Understanding the essential concepts of how billing works in Alberta is the first step to making sure you are billing correctly. In this post, we’re going to review 5 essential concepts that will help you optimize your billings. Even experienced billers can benefits from a review of the basics – so here’s an Alberta Billing 101.
Note these basic concepts apply to Alberta Health Care Insurance Plan (AHCIP) billing. Payments from other sources, including WCB, Medavie Blue Cross and private billings, follow similar concepts but different rules and details. With that noted, let’s jump in:
Billing Codes and Modifiers:
Concept: Billing codes + modifiers are the basic structure of AHCIP billing
Physicians in Alberta bill the Alberta Health Care Insurance Plan (AHCIP – the Alberta Government’s provincial health insurance plan), using health service codes (HSCs), often referred to as billing codes. Each HSC represents a medical service provided. Medical services provided can include visits, procedures, tests or medical discussions with other health professionals. The monetary value for a HSC is defined in the AHCIP Schedule of Medical Benefits (SOMB).
Billing Codes can have up to 3 modifiers that change the value of the code based on the role of the physician, when the service was provided, the complexity of the patient / service and the time spent with the patient. There are no billing scenarios where more than 3 modifiers are applicable.
You are GP consulted to see a complex patient in your clinic and preformed a pelvic exam. The full time spent with the patient and charting related to the consult is 35 minutes. The patient has a BMI of 42. The appropriate billing is as follows:
Billing with modifiers: In this case, we bill two codes: 03.08A (comprehensive consult – in office) and 13.99BE (pelvic examination). For the comprehensive consult 03.08A, the base value is $79.23. When we add the GP modifier, the code value becomes $124.25. Because the consult took more than 30 minutes, we can add a CMXC30 modifier that will increase the base amount by $31.43. For the pelvic examination 13.99BE, the base rate is $28.53. As the patient has a BMI of 40 or more, we can add a BMIPRO modifier that increases the value of the code by 25% to $35.66. The total reimbursement of the visit is then $124.25 + $31.43 + $35.66 = $191.34.
Note that we cannot bill a BMI modifier for the comprehensive consult 03.08A and there is no GP Skill modifier or +30 minute time modifier for the pelvic examination 13.99BE. Not all types of modifiers apply to all codes. The SOMB defines what modifiers are available to be billed with any particular code.
Billing without modifiers: To demonstrate the value of correctly using applicable modifiers, let’s imagine we just billed the comprehensive consult and pelvic examination without modifiers. The reimbursement for this billing would be $79.23 for the comprehensive consult 03.08A and $28.53 for the pelvic examination 13.99BE. The total reimbursement of the visit is $79.23 + $28.53 = $107.76.
Now compare reimbursements with and without modifiers:
Billing without Modifiers
Billing with Modifiers
|03.08A | GP | CMXC30 |||$124.25 + $31.43||$155.68|
|13.99BE | BMIPRO |||$35.66|
Correctly using modifiers increases your income by 78% or $83.58 for this 1 visit! Correctly using modifiers and knowing which modifiers to add on what codes is central to optimizing your billings. Time based modifiers, after hours modifiers and complexity modifiers are discussed in more detail later in this post.
Concept: Billing codes are grouped when providing services to a patient.
An encounter is defined as “Each separate and distinct time a physician provides services to a patient in a given day.” Encounters are important for 3 reasons:
- There are restrictions to codes that can be billed together on 1 encounter
2. If you see the same patient multiple times in 1 day, multiple encounters provide higher billing code opportunities
3. If multiple encounters are billed, you must carefully follow rule regarding what qualifies as a new encounter
You are a physician assigned to pain service. You received a request for consultation for pre/post operative pain control for a patient having a below knee amputation the morning of their surgery at 0800. You perform a femoral nerve block at this time. At 1630 the nurse caring for the patient calls you as the patient is experiencing high levels of pain and has requested advice and for you to return and see the patient. At 1645 you see the patient on the ward again and adjust their pain control schedule.
So how do we bill this correctly? The first step is to identify which of these interactions qualify as a separate encounters. The consultation (03.08AZ) and insertion (16.91A) qualify as one encounter. The call from the nurse (03.01NG) qualifies as a second encounter. The follow-up visit (16.91B) qualifies as a third encounter. Knowing this, we can bill as follows:
Billing without correct encounters (1 EN used)
|EN1 @ 0800||03.08AZ||$115.00|
Billing with correct encounters
|EN1 @ 0800||03.08AZ||$115.00|
|EN2 @ 1630||03.01NG||$17.43|
|EN2 @ 1645||16.91B||$42.74|
In the example above, we separate each patient encounter. Indicating them this way, the additional codes for the phone call and follow-up for pain control are paid. If the encounters were not correctly indicated (for example, submitted all on encounter 1), these codes are applied at $0.00. Correctly using encounters increases your income by 27% or $60.17 for this patient.
Time Based Billing
Concept: Physicians can bill more for services that take longer to provide.
Based on the billing situation, the SOMB offers different methods to submit time based billing.
Health Service Codes with time calls. Some HSCs require time calls to indicate the amount of time spent caring for a patient. For example, the billing code 13.99H (critical care of severely ill or injured patient) is billed in 15 minute time increments. If a physician spends 45 minutes with the patient, the correct billing is 3 calls of 13.99H.
Modifiers based on service duration. Let’s say you are a GP and you conduct a limited assessment. In this case we would bill 03.03A – Limited Assessment Out of Office (value $38.03). But what if that assessment took 20 minutes? Or 40 minutes? Depending on your specialty, you can add modifiers CMXV15 or CMXV20 that increase your reimbursement by $15.70 or modifiers CMXV30, CMXV35 that increase your reimbursement by $31.43. As the code suggests, a CMXV15 can be applied for eligible specialties if the consult took over 15 mins. These codes create a time threshold – if the time you spend if above the threshold, you can add the modifier.
Modifiers with time calls. There are also time modifiers that are based on the number of units of time you spend with the patient. For example, the CMGP modifier (applicable to GPs), increases the value of the 03.03AZ code by $18.43 for each 15 mins you spend with the patient. For a 45 minute consult, you can bill 3 calls of this modifier. This would be 3x $18.43 in addition to the underlying 03.03AZ base amount ($38.03 for a GP).
Additional billing codes based on service duration. A different method the SOMB uses for compensate extra time required is a different code. So instead of adding a modifier to the base code, you add a different code. Let’s say your an internal medicine specialist doing a major consultation (03.08AZ – Major Consultation value $198.70). What if the consult takes 60 minutes? If the consultation takes over 30 minutes, in addition to the 03.08AZ, you can also bill a 03.08IZ which pays $42.75 per 15 minute call over the 30 minutes.
It is important to note that these various time based modifiers and codes cannot be applied to all codes. Available time based modifiers and codes are defined in the Schedule of Medical Benefits with restrictions that must be adhered to.
An internal medicine physician sees a patient in hospital for minor consult and spends 30 minutes on patient. The relevant code is 03.07AZ (minor consult – out of office) with an INMD modifier (Internal Medicine role – value $111.27) and a time modifier CMXV30 (increases base by $31.43).
Billing without time modifiers
Billing with time modifiers
|03.07AZ INMD CMXV30||$142.70|
Billing is the correct time modifier in this example increases the physician reimbursement by $31.43, a 28% increase.
Afterhours modifiers and premiums
Concept: Physicians can bill more for services when working evenings, nights, weekends and holidays.
The SOMB provides different methods for physicians to increase their reimbursements if the are providing services on evenings, nights, weekends or holidays. There are two methods:
Afterhours Modifiers (also called encounter surcharge) that increase the value of a code based on when an unscheduled visit or procedure is performed. These are:
EV – Evenings (1700-2200)
NTPM – Nighttime PM (2200-2400)
NTAM – Nighttime AM (2400-0700)
WK – Weekends and Statutory Holidays (0700-2200)
Time Premium Codes can billed in addition to other codes you are billing on an encounter. They provide a flat amount for working after-hours like a shift premium. You may only bill a maximum of 4 time premium codes per eligible hour. To apply the time premium code, you bill a 03.01AA with a modifier indicating the time of day you worked and the number of calls (15 minutes per call). These modifiers are:
TEV – Evening, weekdays (1700-2200), maximum 20 units per day
TNTP – Nighttime PM, everyday (2200-2400), maximum 8 units per day
TNTA – Nighttime AM, everyday (2400-0700), maximum 28 units per day
TWK – Weekend (0700-2200), maximum 60 units per day
TST – Statutory Holiday (0700-2200), maximum 60 units per day
TDES – Designated Holiday (0700-2200), maximum 60 units per day
A general surgeon has been called for an urgent appendectomy in the OR on a Saturday evening. The case runs from 2145 to 2315. The surgeon has not seen this patient before. The relevant codes in these care could be 03.08AZ (comprehensive consult – out of office) with a GNSG modifier (General Surgery role – value $153.19), 59.0 A (appendectomy) and 03.01AA TWK/TNTP (after hours time premium). As this was an unscheduled procedure, we can add the WK encounter surcharge ($48.70).
Billing without Time Premiums
Billing with Time Premiums
|03.08AZ GNSG WK||$153.19 + $48.70||$201.89|
|03.01AA TWK x 1||$22.79 x 1||$22.79|
|03.01AA TNTP x 5||$45.55 x 5||$227.75|
For the total time spent with the patient (2145-2315) we have indicated the time premium code 03.01AA with the applicable modifiers of 1 x TWK (2145-2200) and 5 x TNTP (2200-2315) based on 15 minute increments. We can only claim 1 afterhours surcharge per encounter, so the WK surcharge applied to the 03.08AZ cannot be again applied to the 59.0 A.
Billing the correct after hours modifiers and premiums in this example increases the physician reimbursement by $299.24 or a 44% increase.
Concept: Physicians can bill more for services that are more complex or difficult to provide
The Schedule of Medical Benefits recognizes that some patients or medical services have additional complexity that increases the difficulty or skill required. There are complexity modifiers that increase the value of the codes you bill. Here are examples:
Body Mass Index (BMI) modifiers. For designated codes and eligible patients, physicians can add a BMI modifier that increases the value of the billing code by 25%. The BMI modifier is applicable for adult patients with a BMI over 40 and pediatric patients over the 97th percentile on an approved pediatric growth curve.
Age modifiers. There are modifiers that increase the value of a code based on the age of the patient. The G75GP modifier allows physicians with the skill of GP to be paid 20% above the regular GP rate for select codes. The L1 modifier increases the value of select procedures performed on patients under 1 years of age.
Comorbidity modifiers. The modifier COINPT can be used for management of complex hospital inpatients. This code has a variety of restrictions and may only be claimed for the management of complex hospital inpatients with multi-system disease.
A physician performs a bronchoscopy on a patient that is 10 months old. The relevant code is 01.09 (other nonoperative bronchoscopy).
Billing without age modifier
Billing with age modifier
By adding the L1 modifier (indicating the patient is under 12 months of age) the base amount for this health service code increases reimbursement by 31%, an increase of $40.69.
Get Paid Correctly
The AHCIP SOMB is complex with many different rules and restrictions, but understanding the basic concepts in billing is important to being paid correctly. Your medical biller should be an expert in the SOMB and be able to help you bill correctly and optimally. They should provide you with advice and billing feedback on the work you do and what you submit. Statgo’s software can help you bill correctly by identifying missing modifiers and optimizations.
Not yet a Statgo client? Our software helps physician’s improve their billings by 2%-30%. We make it easy to bill correctly and maximize your reimbursements. Contact us today and start get your billing problems resolved!