing as this was covered in our previous blog entry. 

For long term care all you would bill is W010, which covers two visits per patient per month. W010 covers a wide range of services, see the ** note corresponding to this code on the bottom of the page- that's why you generally bill W010 only. 

For obstetrics you will use your P billing codes. Generally you would bill P005 + P003 or P004 for giving the integrated prenatal screening discussion/education. You can only bill this once during the pregnancy. Typically after the initial prenatal screening process you would bill P004 for the entire pregnancy.

Office procedures are pretty straight forward but make sure you don’t miss out on billing E542, the tray fee, this can also include using the autoclave on your instruments.

This information can be found in the Schedule of Benefits released by the MOHLTC.

For those interested, Mo-Billing App actually provides an electronic platform where you can collect, store, deliver (to your billing agent) and retrieve all your billing information. You can simply create claims on the go and have most of your fee codes auto-generated for you depending on your type of practice.

On the app, all hospitals and diagnoses are searchable so you don't have to worry about memorizing any codes. Furthermore, to save time you can take a picture of the patient sticker rather than typing out the patient information.  Read more about the app at www.mo-billing.ca. Or you can create an account for free at http://app.mo-billing.ca.

OHIP Billing how-to: Hospitalist billing, as easy as pumpkin pie

Yesterday, I baked a pumpkin pie from scratch. It was very good. (Even the nurses agreed, so it has to be true). Yet I don't know why they say " it's as easy as pie". Making a pie isn't that hard, but I wouldn't say it's easy either.

Just like baking a pie, the hospitalist billing is not hard, but it takes some getting used to.

In a nutshell, this is what you do.

1. Hospital number

First you need to know what your hospital number is. Here is a government list of all the hospital numbers. If you are a big shot doctor working in a big shot hospital, you might have multiple numbers. Often times the hospital designated with the AT code is the one you want. (On page 5 there is an index for all the codes).

For example for The Ottawa Hospital, Civic site the choices are shown below:

 OTTAWA HOSPITAL ( THE )-CIVIC SITE AM 4079

 OTTAWA HOSPITAL ( THE )-CIVIC SITE AT 4046
 OTTAWA HOSPITAL ( THE )-CIVIC SITE MH 4546

You would most likely  choose 4046 since it is designated with the AT code. Our app will have a searchable list whereby simply typing in a keyword (Or even a few letters!) will give you the proper hospital number you are searching for.

2. Diagonsis code

Next you need the diagnosis, this is not any different from other billing. Again our app will have a searchable list.

3. Billing codes

You need to enter daily billing (fee) codes as per the following scheme:

Day of admission: C933A + E082A
"Day 1": C122A + E083A
"Day 2": C123A + E083A
Days in between: C002A (up to 5 weeks) + E083A
Discharge date: C124A + E083A

Here is the explanation: C933A - admission assessment. You were called down to admit this person. You have to do the whole history/physical and the dreaded dictation. Good for you! You get to bill this code (currently $79.90). E082A is a 30% premium you can apply to C933A for being the "most responsible physician (MRP)" for the patient that day.

C122A, C123A and C124A is for day 1, 2 and discharge, respectively. The government assumes that recently admitted patients as well as patients to be discharged require more attention from the physician so they will pay you more on these days (currently $58.80). E083A is a 30% premium that can be used for all days other than the admission day.

Finally, C002A (currently $31.00) is used for the days in between "Day 2" and the discharge day. You are a smart doctor, you have figured it all out and the time spent between "Day 2" and the discharge date is simply waiting time while the patient gets better. Well... most of the time at least. Again don't forget the E083A premium code with the C002A codes.

For those interested, Mo-Billing App actually provides an electronic platform where you can collect, store, deliver (to your billing agent) and retrieve all your billing information. You can simply create claims on the go and have most of your fee codes auto-generated for you.

On the app, all hospitals and diagnoses are searchable so you don't have to worry about memorizing any codes. Furthermore, to save time you can take a picture of the patient sticker rather than typing out the patient information. We have also implemented a feature that will auto-generate your most common fee codes for you given you enter the admission date, the first day you saw the patient and the last day you saw the patient. Read more about the app at www.mo-billing.ca. Or you can create an account for free at http://app.mo-billing.ca.

A real example

Patient Joe Smith was seen at the lovely Civic Hospital for pancreatitis (a little excess with the holiday "spirit"!).  Showed to the ER on Dec 28, admitted Dec 29 and discharged Jan 3rd. The following is the complete set of info one needs to bill for this admission:

Patient name: Joe Smith
DOB: 5-5-1955
OHIP:###########ZZ
Admission date: Dec 29, 2013

Hospital code 4046
Diagnosis code 577

Dec 28: we don't care what ER docs do :), your billing starts on Dec 29.
Dec 29: C933A + E082A
Dec 30: C122A + E083A
Dec 31: C123A + E083A
Jan 1: C002A + E083A
Jan 2: C002A + E083A
Jan 3: C124A + E083A

Enter this information into your favourite billing program or give it to your billing agent.

Stay tuned as we will be posting the billing practice to use in more complicated, yet common, scenarios.

We are on Twitter

We are now on Twitter, you can follow us on @MoBillingFo8!

Uninsured Services Medical Billing

Sometimes there can be confusion on what an uninsured service is, therefore the goal of this blog entry is to clarify the definition of uninsured services and to provide input on how to deal with uninsured services.

Any service which is not paid for by OHIP is considered an uninsured service. This includes any services which are not paid for by WSIB (see my previous blog entry).  These uninsured services are expected to be paid for by the patient. While there are several examples of uninsured services, the most common uninsured services doctor’s are faced with are requests initiated by third parties. Third parties exist in the form of insurance companies, law firms, employers; essentially any person/organization other than the patient. These third parties often request the completion of forms or reports pertaining to their client (your patient), which are categorized as uninsured services.

At times the definition of uninsured services may not be adequate enough in determining how to deal with a certain situation. For example, if the physician must examine the patient in order to complete a form requested by a third party, the examination in addition to filling out the form is an uninsured service and OHIP should not be billed for either. However, if the physician so happens to come across a medical problem during the examination which deems the examination to be a medical necessity, they can bill OHIP for the examination but not for the completion of the form. There always exist exceptions to rules. You can easily determine whether or not to bill OHIP for the service by asking yourself : “was the service medically necessary?”, if your answer is yes then bill OHIP for the service but continue to bill the patient (or third party) for completion of the form.  Another good example is the transfer of medical records- if a patient requests to have their records transferred to another physician and it is not medically necessary, the patient should be charged.

Setting up a fee schedule:

Third party requests are seemingly increasing; everyone seems to want patient reports. Schools for trips, employers for pre-employment assessments, license organizations for issuing licenses, etc. With uninsured services coming up so often, it is essential that an appropriate fee schedule for uninsured services be established. The OMA provides suggested rates for uninsured services and recommends that if you deviate away from their suggestions to be sure you are able to validate the rates chosen for uninsured services, as excessive prices can be considered professional misconduct.  TIP: Seriously check out the OMA suggested rates for uninsured services because you will probably notice some services you have been providing which you should be charging for.

Alternative to on the spot uninsured service charges:

A physician can setup Block Fees with their patients which encompasses a flat fee charged to the patient for a number of predetermined uninsured services during a predetermined amount of time. The amount of time must fall within 3-12 months as per the College of Physicians and Surgeons of Ontario (CPSO) policy. The CPSO provides some important pointers physicians must keep in mind if they choose to implement block fees. For example, patient’s with or without block fees should not get preferential treatment.    

Some useful scenarios:

Patient that cannot afford to pay

The OMA recommends to try to avoid such situations by discussing uninsured fees with the patient before providing the service. Even with a warning, the physician must consider the burden the uninsured service may place on the patient and should be willing to provide options (ie. cost reduction, payment plan).

Third party requests for patient information

Third parties often get their clients (your patients) to sign waivers or consent forms for the release of their medical records. Patients often misunderstand this as consent to release only their medical records pertaining to the one specific injury corresponding to their claim when really they have given consent to release their entire medical file. When third parties call in and provide proof  of this consent, contact the patient first and make sure they understand that you are going to release their entire file. If they are uncomfortable with that, the patient is allowed to withdraw the waiver or consent previously given.

A couple tips:

1.      There are only two government forms which are billable, the Disability Medical Report Form and the Narrative Medical Report (requested for CPP purposes) - all other government forms are not billable, they are the doctor’s responsibility as part of the community.

2.      Insurance companies can be real pushy and sometimes they send a cheque to cover their request- by accepting this cheque you have let them set your fees. Do not accept their cheque and send them your rates and estimated time in advance. Make sure you get pre-authorization for coverage, signed and returned. This approach applies to most third party requests.

3.      Keep patients informed of uninsured service fees; if they are consistently reminded there is no reason for any misunderstandings.

Some common uninsured services:

-          Sick notes for employers or school

-          Medical-legal reports

-          Insurance report forms

Useful contacts:

OMA 1-800-268-7215                     CPSO www.cpso.on.ca

 

Note: All this information was obtained from documents made publicly available by the CPSO and OMA. We are not to be held liable for any occurrences that arise from following our understanding of uninsured services medical billing.

Business cards, T-shirts

After comparing a few services, we decided to go for Vistaprint.ca to order our business cards and t-shirts, especially in preparation for the upcoming FMF.

Overall it makes a decent product for a decent price. (I have ordered their business cards and stamps in the past for my medical prof. corp.) However, I have to say they really need to work on their website. For instance, when one changes the text on the business card, it will not update it right away on the "on-line proof" stage. How can you proof it if you can't see the updated text? However, the updated text will eventually make itself home in the business card on next stage after you proof the "un-updated" text.

Or what about the fact that after spending 30 minutes on a t-shirt design, you can only order it in one size. You cannot order 2 in medium size and 2 in large size. Or let's say now you want to use the same design but change the t-shirt for "women's t-shirt". Not only does it cost more than a "men's t-shirt" you have to start the whole designing process again! Of course, you can order as many women's shirts as long as they are all the same size! If you want a different size, be prepared to repeat the whole designing process.

Anyhow, it still is more convenient than having to drive to a shop and go back and forth over a few days to design a business card or a shirt. I would give 3 stars out of 5, given all the problems with the web user interface.

Here's some teasers, but for the real shirts (and the real models!) meet us at the FMF!

Men's

Women's

Workplace Safety and Insurance Board (WSIB) Medical Billing

The purpose of this blog entry is to clarify when and how doctors should be billing WSIB (formerly known as Workers Compensation Board (WCB)). In this blog I will assume that you have a basic knowledge of medical billing. If there is anything you need clarification on, please feel free to contact us.

From what I understand, part of the WSIB role is to provide lost wages to workers who have been injured on the job and to assist those workers in the “return to work” process.

In order to distinguish whether you are to bill the Ministry of Health and Long Term Care (MOHLTC/OHIP) or WSIB you must identify whether the patient was injured on the job.  If the patient implies in any way that their injury occurred at work you should be billing WSIB. To bill WSIB, you would still proceed to bill OHIP the exact same way as you would if the injury didn’t occur at work however, you should bill under WCB rather than the commonly used HCP (Health Care Pool). In addition, you will need to fill out some initial forms/reports and submit them to WSIB.

NOTE: Physicians should register with the WSIB in order to receive their unique 9 digit number which is to be used on reports. This number is important as it serves as your invoice to WSIB. When you submit a form/report you will be paid by WSIB using this 9 digit number.  

The forms that are commonly completed when you have a patient injured on the job are Health Professional Form 8 (first report), Progress Report Form 26 (only if requested by WSIB), and Functional Abilities Form (FAF) for timely return to work (requested by employer/employee but paid to be completed by WSIB). As a tip, all three forms can be mailed/faxed/electronically submitted but for electronic submission the pay is higher (ex: Mail- $65 vs. Electronic-$85) which is a nice incentive to go paperless. You can also be asked to do a telephone interview, an in person interview or to write a narrative report; of course you are paid for complying with any of these requests.

Some useful scenarios:

Patient with no MOH number

You get a patient that was injured on the job, and you go to submit the claim to OHIP under the WCB category when you realize the patient does not have a Ministry of Health (MOH) number. In this case you would bill WSIB directly using their Provider Payment Request Form. Indicate on the form why you used the form (ex: No MOH number).

Providing uninsured health care to patient injured on the job

If the patient was injured on the job and requires uninsured health care (anything not covered by MOH) then you can fill out the WSIB Provider Payment Request Form to get pre-approved for payment from WSIB for the uninsured health care you will be providing. WSIB will most likely provide you with fee code to use to bill for the uninsured health care.

Patient does not want to claim WSIB

If the patient implies in any way they were injured on the job, but they decide they do not want to submit a claim to the WSIB then they must incur all medical costs. You cannot bill OHIP under HCP. This isn’t uncommon as some patients are afraid of submitting a claim in fear of the consequences of their employer.

A couple tips:

1.      When a worker is injured on the job either the injured worker (the employee) or the employer can file a claim with the WSIB. As soon as the claim is filed it is implied that the patient provides consent to the WSIB to seek out all medical records required to adjudicate the file. Physicians take note of this and pass on the message to your staff. When the WSIB calls for the relevant patient records, you do not need to acquire your patient's consent prior to providing the information to the WSIB.

2.   Be aware- if the employer or the injured employee has not submitted a claim to the WSIB but you still proceed to bill WSIB and fill out the applicable forms, you will not be paid. WSIB must match your claim with a claim entered by the injured employee or employer.

3.      All provinces have their own WSIB or its equivalent. You should be billing the WSIB of the province within which the employer is located.

Note: All this information was obtained from documents made publicly available by the WSIB and MOHLTC. We are not to be held liable for any occurrences that arise from following our understanding of WSIB medical billing.

Figure of Eight Inc.

We are incorporated as of Sep 5!

Just in case you're confused, Figure of Eight Inc. is our official company name. Mo-Billing is the app name.

Facebook page

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https://www.facebook.com/mobilling.fo8
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Upcoming Event

Nov 7-9: Family Medicine Forum 2013

November 7th-9th we will be attending the Family Medicine Forum in Vancouver. We will have a table set up to showcase most likely our finished product, if not we will be showcasing our latest version closest to the finished product. We will post pictures and provide an update on how the conference went when we return.

Mo-Billing App: Progress Report 1

You have now seen some screen shots of our in-house made prototype. The prototype was used for proof of concept, and yes, we did prove our concept would work!

Using the prototype software created by myself, Caleb Chan and Bradley Jung, a group of Carleton University Engineering students, we were able to successfully bill OHIP a significantly large test batch of claims. Pil was the so called "lab rat" in the experiment, as it was his batch of claims we tested the prototype on. I did all the behind the scene submission to OHIP. Since it was my first time submitting claims to OHIP, I really learned a lot on the subject of OHIP billing, mostly for hospitalist work. Pil taught me the basics and I learned a lot through research and continuous contact with the MOHLTC (I'm sure they found my phone calls annoying). I will be sharing this information with you in due time.

Now that we've proven our concept to work we are in the process of creating our marketable version. This will be created by Jevin Maltais, the founder of Quickjack Solutions, a company with expertise in building web and mobile apps. Together with Jevin, and based on our prototype work we have scoped out and planned our marketable version. Below is a teaser, showing part of the mock-ups that resulted after 2-weeks of intensive discussions/meetings and multiple iterations.

An Introduction to OHIP billing

Most residents get some exposure to billing. During my residency, I was mostly exposed to family medicine clinic billing. A007 billing code was used to bill for most things, A001 for a simple prescription renewal, A003 for a periodic health exam... it was pretty simple.

The simplicity quickly disappeared once I started working in areas other than family medicine clinics. Nobody ever taught me how to go about emergency room billing or hospitalist work billing. I tried to find some resources, but couldn't seem to find anything helpful. I ended up learning by trial and error, some of which was quite painful. I hope that this series, an OHIP billing guide, will shed some light and give direction to those who must deal with the wonderful world of OHIP billing.

Billing Methods

The newly minted doctor needs a few things to get paid. You need an accountant. You need a financial advisor. You need an OHIP billing number, CPSO number, WSIB number; the list goes on and on...  Finally the doctor must decide how they want to go about their billing. There are two options: do-it-yourself (DIY) or hire a billing agent; both of which I will attempt to explain.

DIY option

The DIY option, which I have done in the past, is a difficult route given the little guidance I had available, but you learn a lot from the process. First, you need to get an EDT login and password. Second, you need a software where you can type in the patient info (name, DOB, OHIP #) as well as the diagnosis/billing codes. The software is used to churn out some text file that the government processing computer can understand.

Then comes the fun, archaic and techy part. You login to the EDT server via a modem (yes, a modem, like the old 90s dial up modems- remember those?) That means you need a computer with a modem which is a rarity these days, or you can buy a USB/PCI modem and plug that into your computer. Great, now you've logged into the EDT server with DOS user interface, which you haven't seen since probably high school. You navigate through the menus and upload the text file your software just made. The government looks at the file and will either filter out any obvious errors (like a DOB or OHIP # mismatch) or let the claim through. Ah, but you're not done yet. The government might still reject your claim if you used the wrong billing code or if you break one of the rules the government has set (for example, you cannot bill C007, a subsequent visit on weeks 6-13 for hospitalist work, more than three times a week). You will be notified about your claim rejections via the "Remittance Advice", a sort of summarizing report they give you every month. Hopefully most of your claims go through and you still get a cheque, but you also have to work through your rejections. Now the rejections get submitted on paper, yes paper, hand written and faxed or mailed.

Doesn't it sound complicated? It is, especially learning and doing it right the first time. Does it take a long time to learn the process? Yes it does. Do you like tedious data entry? Probably not. This is why most people choose to go with a billing agent who will do this work for you and make sure the rejections/errors are taken care of. Most of the time the expense is worth it. When I do hospitalist work, I could recuperate the billing agent fee, usually by avoiding one patient claim that doesn't go through for whatever reason. (Often times, the problem is not processing the rejections/errors within the time limit. OHIP gives 6 months from the date of service.)

Billing agent option
 
Once you find a good reliable billing agent you have to keep a record of all your billable services. In terms of patient data, you basically need the patient's name, DOB and OHIP #. For your service, you need the date (on which you gave the service), diagnosis code and billing code. You write all this down on a piece of paper (many people use 3x5 index cards on which they may stamp the patient's hospital card for instance.) Or if you have a receptionist at the clinic, often times they will prepare a list of patients with their data with a blank line for you to write the diagnosis and billing code. When you have a billing agent, you arrange a time and place to meet the billing agent. You pass off your records and the billing agent does the processing work, as well as deals with rejections/errors for you. Just as in the DIY option, you get a cheque from OHIP in your mailbox the next month. The billing agent takes a cut from this payment, usually about 4% (range I have seen is 2.5% - 5%).

Some common scenarios

For new graduates, this whole billing agent thing is some kind of black magic. Some clinics will offer to do the billing for you but you could also do it yourself. What happens if you work at two clinics? Three clinics? Or God-forbid you become a career locum tenens, working in a different clinic every month, week or even every day? Who looks at the monthly Remittance Advice to reconcile claim rejections from all the places you work at? Without a billing agent of your choice, one of the clinics, responsible for your billing, will be receiving and dealing with your monthly Remittance Advice and unless you work there often they might not put a lot of effort into making sure you get paid for the work done elsewhere.

In terms of hospitalist billing, it is mostly left to the doctor. The doctor is responsible for collecting and keeping daily patient records. This is one area of work where the doctor would benefit from a billing agent the most. ERs usually work as a group practice and have one billing agent working for the entire group.

That was somewhat of an oversimplified review of how billing gets done for most people. On the next installment we will try to get into the details of some billing situations.

Logos, logos...

I just spent an hour at cooltext.com which is an awesome site where you can freely create logos of different pre-design and then tweak with what seems to be hundreds of cool fonts.

Here are few entries... some of them quite hilarious.

First, "I am a teenager and I am building a website." Burn baby, burn!

Oh yeah, tough billing!

This one I like, it's cute.

Bling Metallica? 

Real cute.Spelling mistake makes it look like "Mo-Bling"

Hmm...

Irish anyone?

Shrek gone Mo-Billing

Death metal Mo-Billing

The latest entry... ho hum...

Figure of Eight Inc.

We have started incorporation process. Ron Mckenna from Cognition LLP is helping out with the process. Our company will be called Figure of Eight, after one of the most secure and practical knots out there and used by rock climbers day in, day out.

We are in the process of hiring an accountant. A graphic designer is in negotiation to create a beautiful logo.

Things are moving!

Screenshots from our android prototype

Here is some screenshots from our android prototype. Kudos to Mr. Caleb Chan, Mr. Bradley Jung and our tech lead, Suzan.