Alberta Health Care Insurance Plan

Transcription

1 Alberta Health Care Insurance Plan Number: Med 127 Date: December 18, 2007 Page: 1 of 3 Subject: Schedule of Medical Benefits amendments/other claim submission infonnation Reference: Schedule of Medical Benefits/ Explanatory Code ListlFacility Listing To: all practitioners and hilling staff Schedule of Medical Benefits amendments In accordance with the Physician Services Agreement and discussions between the Alberta Medical Association, the Regional Health Authorities and Alberta Health and Wellness, amendments are being made to the Schedule of Medical Benefits. Some amendments are retroactive to July 1,2007 and are detailed in Attachment A of this Bulletin. Other amendments are effective January 1,2008 and are detailed in Attachment B. New and amended text is shown in bold print. The January 1, 2008 Schedule will be posted on the Alberta Health and Wellness website as soon as possible at The Alberta Medical Association website at will also contain a link to the Schedule. Your accredited submitter will receive details of these changes in order to provide you with required updates. If you wish to obtain a CD-ROM or hard copy of the revised Schedule from Alberta Health and Wellness, you can fax a request to Please include your Practitioner Identifier number (PRAC 10) with your request. Billing note re: special calls to emergency room, advanced ambulatory care centre (AACC) or urgent care centre (UCC) When an emergency room physician is called in early for a scheduled shift or called in to work due to an emergency or because beds have become available, a special callback (health service code 03.03K, 03.03L, 03.03MA, 03.03MB) may be claimed if appropriate for the first patient seen. However, if a procedure is perfonned on the first patient, a procedural benefit with the applicable unscheduled service benefit (modifier SURC) should be claimed for the first patient. Claims for second and subsequent patients should use scheduled rotation duty visits (03.05CR, 03.05DR, 03.05ER, 03.05F or 03.04F, , 03.04H) or the procedural benefit plus the scheduled rotation duty off-hours benefit (modifier SURC-prefix RD). Contact: Client Services Branch Approval: Telephone: Local Toll Free Position: Executive Director Client Services Branch Fax:

2 Number: Med 127 Date: December 18, 2007 Page: 2 of 3 Subject: Schedule of Medical Benefits amendments/other claim submission information Reference: Schedule of Medical Benefits/ Explanatory Code List/Facility Listing Revised explanatory codes Please update your explanatory code list to reflect the text changes shown below. Changed text is indicated in bold print. These changes will be reflected in the explanatory codes section of the January 1, 2008 Schedule of Medical Benefits. 37 BUSINESS ARRANGEMENT The Business Arrangement number on the claim: (a) (b) (c) (d) (e) (f) is invalid or blank or is restricted to performing specific services or is restricted to performing services at a specific facility or is not registered with the Submitter of the transaction or does not have a relationship with the Practitioner Identifier (PRAC ID) submitted or is restricted to patients from a specific area. 37A PRACTITIONER IDENTIFIER (PRAC ID) The Service Provider ID (PRAC ID) field is blank, invalid or not effective for the date of service submitted. 45 INVALID REFERRING PRACTITIONER IDENTIFIER (PRAC ID) The Referring Practitioner s Identifier (PRAC ID) on the claim is (a) (b) (c) blank or invalid or not an intraspecialty or from a practitioner without the appropriate discipline or skill 45AA REFERRAL PRACTITIONER IDENTIFIER (PRAC ID) INVALID UNABLE TO RESOLVE Your claim has been refused as the Referral Practitioner Identifier (PRAC ID) is invalid. Contact the referring practitioner for the correct Practitioner Identifier (PRAC ID). 48 PRACTITIONER IDENTIFIER (PRAC ID) This claim was refused as the Practitioner Identifier (PRAC ID) cannot be changed. Delete the original claim and submit a new claim with the correct Practitioner Identifier (PRAC ID). 60E EMERGENCY DEPARTMENT/AACC/UCC VISITS Payment was refused as: (a) another physician has claimed for the same service. Submit a new claim with a DSCH modifier according to General Rule 5.1 or (b) Health service code 03.05F cannot be claimed by the same physician who provided the initial assessment prior to determining the disposition status of the patient.

3 Number: Med 127 Date: December 18, 2007 Page: 3 of 3 Subject: Schedule of Medical Benefits amendments/other claim submission information Reference: Schedule of Medical Benefits/ Explanatory Code List/Facility Listing Revised explanatory codes (cont.) 60EA CRITICAL CARE EMERGENCY DEPARTMENT/AACC/UCC VISIT Payment was refused as the information/diagnostic code provided does not support payment under this Health Service Code. Submit a new claim with the appropriate emergency department/ AACC/UCC visit. 60EC SPECIAL CALLBACKS TO AACC/UCC HOSPITAL EMERGENCY OUT-PATIENT DEPARTMENT Payment was refused according to General Rule 5.2 in the Schedule of Medical Benefits or General Rule 17 in the Schedule of Oral and Maxillofacial Surgery Benefits. 65 NON-INVASIVE DIAGNOSTIC PROCEDURES IN HOSPITAL, AACC OR UCC Benefits for non-invasive diagnostic procedures performed for a hospital inpatient, registered outpatient, AACC or UCC patient are not payable under the Schedule. Payment for these services is the responsibility of the hospital/regional Health Authority. This applies to both the technical and professional components. Facility Listing updates Auxiliary hospital updates Islay: Facility # 245 for the Islay Care Centre at Street was ended November 30, This facility has been converted to a supportive living facility. As such, claims for services provided to residents at this location on or after December 1, 2007 are to be submitted with location code HOME. Vegreville: The Vegreville Care Centre has moved from Street to Street, Vegreville, T9C 0A1. Facility #224 from the old location is transferred to the new location effective January 1, Nursing home update: Vegreville: The Vegreville Care Centre at Street is closed and its facility # 474 is ended January 1, 2008.

4 Attachment A Schedule of Medical Benefits amendments retroactive to July 1, 2007 Amended general rule General rule 18 Amend to read as follows: 18 The Body Mass Index (BMI) modifier may be claimed for selected procedures, obstetrical services, anaesthesia, second qualified surgeon and surgical assistant services when the following criteria are met: a) An adult patient has a body mass index of 35 or more. b) A pediatric patient is above the 97th percentile for BMI on an approved pediatric growth curve. c) The BMI modifier may only be claimed for - procedures performed under general, spinal, epidural anaesthetic or regional nerve block performed in an operating room, day surgery or labour and delivery room or surgical suite; - obstetrical services provided in an operating room, day surgery or labour and delivery room; and - endoscopies performed in an operating room, day surgery or endoscopy suite other than those of the sinuses and nasopharynx. d) The BMI modifier may not be claimed by the surgeon for surgical procedures above the neck, with the exception of those performed on the oropharyngeal and cranial cavities; see e) below for groups of excluded services. The modifier may be applied to anesthetics for these procedures when the requirements listed in a) or b) and c) are met. e) The BMI modifier may not be claimed for health service codes listed under the following sections of the Schedule of Medical Benefits: - Operations on lacrimal apparatus - Operations on eyelids - Operations on ocular muscles or tendons - Operations on conjunctiva - Operations on cornea - Operations on iris, ciliary body, sclera, and anterior chamber - Operations on lens - Operations on retina, choroid, and vitreous - Operations on orbit and eyeball - Operations on external ear - Reconstructive operations on middle ear - Other operations on middle and inner ear - Operations on nose - Operations on nasal sinuses SOMB amendments July 1, 2007 Attachment A Page 1 of 3

5 Amended health service codes Price List 03.07A Amend the rate for skill code CRCM to B Amend the rate for skill code CRCM to A Amend the rate for skill code CRCM to N Amend the CALL NBRSER modifier details to read as follows: CALL NBRSER 1 For Each Call Pay Base At 100% 2-5 For Each Call Increase By G Add the following modifier details: HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT BMI BMIABD Y Increase By 25% 36.99F and 49.98W Add the following modifier details: HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT BMI BMISRG Y Increase By 25% Amended and new modifier definitions BMI Amend the definition of modifier type BMI and modifier code BMISRG to read as shown below. Also add new modifier BMIABD as shown below. BMI BMI - (Explicit) - This modifier is used to support the additional payment of 25% for selected procedures, obstetrical services, anesthesia, second qualified surgeon and surgical assistant services for adult patients with a BMI of 35 or more and pediatric patients above the 97th percentile for BMI on an approved pediatric growth curve. BMIABD BMIABD - Body Mass Index, ANAESTHETIC BY DEFINITION - (Explicit) - The physician functions as the Anaesthetist and is claiming a Health Service Code (HSC) which is an anaesthetic by definition and does not have modifier ANE. BMIANE BMIANE - Body Mass Index, ANAESTHETIST - (Explicit) - The physician functions as the Anaesthetist and is claiming the listed anaesthetic benefit. BMIANT BMIANT - Body Mass Index, ANAESTHETIST TRC - (Explicit) - The physician functions as the Anaesthetist and is claiming a benefit based on the duration of the anaesthetic. BMISRG BMISRG - Body Mass Index, SURGEON/SECOND QUALIFIED SURGEON/ SURGICAL ASSISTANT - (Explicit) - The physician functions as the Surgeon, Second Qualified Surgeon, or as a Surgical Assistant and is claiming the listed applicable benefit. BMI2AN BMI2AN - Body Mass Index, ANAESTHETIST TRC 2 - (Explicit) - The physician functions as the anaesthetist and is claiming anaesthetic time premium units based on the duration of the anaesthetic. SOMB amendments July 1, 2007 Attachment A Page 3 of 3

6 System rule changes The following system rule changes are retroactive to July 1, When applicable, BMI modifiers may be claimed for services provided in obstetrical intensive care units functional centre codes IC01, IC02 and IC03. For those surgery health service codes which have BMI modifier BMISRG and surgical assist role modifier ASIC, SA or SAQS attached, and where the surgeon is eligible to claim modifier BMISRG, the surgical assistant is also eligible to claim modifier BMISRG. Billing note As a result of the retroactive Schedule amendments and system rule changes described in this Attachment, physicians may need to resubmit previously processed claims for services provided between July 1, 2007 and December 31, Please refer to the guidelines below. Where claims were previously refused and a resubmission is appropriate, submit a new claim with action code A (add) and a new claim number. Where claims were previously applied and a resubmission with new/corrected data is appropriate, submit the previously processed claim (same claim number) with action code C (change) and the new/changed claim data. Example: An applied surgical assistant claim that is retroactively eligible for a BMI modifier would be resubmitted with action code C and modifier code BMISRG. To avoid being refused as outdated, any resubmitted claim that is sent/received more than 180 days after the date of service will require supporting text. Your accredited submitter can assist you with the resubmission process. Claims for 03.07A, 03.07B, 03.08A and 16.09N that are affected by the retroactive rate increases described on page 2 of this Attachment do not need to be resubmitted. These claims will be reassessed automatically as soon as possible to pay the correct amount and will appear on a future Statement of Assessment. SOMB amendments July 1, 2007 Attachment A Page 3 of 3

7 Attachment B Schedule of Medical Benefits amendments effective January 1, 2008 New health service code Procedure and Price List 03.04I Add the following new health service code after 03.04D: 03.04I Comprehensive visit, including completion of form, required for admission to an Alberta Alcohol and Drug Abuse Commission (AADAC) residential treatment facility HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT 03.04I V Amended health service codes Procedure List 03.05JC Amend to read as follows: 03.05JC Family conference relating to acute care facility in-patient or registered emergency or outpatient, or auxiliary hospital, nursing home patient, AACC or UCC patient, per 15 minutes or major portion thereof NOTE: Intended specifically for patients whose condition warrants periodic family conferences or for patients who are unable to properly communicate with their physician (e.g., situations where there is a language barrier, unconscious patient, etc.) 10.04B Amend to read as follows: 10.04B Intubation performed in an emergency room, AACC or UCC NOTE: 1. May only be claimed when performed in an emergency room, AACC or UCC. 2. May not be claimed in addition to HSC or 13.99E when performed by the same physician. 3. May be claimed in addition to visits or other services provided on the same day by the same physician DD Amend to read as follows: 13.99DD Non-surgical reduction of abdominal or inguinal hernia NOTE: 1. May be claimed in addition to a visit or consultation at the same encounter. 2. May only be claimed in an emergency room, AACC or UCC. SOMB amendments January 1, 2008 Attachment B Page 1 of 2

8 13.99H Amend to read as follows. Also, Note 5 is deleted (added in error to the October 1, 2007 Schedule) H Critical care of severely ill or injured patient in a hospital emergency department, AACC or UCC requiring major treatment intervention(s), per 15 minutes NOTE: 1. May only be claimed when a patient presents with a serious condition requiring at least a two hour stay in the active treatment portion of the emergency department, AACC or UCC or care results in hospitalization. The two-hour period criterion does not apply in cases where the patient dies after having been seen. 2. Time spent with a patient may be claimed on a cumulative basis per day (defined as 0001 to 2400). 3. Major treatment intervention is defined as a medical intervention which prevents or treats a condition that may result in significant morbidity. 4. A scheduled rotation duty off-hours benefit may not be claimed for 13.99H by a second physician who, due to a shift change, has taken over care of a patient B Amend to read as follows: 91.75B Closed reduction of patellar dislocation NOTE: 1. May be claimed in addition to a visit or consultation at the same encounter. 2. May only be claimed in an emergency room, AACC or UCC. X 27E Amend to read as follows: X27E Screening mammography (age 70 years and over) NOTE: 1. Benefits for X27C, X27D and X27E include patient education. A visit benefit may not be claimed in conjunction with these services by the radiologist performing the screening mammogram or by a different radiologist in conjunction with the same radiological examination. 2. Only one Screen Test or fee-for-service benefit may be claimed every calendar year for X27C or X27D. Only one Screen Test or fee-for-service benefit may be claimed every two calendar years for X27E. 3. X27C and X27E must be referred. Subsequent yearly referrals are not required. X27D does not require a referral. 4. X27C or X27D may not be claimed if an X27 was provided within the previous calendar year. X27E may not be claimed if an X27 was provided within the previous two calendar years. 5. Supplementary views, refer to X27F. 6. X27C, X27D and X27E require submission of data to the Alberta Breast Cancer Screening Program through either the Alberta Society of Radiologists or the Alberta Cancer Board. Amended health service codes Price List 16.91A, 16.91C, 16.91F, 36.99A, 36.99B and 36.99C Delete modifier BMISRG from these health service codes and add the following modifier details: HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT BMI BMIABD Y Increase By 25% SOMB amendments January 1, 2008 Attachment B Page 2 of 2