MEMBERS ONLY

In this issue’s column, we will be going over some previous billing errors made by some surgeons as well as some of the billing cases which we discussed at the 2014 OAGS Annual Meeting.

Diabetic Foot Billing
For Surgeons who have to debride diabetic foot ulcers, there is always considerable difficulty in having to bill these.

The payment for basic debridement (Z084) is minimal and pays only $60. This is not representative of the amount of work involved in treating these patients. If one looks for alternative ways of billing outside of traditional General Surgery billing codes, better remuneration may be found. If one looks at billing for plastic surgery procedures on page M17 of the Schedule of Benefits and Fees (SOBF), it will be seen that there are various ways to bill plastic surgical procedures of varying complexity from R150 - Very Minor ($92.30) to R154 Extensive Major ($568.95). These billings require the operative report to be submitted with the billing. It would be justifiable to bill an R152 - Intermediate ($259.20). The problem with this billing method is the fact that the operative note must be submitted and the likelihood of delayed payment is high.

A reasonable alternative for billing diabetic feet is to look at Orthopedic billings. If one looks under Amputation (pg. N43), a Ray amputation (R621) pays $217.15 - close to the intermediate Plastics billing but without requiring submission of an OR note. Also under Orthopedic billings is billing for Incision and Drainage (pg.N45) of bone (R220). This pays $227.40. Code Z228 ($97.35), debridement of soft tissue, may also be billed in addition to the boney drainage resulting in a total billing of $324.75. This is the most lucrative way to bill the procedure and does not require submission of the operative note for justification.

Z Codes
It still surprises me that General Surgeons continue to neglect to bill visit codes in addition to Z codes. Z codes are billed in addition to all other billings and not subject to a 15% reduction. For every Z code billed, a visit code should be billed. For example, an EGD should be billed at minimum as an A034 (partial assessment at $24.10) and an EGD. At minimum, this adds $24.10 to every Z code billed by a Surgeon.

U of T Update in General Surgery
At this year’s U of T Update on General Surgery, I’ll be doing Billing Corner seminars during the Saturday morning sessions. I’ll be presenting some of the topics we’ve discussed at the last few OAGS Annual Meetings and in previous Billing Corner columns. Anyone interested can submit questions through OAGS prior to the update (see below). I’ll be available to answer questions at each of the seminars, but questions submitted in advance will allow me to find the best method to bill your procedures.

MOH Unilateral Action
As we are all aware, the Ministry of Health has imposed a unilateral fee agreement on the OMA. The OMA Board has decided not to work with the MOH on the imposition of this. In short, this means a cut of about 3.1% to General Surgery. Overall, from a billing perspective, it appears too early to make a determination as to the best methods for billing and workload commitments. To this extent, the Billing Corner is recommending that Surgeons stay the course and continue their current billing habits and a maintenance of current workloads. As more information becomes apparent, different strategies may be recommended.

That’s all for this issue, see you at the U of T Update (April 23-25). - Al

- Dr. Alan Lozon, OAGS Board Member and OMA Section Tariff Chair, is on staff at Grey Bruce Health Services, Owen Sound.

NOTE: Please note that the opinions expressed above are those of the author and do not necessarily represent OMA, Ministry or OHIP Policy. We are always looking for ideas or tips/tricks, so members are MOST encouraged to send us your questions or suggestions. Ideas can be sent via email (info@oags.org), fax or mail. Further information can be found on the MOHLTC/ Schedule of Benefits website: https://www.oma.org/Member/Programs/Billing/Pages/default.aspx

For this issue’s column of the Billing Corner, I have opted to go over a recent meeting we had with the Ministry of Health and OHIP representatives back in June regarding some disconcerting changes that the membership had noted with respect to payment and billing. There had been quite a number of complaints made to both the OMA Section on General Surgery along with the OAGS Billing Corner regarding delayed payment, late payments and refusal of payments. Both the OAGS and the Section were fortunate to have had a very productive meeting with the representatives to try to sort out what the changes were and how to avoid future problems for General Surgeons attempting successful billing.

I have broken this article down into a number of different subcategories. I’ll review the process that OHIP goes through regarding billings and also explain both the appeal process and dealing with issues pertaining to stale billings, using billing agents and current OHIP health card numbers. Hopefully, these are of benefit to the membership with respect to future billings. In addition, the Ministry of Health has been kind enough to make representatives available for our next Annual Meeting, as our Billing Corner Roundup will be extended by 30 minutes at the end of the day to discuss the process of billing. Hopefully, you will find this informative as well.

Billing Process
To begin with, we will initially go over the adjudication process and the process determining billings. The majority of billings are initially assessed through the computer and approximately 80% of these billings are immediately approved and paid out. There are about 20% of billings which are not system assessed and are forwarded on to Claims Assessors for assessment. The system will automatically ask for review from the Assessment Officer in the cases of multiple procedure codes and duplicate billings. (Although OHIP does not confirm, other criteria such as total amount billed and billing history are likely utilized by the system.)

When these billings move on to the assessor, they initially are reviewed by the Claims Assessor to determine if they can simply be paid out or if further documentation is required. If further documentation is required, notification is sent to the surgeon to submit supporting documentation. Following submission of additional documentation, the billing is then escalated to an Assessment Officer for further review. In circumstances where the Assessment Officer determines that the surgery and the documentation are too complex or unclear, then it would be escalated to a Medical Advisor for review. Once the claim has been assessed, it will appear on the provider’s monthly Remittance Advice (RA) either as a full, partial or denied payment.

If a lesser payment or a complete rejection is applied, the surgeon may still appeal this by completing a Remittance Advice Inquiry (RAI) form, usually accompanied by a letter, a note and any other additional documentation which may be of benefit. This new information would be reviewed and if it supports the claim submitted, it will then be adjusted for payment. If the Assessment Officer or Medical Advisor supports the initial assessment, then a response will be sent to the provider with explanation. If the Surgeon, upon receipt of the result of the decision, still does not agree, there is a further option for appeal. An RAI accompanied by a formal letter can then be sent, and at this time the billing will be reviewed and discussed by a panel of three Medical Advisors. All three Medical Advisors must be in agreement on the assessment. If one of the three Medical Advisors does not agree, then the decision will be in support of the surgeon’s billing and the claim will be adjusted for payment.

To review the process quickly: tthe billing is assessed by computer; t80% paid; t20% sent to Claims Assessor; tClaims Assessor agrees to the billing or asks for further information (RAI form #1); tthis information is then reviewed by Assessment Officer and either paid out, refused (rarely) or lower billing paid; tif the Surgeon disagrees, RAI #2 is filled out with more supporting documentation and sent to the Medical Advisor – decision rendered; tif there is still a disagreement, the surgeon can ask for a panel review from 3 Medical Assessors and all three must agree or the claim is adjusted for payment.

Time Frame
The time frame for this process is ideally bench marked for a total of three months. The targets are for a one month evaluation for the initial Claims Assessor. Following this when documentation is received by the surgeon in the form of the first RAI (#1), there is another one month target for the Assessment Officer to evaluate this and respond to the surgeon. If a second RAI (#2) along with further documentation and reasoning is submitted to the Medical Advisor, then an additional month is the target for this. Ultimately, it is hoped that the entire process be resolved in the course of three months.

Stale Billings Beyond Three Months
With respect to its time frame regarding stale billings, a stale billing is a billing which is not submitted correctly within six months of the performance of the procedure. This six month interval applies to the initial billing and the first response to the Claims Assessor. After the first response to the Claims Assessor, the six month stale billing rule no longer applies and payment will be made out beyond six months. To this effect, it behoves the surgeon to proceed with his billing promptly in order to ensure full amount of time to respond to any possible Claims Assessor in the form of the first RAI and any supporting documentation. As soon as this is submitted to OHIP, the claim can then go on and be paid out beyond the six month window. When we discussed this with the Claims Assessors, ultimately they noted problems with Billing Agents and offices submitting billings five months after the procedure and not having enough time to have these claims assessed prior to them becoming stale. It is, therefore, important to ensure that billings are submitted promptly, following performance of the procedures.

In addition to this, there have been numerous complaints that surgeons are not paid the amount of money that is owed to them while this process is going through. In the case of private practice surgeons and surgeons not on a GFT (geographically full-time) at a University centre, OHIP will make a payment of 85% of the billed amount, while the review is being performed. Once supporting documentation is attained and the billing approved, the remaining 15% is then paid out to the surgeon. Unfortunately, this is currently not possible with respect to GFT and academic-appointed surgeons. Those surgeons will not be getting their full amount until all documentation has been submitted and approved. We have made OHIP aware of this.

OHIP Numbers and Version Codes
Moving on to other concerns, the other significant matter that was addressed by the membership is payment regarding current OHIP numbers and version codes. Health care facilities (e.g. hospitals, emergency rooms, doctors’ offices) may choose to set up a PIN number with Service Ontario in order to obtain Health Number Lookup Services via the 24/7 Help Desk. Health Information Custodians wishing to sign up for this service may contact the Help Desk at 613-545-4391 or via email at 24x7@ontario.ca.

Other tools that are available are the Health Card Validation (HCV) service and the Interactive Voice Response (IVR) system. HCV service is a web service that enables health care providers and other clients to determine patient eligibility and the validity of an Ontario health card. IVR allows health care providers and organizations to validate health cards with the Ministry in real-time using the toll-free telephone access. For those wishing to register for either of these services, you can contact Service Support Contact Centre at 1-800-262-6524. These tools can assist with reducing the number of eligibility and version code rejects.

Billing Services That Work On Commission Percentage
The issue of Billing Services was discussed, and we were reminded that all billing submitted on behalf of a physician are the responsibility of that physician. Billing services, because they often work on a percentage basis, will often include additional codes which may not be appropriate. For example, some billing services are automatically also submitting billings for repair of umbilical hernia with every Laparoscopic Cholecystectomy. Other examples exist but ultimately if this is being done by your billing service, then you, the surgeon, are the one ultimately responsible. It is the physician who bears the brunt of potential fraudulent billings, and if your billing service is billing fraudulently on both your and their behalf, it is you who will be responsible. To this extent, OAGS recommends that all physicians do their own coding to ensure that this does not happen.

How Payment Is Determined
In addition, when we had a discussion with respect to how the Medical Assessors determine the billings, essentially the information must be available in the operating room note. If an umbilical hernia was indeed repaired at the time of a laparoscopy but there is no documentation in the OR note, it cannot be paid. To this extent, it behoves the surgeon to ensure that everything that was performed in the operation is well documented in the operating room note. This is of particular significance to surgeons who have residents dictating operative notes for them and ultimately these operative notes may be the ones that get reviewed to determine payment or not.

Also, the advisors have cautioned us that in the case of communications with the Ministry of Health, the best way to ensure that the exchange has actually occurred is to essentially create a paper trail of communication. So, when sending any form of email to the Ministry of Health, you should “request a read receipt” in order to ensure that there is documentation of your communication with OHIP and acknowledgement of the individual with whom you were corresponding. We have heard complaints of individuals talking to a Billing Representative on the telephone and not having any evidence that the communication took place. To this extent, it is important to ensure that a line of communication is well documented and a read receipt was the suggested method of doing this specifically for emails. Furthermore, emails have the advantage of potentially being printed out in order to document the conversation that had occurred.

Future Plans
Going forward, the Ministry is reviewing possible changes to the automatic computer payments system which would allow claims to be processed without being rejected automatically. The Ministry is currently in the testing stages of possible changes and hopes to have this completed in the next few months and implemented in the fall of 2014.

Furthermore, with respect to difficult or new procedures, I would like to draw your attention to the codes R990 and R993 (page SP3 OHIP SOB, May, 2014), which are codes that can be used for evaluation for independent consideration. These codes are ideal if there is a new procedure or a different procedure that is more complex than usual. These procedures can then be submitted immediately for manual review. This allows avoidance of finding similar codes or codes which may not be representative of the actual procedure done, and the R990 and R993 are less likely to get rejected for these reasons.

Again, I encourage the membership to attend the Billing Corner portion of the Annual Meeting this fall (Nov.1) when three representatives from the Ministry of Health (Health Services Branch and Claims Services Branch) will be going through this process and discussing ways to improve surgical billings. Until then, happy and successful billing. - Al

- Dr. Alan Lozon, OAGS Board Member and OMA Section Tariff Chair, is on staff at the Grey Bruce Health Services, Owen Sound.

NOTE: Please note that the opinions expressed above are those of the author and do not necessarily represent OMA, Ministry or OHIP Policy. We are always looking for ideas or tips/tricks, so members are MOST encouraged to send us your questions or suggestions. Ideas can be sent via email (info@oags.org), fax or mail. Further information can be found on the MOHLTC/ Schedule of Benefits website: http://www.health.gov.on.ca/english/providers/program/ohip/sob/physserv/physserv_mn.html

For this month’s Billing Corner column, I will be reviewing the presentations made at the recent 19th OAGS Annual Meeting.

Extra Codes For Certain Procedures:
Some surgeons are billing additional procedures when they are performing certain cases. The two examples that have come to light have been 1) an additional billing for an umbilical hernia while doing a laparoscopic cholecystectomy, and 2) billing a ventral hernia repair while doing a Hartmann’s reversal. If there is an umbilical hernia present or if a stomal hernia is present, then these can be considered appropriate billings. If there is no hernia present, these should not be billed, as it would be considered fraudulent. In the situation where the hernia is present, sending the sac for pathologic confirmation would prove the hernia was present and be useful in the event of payment refusal for the additional procedure.

Number of Consults Per Year:
One of the questions that arose last year was how many consults (A035) is a surgeon allowed to bill in a year. The answer to this is quite straight forward. A surgeon can bill two A035’s on a single patient in one year, provided the consults are for two completely different issues. The OHIP Schedule of Benefits (SOB-Oct2013) states as follows in the General Preamble (p.GP12):
“Consultations, except for repeat consultations (as described immediately below), are limited to one per 12 month period unless the same patient is referred to the same consultant a second time within the same 12 month period with a clearly defined unrelated diagnosis in which case the limit is increased to two per 12 month period. The amount payable for consultations in excess of these limits will be adjusted to the amount payable for a general or specific assessment, depending upon the specialty of the consultant.”
So, based on this, the surgeon can bill two full consultations for two completely different diagnoses. There can only be two in a 12 month period (not in the calendar year). Any additional consultations can be billed as A036 (repeat consultation) to an unlimited number.

How To Bill Surveillance Colonoscopy:
There is no description in the Schedule of Benefits for billing surveillance colonoscopy after colon cancer resection at the 1,3,5 year intervals as recommended. For this, we (and OHIP) are advising the use of Z498 (surveillance) and have been assured it will be paid.

Billing Reviews:
It had come to our attention that some surgeons were experiencing more billing refusals and reviews than traditionally had been occurring. To this extent, I poled the membership at the last meeting to see if this was the case and how many more surgeons were involved. The results showed that 60% of surgeons had noted an increase in the number of reviews and refusal for payments. Most of these were General Surgeons (at 71%) followed by colorectal (11%) and surgical oncology (9%). Of the respondents, 49% reported to the Oshawa office.
As far as commonalities in the refusals, the only one identified was for billings that were for 2 or more codes with 55% of surgeons reporting refusals on the basis of this. Of surgeons, 37% were not able to identify any specific cause for the increased reviews or refusals.
Based on this data, the only suggestions that I have would be to ensure that if you are billing two or more codes on a patient, then be sure to have full documentation in the form of specifics in your operative notes along with supportive pathology or other documentation.

That is all for this month’s Billing Corner. Keep the suggestions and questions coming. - Al

- Dr. Alan Lozon, OAGS Board Member and OMA Section Tariff Chair, is on staff at the Grey Bruce Health Services, Owen Sound.

NOTE: Please note that the opinions expressed above are those of the author and do not necessarily represent OMA or OHIP Policy. We are always looking for ideas or tips/tricks, so members are MOST encouraged to send us your questions or suggestions. Ideas can be sent via email (info@oags.org), fax or mail. Further information can be found on the MOHLTC/ Schedule of Benefits website:
http://health.gov.on.ca/english/providers/program/ohip/sob/sob_mn.html.