Alberta Health billing codes have restrictions and modifiers applied on a patient’s age or gender. These can cause unexpected rejections and offer opportunities for billing code optimizations. In this post, we explore common age related restrictions and modifiers and how to make sure your claims are optimally submitted and fully paid.
Rejections related to age related restrictions show on your statement of assessment the following explanatory code:
39BB – Age restriction: patient is not eligible for this service due to age.
If you have received this rejection, you’re dealing with an age related restriction.
We cover gender related restriction in a separate post here.
Age Related Billing Code Restrictions:
Physicians need to ensure they use appropriate AHS billing codes based on the age of the patient at the time of service. AHCIP puts age related restrictions on the billing of certain codes for two reason:
Use Restriction: The service is restricted to certain age groups
Different Code Value: Alberta Health has different billing codes and compensation amounts based on the inherent complexity of the procedure for specific age groups
Here are examples:
Restrict their use to certain age groups
Example 1:
03.03FA – Prolonged repeat office or scheduled outpatient visit in a regional facility, referred cases only, full 15 minutes or portion thereof for the first call when only one call is claimed. For this code, the patient must be 18 years of age or under. The code is also restricted to a variety of specialties.
Example 2:
03.05JK – Pediatric conference with parents/guardians of patients, without the patient (child) being present. For this code, the patient must be 18 years of age or under.
In both these examples, the billing code requires the patient be 18 years of age or under, or else the billing code will be rejected.
Lower or higher billing code compensation based age
Example 3:
A physician provides a Tonsillectomy for a patient who is 12 years of age. Consider the following AHCIP billing codes:
- 40.1 Tonsillectomy for patient 14 years of age and over – Base rate: $364.80
- 40.1A Tonsillectomy for patient under 14 years of age – Base rate: $292.21
If physicians bills 40.1 for this patient, the billing claim will be rejected. We must bill the code 40.1A which is of lower value.
Age related billing code modifiers:
There are certain age related billing modifiers within the health service codes which may increase the value of the service billed. To optimize billings, physicians need to ensure they bill the age appropriate modifier.
Example 4: Consider a case where a physician completes a closed heart vasectomy on a patient that is 25 days old. Two billing code options are available:
- 47.02A – Closed heart vasectomy, mitral valve – Base Rate: $1751.03
- 47.02A L30 – Patient is under 30 days of age Base Rate x 150% = $2626.55
In this case, a physician could bill 47.02A without a modifier for a patient under 30 days of age, but they would be submitting a unoptimized billing. Being aware of the age related modifier increases billing compensation by $857.52 for the procedure.
Example 5: Here we have a case where a physician provides a consult with a complex pediatric patient in the hospital for 30 mins. Let’s consider 3 code submission options:
- 03.03D – Hospital Visit – Base Rate: $42.26
- 03.03D COINPT – Hospital visit, complex in-patient care (must be 20 mins or more.) – Rate – $82.67
- 03.03DG – Complex pediatric hospital visit per full 15 minutes – Base Rate $77.01, @70% after 1st call. Billed for patients 18 years or under. Submitted billing would be $77.01 + 70% x $77.01 = $130.92
A physician could submit any of these billing code combinations and the claim would be accepted. But there is a big difference in value. It’s clear the physician’s best option is to submit 03.03DG based on calls. Submitting 03.03DG on calls is worth over 3x simply submitting a basic 03.03D hospital visit.
Conclusion:
It is important that physicians and their billers are aware of age related billing code restrictions and modifiers. Knowing the rules can ensure physicians avoid rejections and optimize their billing claims. We have only provided some examples here so be aware there are many other age related restrictions. Have a particularly tricky example from your own billing? Let us know! We’re always happy to share good tips with other physicians.