health insurance billing week 10

Health Insurance Billing I Notes

Class Overview

  • Week 10 curriculum covers the following topics:

    • Chronic Disease Assessment Premium

    • Time Units

    • Counselling and Interviews

    • Example scenarios

    • Practice Exercise

Chronic Disease Assessment Premium

  • Definition:

    • A chronic disease is characterized as a condition or disease that has been diagnosed as long-lasting.

  • Key Points:

    • The Schedule of Benefits details the list of chronic diseases approved for premium payments.

    • Diseases not recognized as chronic by the Ministry of Health are not eligible for billing.

Conditions for Billing (continued)

  • The chronic disease premium cannot be billed if:

    • The diagnosis by the physician has not been established.

    • Billing premiums for chronic illnesses is restricted to assessments only.

    • Premium codes for chronic illnesses cannot be applied under the following conditions:

    • Assessments by physicians for patients admitted to hospitals.

    • Assessments for residents of long-term care facilities.

    • Assessments for patients presenting at the emergency department.

Specific Assessment Requirements

  • The chronic disease premium is payable in addition to an assessment when:

    • The assessment is a:

    • Medical specific assessment

    • Medical specific re-assessment

    • Complex medical specific assessment

    • Complex medical specific re-assessment

    • Partial assessment

    • Level 2 pediatric assessment

  • The chronic disease premium code is E078.

Summary of Premium Conditions

  • Criteria for claiming the chronic disease premium includes:

    • An established diagnosis.

    • Payment is only applicable in addition to specific assessments listed above.

    • The chronic disease must be listed among the approved chronic diseases.

    • Only designated specialties can claim these premiums.

    • The EMR (Electronic Medical Records) system automatically adds 50% to the procedure code when entered on a claim.

Time Units

  • Definition:

    • Time units correlate to the duration of service rendered, calculated based on minutes.

  • Details:

    • Each block of time corresponds to a unit; for instance, 20 minutes equates to one unit.

    • The number of minutes per block can differ according to the specific services provided.

Usage of Time Units

  • Time units are essential for billing when:

    • Delivering counseling or mental health therapy.

    • Performing procedures alongside therapy; excluding those listed separately in the Schedule of Benefits (SOB).

    • Planning subsequent assessments, procedures, or therapies.

    • Facilitating follow-up care.

    • Conducting interviews, and providing supplies, equipment, and personnel.

    • Engaging in critical care activities.

Time Unit Calculation

  • Billing for services is calculated in 30-minute increments.

  • The minimum direct contact time with the patient (or their representative) is crucial for billing purposes, summarized in a defined table.

Counselling and Interviews

  • Codes used:

    • K005 = Counseling

    • K002 = Interviews

  • Billing Criteria:

    • Based on time units relevant to all specialties.

    • Each unit is defined as the minimum increment; sessions must be separate appointments to be billable.

    • Services lasting less than 20 minutes do not meet the billing unit criteria.

    • These codes are referenced in the Family Practice/Practice in General section of the SOB.

Example Scenario

  • Case Study:

    • An endocrinologist sees Patient 1 for a medical-specific assessment focused on diabetes mellitus (chronic) on Tuesday at 1 p.m.

    • A 50-minute interview occurs subsequently with the patient's family at 2 p.m. (noted as a separate appointment).

Details to Record:

  • Procedure Code: A153A

  • Diagnostic Code: 250 (denoting diabetes mellitus)

  • Premium Code: E078A

  • Procedure Code for interview: K002A

  • Units for the interview: 2 (based on 50 minutes of counseling time)

Practice Exercise

  • Location: Accessible under the Week 10 folder in the Quiz Tool.

  • Assessment Weight: Graded, worth 2.5% of the total course grade.