Key Steps to Improve Billing Accuracy and Your Reimbursement

Checking that your patient has valid health care

Consider checking with Alberta Health that the PHN is valid:

Phone 1-888-422-6257 to instantly validate the PHN 24 hours a day via an automated phone system.

OR

Check Netcare – ensure that you see a specific ‘eligibility start date’ in the patients profile. Patients may have an Alberta PHN but without a ‘start date’, these health care numbers are not valid for billing.

Recognizing out of province HCN’s

In some facilities, patients from out of province are assigned a Unique Lifetime Identifier (ULI) that looks identical to a valid Alberta Health Care number. This informative PDF shows you how to recognize OOP patients and how to correctly enter their demographic information to avoid refusals from Alberta Health.

Errors with out of province billing

Good Faith Billing

Good Faith Billing is used for Alberta Patients that do not yet have valid Alberta Health care coverage but meet other criteria. The criteria and timelines for billing on Good Faith are very restrictive by Alberta Health. This informative PDF explains the criteria and how to correctly enter a Good Faith claim.

Private Billing

Private Billings can be used for patients that do not have valid health care coverage in Alberta or any other Canadian province (with the exception of Quebec), do or do not have insurance coverage in their country or the procedure they are having done is not covered by the Alberta Health Care program. In these situations you may download the Credit card authorization form so that you may direct bill the patient.

Using Diagnostic Codes Correctly

Alberta Health will reject your claims if you apply a diagnostic code to an anesthetic code. Diagnostic codes are only required for specific codes (most often consultations). This informative PDF explains how diagnostic codes are used.

Using diagnosis codes correctly

Multiple Calls

General tips for billing for multiple calls

Billing for the same code multiple times is permitted under specific conditions. Some codes pay multiple calls to surgeons but not to anesthesiologists.

Often multiple call will be rejected without supporting text. STATGO software will alert the user to enter text to support multiple calls. If text is not entered these “excess” call will be automatically rejected by Alberta Health.

Add text to the “supporting text” box under the relevant code. For examples:

98.11F x 2 calls “Debridement left and right elbow” or “debridement face and neck”

14.21B x 2 calls “Left frontal and right temporal subdural hematomas requring two different incisions for drainage”

16.91A x 2 calls ” Two regional nerve catheters inserted – right sciatic nerve and left sciatic nerve”

Multiple Calls of Debridement Codes - 98.11F, 98.11C...

When billing multiple calls of ” Functional Areas” – 98.11F, 98.11E, 98.11D. You MUST LIST the relevant functional areas from the following list: Head, face, neck, shoulder, axilla, elbow, wrist, hand, groin, perineum, hip, knee, ankle, foot, or coverage of exposed vital structures (bone, tendon, major vessel, nerve). For example 98.11F x 2 “Debridement face and neck”

When billing multiple calls of “Non Functional Areas” – 98.11C, 98.11B, 98.11A. You MUST LIST the relevant non-functional areas from the following list: Posterior trunk, anterior trunk, arm (above elbow), forearm (below elbow), thigh, leg (below knee). 98.11C x 2 “Debridement Posterior trunk and forearm”

After Hours Surcharges and Time Premiums

After Hours Surcharge guidelines (EV, TEV, NTPM, NTAM)

Surcharge Codes – Billable once per encounter when called for an “unscheduled service”

Surcharge Code

When to Use

WK

Weekend and Statutory holiday 07:00 – 22:00

EV

Weekday Evening 17:00 – 22:00

NTPM

Night Evening 22:00 – 24:00

NTAM

Night morning 24:00 – 07:00

After Hours Time Premium guidelines (TEV, TWK, TNTP,TNTA, TST, TDES)

For Patient Care “after hours”

Time Code

When to Use

Maximum Number of Units

TEV

Weekdays 17:00 – 22:00

20

TNTP

22:00 – 24:00

8

TNTA

24:00 – 07:00

28

TWK

Weekends 07:00 – 22:00

60

TST

Statutory Holidays 07:00 – 22:00

60

TDES

Designated Statutory Holidays 07:00 -22:00

60

*Note: When a procedure crosses over midnight bill Alberta Heath requires all charges to be billed on the date the procedure started – EXCEPT TNTA units for which you must enter a new claim with the new date after midnight.

Example: Appendectomy Started January 3 at 23:00 completed January 4 at 02:00.

Bill as follows:
-January 3 – 59.0 A ANEST x 36 Units (Anesthesia Time from 23:00-02:00) + TNTP x 4 units (23:00-00:00)
-January 4 – TNTA x 8 units (00:00-02:00)

Obstetrical Billing

Epidural Monitoring -16.91G

Epidural Monitoring (16.91G ) is billed in 5 minute units. Generally these units must be aggregated for each patient of the course of an OB shift and then submitted together in one encounter. In addition, please see our detailed PDF on multiple encounters of 16.91G.

In the example below you are monitoring an epidural on one patient and then stop that to perform a C-section. You then resume epidural monitoring on your original patient:

08:00-09:00 Sarah Smith – Epidural monitoring
09:00-09:30 Julia Jones – Cesarean Section
09:30-10:00 Sarah Smith – Epidural Monitoring

This should be billed as follows: Sarah Smith 16.91G x 18 units (DO NOT bill 16.91G x 12 units and 16.91G x 6 units)

The exception to this is when you are called for a new “encounter” (https://www.albertadoctors.org/fee-navigator/governing-rules/1.14)

In this case you can separate the monitoring billings with different ENCOUNTER numbers and add a surcharge if applicable. NOTE there is a maximum of ONE surcharge per patient/day on 16.91G.

Billing C-Section after epidural monitoring

It is important to change the encounter number when billing a c-section after epidural insertion or monitoring. Please see full details in our PDF c-section after epidural.

Consultations

Consultation Minor and Comprehensive

There are two types of consultations

1) Minor Consultation – code 03.07A (https://www.albertadoctors.org/fee-navigator/hsc/03.07A)
Relevant Modifiers: CMXV20 – $15.62 CMXV35 – $31.27 (This modifier is used to indicate a complex patient consultation or visit requiring that the physician spend 20 (CMXV20) or 35 (CMXV35) minutes or more on management of the patient’s care.)

2) Comprehensive Consultation – 03.08A (https://www.albertadoctors.org/fee-navigator/hsc/03.08A)
Relevant modifiers: CMXC30 – $31.27 (This modifier is used to indicate a complex patient consultation or visit requiring that the physician spend 30 minutes or more on management of the patient’s care.)
Prolonged Comprehensive Consult 03.08L – $14.10 every 5 minutes exceeding 30 minutes – up to a maximum of 6 units.
(https://www.albertadoctors.org/fee-navigator/hsc/03.08L)

Billing a consultation on the same day as an anesthetic or procedure

A consultation is billable on the same day as an anesthetic or procedure if it is a different encounter. Usually the consult would be encounter #1 and the anesthetic encounter #2.

To change the encounter use the box labeled encounter number to the left of the code entry box:

Billing ICU visits

Changing Centre to ICU

Ensure Centre is changed to ICU

Billing 03.05A

Pt John Smith referred for major consult this patient is in an Intensive care unit. He is seen initially in consult for 1 hour (08:00-09:00) then seen the next day for 30mins (10:00-10:30).

Bill as follows:

***** REMEMBER TO CHANGE CENTRE TO ICU – or visit will not pay******

Encounter #1 (08:00-09:00)
03.08A + Modifier CMXC30 + Dx code = $135.39
03.05A x 2 (pays better than extended anesthesia consult 03.08L) – $114.74
Total = $250.13

Next day Encounter #1 (10:00-10:30)
30 min ICU visit 03.05A x 2 – $114.74
Total = $114.74

Pain Billing

Billing 16.91B

Up to 4 separate instances of 16.91B can be billed per patient per day. (Two scheduled visits, two unscheduled visits). Each visit must have a separate encounter number. Multiple calls of 16.91B cannot be billed on the same encounter.

For example, if a patient was seen in the morning and then later in the afternoon, this should be billed as follows:

16.91B x1 Encounter number = 1

16.91B x1 Encounter number = 2

DO NOT bill 16.91B x2 as this will be rejected by AHCIP.

Billing at multiple sites/hospitals

What setting do I need to change if I am billing at different sites?

Alberta Health requires that you enter specific “Facility” and “Centre” information for each location that you see patients.

Setting up "Providers" to remember the defaults for the different sites you normally work

You can set up different “providers” for each of the locations where you work. In this way when you work at a particular site you can group all you billings under that provider and all you Facility and Centre defaults will be preset.

You can either send us an email at [email protected] with a list of you sites and we can set up you providers or you can set them up yourself in the software.

To set them up:

  1. Go to “Providers” in the top menu and then click “add Providers”.
  2. Fill in the required information including the facility and centre information. We suggest you put the name of the hospital/site in the “last name” field.
  3. Next time you wish to bill at that site select that provider.

Alberta Health Billing Payment and Submission Timelines

I have submitted my billings when will they be sent to Alberta Health?

Billings are submitted to Alberta Health Care Insurance Plan (AHCIP) electronically on a daily basis. You can check if a particular billing has been sent to AHCIP by looking at the “status” your billing in the system.

“Submitted” = you have submitted the billing

“Reviewed” = the submission has been reviewed by the billing agent/system and is ready to send to AHCIP

“Confirmed” = the billing has been sent to AHCIP and confirmed by their system as received.

“Paid” = the billing has been accepted and will be paid by AHCIP – you should expect payment in your account approximately 7 days after the billing is marked as paid.

When does Alberta Health assess billings? What are the deadlines for submission to get my billings assess in a particular week?

Alberta Health Care Insurance Plan assess billings once a week.

All billings “confirmed” by Alberta Health Care Insurance Plan (AHCIP) prior to Thursday at noon will be assessed over the weekend. You should see responses from AHCIP in you account on Saturday or Sunday.

When should I be paid for billings submitted to Alberta Health?

If Alberta Health billings are submitted by the Thursday deadline they should be assessed and approved over the weekend you should receive payment via electronic funds transfer (EFT) on the following Friday.

Billing tips

Code Specific FAQ’S

0303D

03.03D is a hospital visit you must specify the DATE OF ADMISSION. If the visit is greater than 20 minutes you may add modifier COINPT.

16.91B

16.91B Epidural followup visit. You may bill up to 4 visits per day. Each visit must be entered as a separate encounter up to 2 visits may be billed with a unscheduled surcharge (WK, EV, NTPM, NTAM).

For more detailed instructions please see the slides bellow.

 APS billing 16.91B

81.29C

81.29C is unusual code in two respects:

  1. This code is billed based on time BUT can be added to other anesthesia codes billed on PROCEDURE.  In other-words you can bill 30 minutes of 81.29C and then bill the procedure codes for the rest of the surgery.  Normally you can bill only on one or the other.
  2. The anesthesia units are DIFFERENT to the surgical units – so if a surgeon say 4 units of 81.29C this is equal to  10 anesthesia units of 81.29C.  This is because surgical units are 15 minutes long 4 units = 60 minutes but anesthesia units are 5 minutes long EXCEPT for the first units which is 15 minutes long.

When billing this code please write in the total time for the 81.29C if you are unsure of how many units to bill.  Note 81.29C will commonly be reduced to %75 if it is billed as a second or subsequent procedure.

Downloads

Useful links