Diane E. Zucker, M.Ed., CCS-PHealth Care Consultant

1033 Wagar Road, Rocky River, Ohio 44116

440-331-5998dezucker@sbcglobal.net

Intro to Medical Billing for aCounty Health Program

Agenda for this morning…

A basic overview of how health care is paid – and where a Health Department may fit in

Credentialing of providers – who, how, why and the process

Immunizations – coding, billing and the process

Collection of money from patients – and how this works with insurance

Resources..

Reimbursement process…Payment for health care is based on several

basic concepts

Valid independent provider – providing the service

Patient authorization to bill for services (insurance card, completed form, etc.)

Documentation of the service provided in a “medical record”

Correct coding of the service provided with both CPT and ICD codes

Submission of claims, collection of money and billing patients for their portion of services

Valid provider…

Valid providers include…

Physicians – MD or DOAdvance practice nurses – APN, CNP, nurse

midwife, CNS*Physician Assistant*Mental health providers – LISW, psychologists,

etc.

Facilities and institutions that are identified to provide certain types of facility services – immunization clinics staffed by nurses but with a medical director

Providers…Provider types are not interchangeable –

what this means is that Dr. A is Dr. A and cannot be coded and billed as Dr B

Insurance programs credential the provider not the degree and not the position

Mid level providers are not interchangeable with physicians for supervision of some services

A word about mid level providers

The State of Ohio has two distinct types of mid level providers

Advance practice nurses – APN, NP, FNP, CNS, CNM – these people practice advanced nursing; have a collaborative plan and can be credentialed independent of a physician

Physician assistants are governed by the state medical board and must practice only with their identified physicians based on their written plan of care

MLP…Can see new patients and new problems

based on their relationship with their supervising physicians

Are paid 85% of the physician fee schedule (except in some primary care settings they are paid the same)

May or may not be recognized by all insurance plans as independent providers

What is “incident to”The concept of “incident to billing” means that a

practice (or setting like yours) codes and bills for services under a physician (or APN or PA) but that person is not actually providing the service

That person must be on site when this is done

That person must sign off on certain types of procedures and services

That person takes responsibility for the insurance (or Medicare/Medicaid) for the services billed under their name and provider status

MLP and incident to…If a mid level provider is billing under the

physician the care must be…

An established patient established problemThe physician must be in the agencyThe physician must either sign off on the note

or be referenced in the note as supervisingMust be part of the initial care plan and

process

There is no way to identify this activity on a claim form, the form looks like the physician did the work!

What can nurses do?In a clinic setting they care provide..

ImmunizationsTB and other lab testing by an order or

identified process Blood draw (36415)Nurse visits (99211) if there is a physician on

site to supervise and sign off on care – and this care must be a continuation of a prior plan and process

Some select services based on contracts with insurance programs

Patient authorization…The is the form the patient completes

providing you with …NameAddressBirth dateInsurance informationA signed statement authorizing you to bill their

insurance/Medicare/Medicaid

May include a self pay clause or statement about responsibility for balances, co-pays and deductibles

Medical record…This is a unique record per patient that

includes the key components needed to provide care for the patientName, birth date, Date of careService received (lot #, date of expiration,

drug)Who provided the serviceForms related to services (vaccine information)

This record is maintained based on Ohio medical records requirements

Coding…Coding is the use of alpha numeric characters to

assign a procedure (CPT) and a diagnoses (ICD) to all services provided

CPT codes are used to identify the “what you did” and are specific to vaccines, nurse visits, physician visits, TB testing…

ICD 9 codes are the diagnoses that identifies “why you did what you did” that are specific to immunizations, exposure, conditions, history and…

Standardization of coding…Because of HIPAA all CPT and ICD coding

done in your setting must be based on the standard rules and process – no made up codes

ICD codes change every October (but now not until October 2014)

CPT codes change every January

HCPCs codes change every January

What is a HCPCs code…These are the codes CMS creates for

services that default to the ..99070 Supplies and materials (except

spectacles), provided by the physician over and above those usually included with the office visit or other services rendered (list drugs, trays, supplies, or materials provided)

Drugs, biological and supplies are in this section (the G and Q codes for Medicare flu vaccine administration and supply)

A couple examples of procedure codes…90658 Influenza virus vaccine, split virus,

when administered to individuals 3 years of age and older, for intramuscular use

90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)

86580 Skin test; tuberculosis, intradermal

A few ICD 9 codes…V04.81 Need for prophylactic

vaccination and inoculation, Influenza

V01.1 Contact with or exposure to tuberculosis

V74.5 Screening examination for venereal disease

098.0 Gonococcal infection (acute) of lower genitourinary tract

A word about ICD 10If you are an entity that is submitting

claims to insurance, Medicare, Medicaid then on October 1, 2014 there is a change in ICD coding from ICD 9 to ICD 10

This change is major and will require education of staff/providers; a computer system to manage this process (for claims) and the ability to convert current coding to future coding

14,000 codes to 70,000 codes

Money for care providedOnce you begin involving a third party

(insurance) into this process many rules you work under change

Patients have co-payments, deductibles and services paid based on a “contract” not your current methods

The rules of the third party supersede what you may want to do (there is no “take what insurance pays”

Insurance programs require…The providers who are billing for services be

the providers that are rendering care (one cannot substitute provider A for provider B)

The documentation supports the services billed under the identified provider

Certain policies about coverage for services

Claims are submitted electronically and payment accepted electronically

As part of the insurance world…You become just like a doctors office or

facility

Verification of patient status (yes this may mean a photo ID)

Collection of a co-pay at the time of careAdvance notification of non covered services

(which you may be expected to know)Balance billing for services applied to a

deductible, co-insurance or denied as non covered

A side not about “agency issues”

Depending on how your agency does business and coordinates your part of the “county” you may need to consider…

A DBA tax identification number to keep your business and practice clean from the rest of the county

A lock box or unique bank account that can handle direct deposits and not co-mingle with general funds for tracking purposes for AR management

A reporting system to your county finance department that may include the ability to refund patients or insurance if mistakes are made….

Claim forms…As a “practice” you would submit your

claims on a CMS 1500 form

This is “red” but 99% of the forms go via the internet… soBilling service or system to submit

electronically

Ability to receive remittance electronically

HIPAA 5010 compliant

The completion of the form..Requires accurate data of…

NameDOBAddressSS#

CPT and ICD codesProvider numbers, location codes, NPI numbers

CredentialingThis process is the examination and

review of the credentials of individuals meeting a set of educational or occupational criteria and therefore being licensed in their field. Strict credentialing is required by both hospital and managed care accreditation bodies. The process is conducted periodically because of the responsibility of the organization for any claims of malpractice by its staff

For an agency…This means that you must have the

professional level of staff to meet the requirements to credential to become a provider

MDDOAPNPA with the identified supervisory physician

Part of credentialing…The standard process for identified providers

is the CAQH format

http://www.caqh.org/form_provider_practice.php

This web site has information about how this process works on both the provider side and insurance side

Medicare and Medicaid still need their own Applications

Medicare via CGS (Cigna)http://cgsmedicare.com/OHB/index.html#You MUST have a National Provider Identifier

(NPI). An NPI is required for a change of information or to apply for a new Medicare number. Your application will be delayed if you fail to provide an NPI with your original submission. See below for additional details.

You MUST agree to accept Electronic Payment. This federally-mandated requirement applies to established providers submitting a change of information that are not already set up for electronic payment, as well as all new enrollees. An Electronic Funds Transfer Authorization Agreement (EFT) form must be included with your application request. Your application will be delayed if you fail to include a completed EFT Agreement with your original submission. See below for additional details.

Medicaid… through ODJFShttp://jfs.ohio.gov/OHP/index.stm

Effective 8/2/2011: The Ohio Department of Job and Family Services (ODJFS) has implemented the new Medicaid Information Technology System (MITS). Please click here to enroll as a new Medicaid Provider, click here to check enrollment status or click here to login to the secure MITS portal to update demographic information as an existing provider

Medicaid provider unit…For additional information please contact us:

. Provider Enrollment UnitP.O. Box 1461Columbus, Ohio 43216-1461

Please listen to the entire message before making your selection Telephone: 1-800-686-1516, select option 3, then option 1, then option 1 again, then option 4

Monday through Friday, 8:00 a.m. to 4:30 p.m

Medicaid managed care…Will not enroll you until you have a valid

Medicaid provider number

May have different rules and process from traditional Medicaid (and vice versa)

They all have links on the internet…

Medicaid plans…CareSource -

http://www.caresource.com/en/Pages/default.aspx

Buckeye - http://www.bchpohio.com/

Molinahttp://www.molinahealthcare.com/medicaid/members/oh/Pages/home.aspx

Amerigrouphttps://www.myamerigroup.com/English/Medicaid/oh/Pages/Ohio.aspx

Credentialing…Requires time and patience

About 6 months from start to provider status (in the best case)

Requires diligence in maintaining contact information, update status and monitoring of process

Are there places that do this for you? Yes

Immunizations…The rules differ for children and adults

The Vaccine for children is only until age 18 (you know that!)

For adults insurance plans may or may not cover this services

The codes for administration are based on method…

90471 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid)

90472 Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

90473 Immunization administration by intranasal or oral route; 1 vaccine (single or combination vaccine/toxoid)

90474 Immunization administration by intranasal or oral route; each additional vaccine (single or combination vaccine/toxoid) (List separately in addition to code for primary procedure)

But Medicare has …G0008 Administration of influenza virus

vaccine

G0009 Administration of pneumococcal vaccine

G0010 Administration of hepatitis B vaccine

And then the actual vaccine…90632 Hepatitis A vaccine, adult

dosage, for intramuscular use90650 Human Papilloma virus (HPV)

vaccine, types 16, 18, bivalent, 3 dose schedule, for intramuscular use

90744 Hepatitis B vaccine, pediatric/adolescent dosage (3 dose schedule), for intramuscular use

90715 Tetanus, diphtheria toxoids and acellular pertussis vaccine (Tdap), when administered to individuals 7 years or older, for intramuscular use

What if…The insurance does not pay us the cost of

the immunization or drug…

Can we balance bill the patient? NOCan we collect at the time of service? NOCan we collect the difference between the

payment and the cost?NO

Do we have to submit to insurance if we are contracted if we know they do not pay enough to cover the cost? (yes)

Patient verification processThis is the process that before a patient is

provided service you..

Validate who they areWhat their coverage isWhat the co-pay may beIf the service is considered self pay

Works for scheduled patient but walk ins…

What is compliance…This is the process of following identified rules

and regulations as they relate billing (submission of claims) to insurance, Medicare, Medicaid..

The service was provided – by who it is billed under

The service is documented and coded and then submitted as provided

Collection of balances is based on claims processed

Write off, adjustments and billing are consistent with standards in the industry

Compliance requires…Staff understand the rules and change in

process

Follow the rules and do not make exceptions

Monitor themselves and others to assure that the care provided is the care billed is the care collected

Fee schedules…Can a setting have more than one fee

schedule?

Yes, but it must be based on set criteria

Can we have a sliding fee schedule based on income

Yes as long as it is consistent and documented how the fee schedule was determined for a patient and that it is monitored on a regular basis

How to set the fee schedule…Many settings use the Medicare fee schedule as

the basis for all services they provide and bill because it is on the internet, and the basis for how you are paid by commercial insurance plans

The rate of payment from insurance plans ranges from 85% to 150% of the Medicare fee schedule

Use of the Medicaid fee schedule – an option but you may leave $ on the table

Who can use CPT codes…The CPT code book is updated every year

The Codes in the book are specific to providers who are “eligible” to provide and receive payment by Medicare or insurance plans alone

What this means is – that just because a “nurse” provides a high level of assessment in your setting does not mean they can use these CPT codes

CPT codes…Each CPT code has an identified relative

value (RVU) that is based on CMS guidelines and process

The diagnoses does not change the payment for a CPT code or service – it either validates the care or not

Are 5 numbers long and…

CPT codes are broken down into various “types”

Are codes that have “5” digits which have a unique order and type

E&M services that start with “99xxx”Procedure codes start with 1, 2, 3, 4, 5, 6Codes that end in “f” are PQRI (and some G

codes as well)Radiology services start with 7 – and requires

“17 and 17ALab services start with 8 – and requires 17 and

17A Additional “medical services” start with 9xxxInjections and supplies or HCPCs codes (alpha

numeric codes)

Resources for “stuff”Where do you begin to educate yourself on

this process and regulations..

This depends on the services you provide

Medicare and the CGS web site is a good place to begin for all things Medicare

ODJFS is the place for Medicaid

Other programs…Credentialing can be programs can be found..

Decision Health - http://www.decisionhealth.com

AHIMA – for coding and general programs

http://www.ahima.org/continuinged/campus/courseinfo/cb.aspx

Many on line resources

Other types of programs..Ohio State Medical Association – OSMA.org

Community colleges and trade schools

Medical billing programs – TRI C in Cleveland, St. Clair in Dayton, Capitol in Columbus

Boot camps and one day programs – but check to make sure they are “Ohio” based

The road begins!