Billing, Coding, & Calculating Fees: Finding Success

Transcription

1 Billing, Coding, & Calculating Fees: Finding Success Janet McCarty American Speech-Language-Hearing Association

2 Today s Agenda BILLING: Learn how to bill for your services. CODING: Learn the codes that describe the services you provide. Use these codes to communicate with health plans. CALCULATING FEES: Learn how to determine fees for your services.

3 BILLING: Superbills Use a Superbill (Billing, Coding, Charges) List ICD-9 and CPT codes used most often in your practice Provide patient information Assign a diagnosis (ICD-9 code) Assign a treatment (CPT code) Provide provider information Total Charges:

4 ICD-9 & CPT Codes ICD-9 (International Classification of Diseases) codes describe the diagnosis CPT (Current Procedural Terminology) codes describe procedures performed

5 Filing A Claim Clinician decides whether patient or provider files claims If the patient files, you will need to provide a bill with CPT & ICD-9 codes, charges, and supporting documentation If you have a signed agreement with the health plan, you may need to file

6 Remember Health plan coverage is an arrangement between the patient and health plan. Clinicians provide necessary documentation, but always make it clear to patients that they are ultimately responsible for payment.

7 Review Patient s Policy Are audiology or speech-language services covered? Claim decisions are based on contract wording. Is coverage clear or vague?

8 Filing A Claim Be sure to obtain patient permission to supply the health plan with relevant documentation

9 Contact Provider Relations What is your provider status? Is your setting recognized (private practice, university clinic)? Do you need a provider #? What documentation is necessary? Pre-authorization needed?

10 National Provider Identifiers (NPIs) Effective May 2007, providers and organizations defined as covered entities under HIPAA will be required to have an NPI NPI will replace current health provider #s The Web site for on-line application for obtaining an NPI: ASHA Web site for NPI information:

11 Billing Policies Q. Can I waive co-payments? A. Usually not. Payers view the routine waiver of patient payments as a breach of contract. Medicare/Medicaid co-pay waivers are not allowed and are viewed as false claims.

12 Waiving Co-pays If provider s fee is $100, but the Medicare 20% co-pay is waived routinely, the federal gov t. says Medicare should be billed $64 (80% of $80 vs. 80% of $100), and submitting a $100 claim is a false claim.

13 Can I offer a sliding scale? Yes. Be sure to have a defined policy and procedure for consistent administration. Have a written policy that establishes guidelines for determining a patient s indigency. Contact local welfare clinics to learn the community standard. Medicare/Medicaid allows for limited documented indigency.

14 Examples of Health Care Provider Fraud Billing for services not performed Falsifying a patient s diagnosis to justify tests Upcoding, or billing for a more costly service than the one performed Unbundling, or billing for each stage of a procedure as if it were separate

15 Office Billing Policies Providers should monitor their practices to ensure compliance with all applicable federal and state laws when determining billing policies. For more information on Billing Policies, go to The ASHA Leader Online at

16 CODING You must be able to support your coding decisions with patient history, physician referral information, evaluation results, and other documentation that supports your professional judgment as to the cause of the patient s condition and required treatment.

17 Coding A Diagnosis Originally, coding allowed retrieval of information by diagnoses for purposes of medical research and education. Coding today is used to describe the medical necessity of a procedure. From: ICD-9-CM Volumes 1&2, p. 3

18 ICD-9 Coding Determine a diagnosis based on test results and assign a diagnostic code Assign the best, or most appropriate diagnostic code Be able to support the assigned code

19 ICD-9 Coding Determine the highest level of specificity, which means using the 5 th digit. For example: Don t use (symbolic dysfunction). Instead, use (symbolic dysfunction, unspecified), or (other; agraphia,, apraxia).

20 Coding To 5 th Digit Keep in mind that , , are subclassifications of 784.6, so when you use those codes, you are not excluding

21 Coding To 5 th Digit Assign 3 digits when there are no 4 digit codes. Assign 4 digit codes if there is no 5 th digit subclassification. Assign the 5 th digit subclassification code for those categories where it exists.

22 Coding Normal Results Many payers will not reimburse for evaluation results reported within normal limits. When coding an uncertain diagnosis ( suspected, rule out ), code the condition as if it existed. When testing produces a normal result, report the sign & symptom or chief complaint as the primary diagnosis.

23 Signs/Symptoms Associated With Aphasia; Language Disorders Difficulty speaking (speech disturbance) Difficulty understanding spoken language (aphasia) Cognitive deficits (symbolic dysfunctions, unspecified)

24 Signs/Symtoms Associated With Audiology Difficulty hearing in noise (unspecified hearing loss) Acoustic trauma (acoustic trauma, explosive, to ear) Delayed speech/language (dev. articulation disorder) or (delayed milestones; late talker/walker

25 Coding Procedures Use CPT codes to describe the service or treatment Choose the CPT procedure code that best describes the services

26 CPT Coding: Time Components There are no time components associated with many SLP/AUD procedure codes Asking for time-based codes can be risky Time is already factored into relative value process

27 CPT Coding: Using Modifiers -22 Unusual services: the service provided is greater than that usually required -52 Reduced services: procedure is partially reduced

28 CPT Coding Understand the CPT Process Step 1 & Step 2

29 The CPT Process Step 1 Owned by the American Medical Association (AMA) ASHA s Health Care Economics Committee proposes new codes Multiple-step process for approving new codes Collaboration with related organizations

30 The CPT Process Step 2 1. The AMA Relative Value Committee values the procedure, or new code, and makes a recommendation to CMS (Centers for Medicare/Medicaid) 2. CMS revalues the procedure taking into account: work, time involved, professional liability, equipment & supplies; then assigns reimbursement

31 CALCULATING FEES Health care providers have some flexibility when setting private fees. Clinicians can choose a pricing philosophy, and then gather available charge information to establish a fee schedule and negotiate health care contracts.

32 Choosing A Pricing Philosophy 1. Market-driven approach: Known as UCR (usual, customary, reasonable) ties medical pricing to industry trends in local communities; assumes patients are pricesensitive. 2. Relative value approach: Fees are tied to worth of a procedure and considers skill, time, risk. Medicare Physician Fee Schedule uses the relative value method.

33 Available Fee Data Compare your fees with the Medicare Physician Fee Schedule. Use the fee data (from Milliman) found in ASHA s Negotiating Health Care Contracts & Calculating Fees to determine average costs by CPT code. The Milliman fee data cannot be directly shared beyond ASHA members, but can be used as a reference for negotiating rates. National Fee Analyzer

34 Calculating Fees: WARNING Setting prices in collusion with colleagues is illegal. Avoid price-fixing, such as discussing fees with local providers.

35 Understanding Fee Data 50 th percentile: 50% of charges are below this rate; 50% of charges are at or above this rate. 75 th percentile: 75% of charges are below this rate; 25% of charges are at or above this rate. (Ingenix) Milliman data: average charges for services

36 Calculating the Medicare Reimbursement Rate CPT (Auditory Evoked Potentials; comprehensive) Physician Work RVUs 0.50 Practice Expense RVUs 2.06 Malpractice RVUs 0.17 TOTAL RVUs x $37.89 = $103.43

37 Fee Data CPT (Speech & Language Eval.) 50 th percentile: $ th percentile: $ Medicare rate: $ Milliman data: $152.71

38 Fee Data CPT (Speech-Lang. Treatment) 50 th percentile: $ th percentile: $ Medicare rate: $62.53 Milliman data: $117.66

39 Fee Data CPT (Comprehensive Audiometry Evaluation) 50 th percentile: $ th percentile: $ Medicare rate: $49.65 Milliman data: $86.04

40 Fee Data CPT (Tympanometry) 50 th percentile: $ th percentile: $46.36 Medicare rate: $21.98 Milliman data: $39.96

41 Establishing Fees Establishing fees takes care. Fees that are too high will lead to disputes with patients and payers. Fees that are too low will result in inadequate reimbursement.

42 Negotiating Better Reimbursement Rates 5 Step Process

43 Negotiating Better Reimbursement Rates Step 1 Determine the most common CPT codes -Codes that account for 75% of your total practice charges -Record the # of times you provided the service over 12-month period (CPT 92557: frequency 500)

44 Negotiating Better Rates Step 2 Determine your top payers -Focus on 3-4 payers = bulk of your reimbursement -Medicare/Medicaid use established fee schedules and do not negotiate

45 Negotiating Better Rates Step 3 Determine your reimbursement for each code -Note how much each payer allows for each code on your list -Calculate each payers reimbursement as a % of Medicare s fee schedule

46 Calculate Payer Rate As A % of Medicare Rate CPT Medicare Allowed Amt. Health Plan Rate Payer Payment as a % of Medicare Tymp. $21.98 $ %

47 Negotiating Better Rates Step 4 Review your fees for each code -Calculate your fees as a percentage of Medicare s rates -Update your fee schedule annually

48 Calculate Your Fees As A % of Medicare s Rate CPT Medicare Allowed Amt. Your Current Fee Your fee as a % of Medicare $21.98 $ %

49 Negotiating Better Rates Step 5 Organize and analyze the data -Compare rates between plans -If payer reimburses in full, may mean your fees are too low. Plan may be willing to pay more. -Consider raising fees or standardize all your fees at some % of Medicare, say 125%

50 Negotiating Better Rates Organize & analyze the data -Is one plan s rates lower, or is one code paid at a much lower % of Medicare than others? -Establish target reimbursement rates for your negotiations, say 120% of Medicare

51 Develop An Action Plan Negotiate individual fees: Your first contact might be Provider Relations rep, then the Contracting Manager Drop the plan: Rates too low, no longer accept patients. Patients may find another provider, or complain to their employer. Close to new patients if you don t want to drop a health plan completely.

52 Coding Examples Let s look at some patient cases and code the service and diagnosis.

53 Coding Example Case: Patient seen for voice prosthesis evaluation and fitting. ICD-9 diagnostic code: from physician (aphonia) primary vs. secondary diagnosis CPT procedure code: (eval for use/fitting of voice prosthesis)

54 Coding Example Case: Patient needs modification of trach-esophageal prosthesis during follow-up visit ICD-9 code: from physician aphonia CPT code: (speech-language treatment).

55 Coding Example Case: Audiological eval reveals sensorineural hearing loss bilaterally. Middle ear function WNL. ICD-9 code: (sensorineural hearing loss of combined types, bilateral) CPT code: 92557, 92567, 92568, (comprehensive aud., tymp., acoustic reflex testing, decay)

56 Coding Example Case: A 35 y/o male has impaired language & cognitive skills after head injury. ICD-9 code: (symbolic dysfunction, coded to 5 th digit) CPT code: (speech-lang. eval.)

57 Coding Example Case: 35 y/o male is cognitive/language impaired due to head injury ICD-9 code: CPT code: (speech-lang. treatment) OR (development of cognitive skills to improve attention, memory )

58 Coding Example Case: 4-month old boy is seen for auditory brainstem response (ABR) to rule out hearing impairment. ICD-9 code: (sensorineural hearing loss of combined types; bilateral) or (unspecified hearing loss) CPT code: (auditory evoked potentials); (evoked otoacoustic emissions; comp.); (tympanometry)

59 Coding Example Case: 5 y/o with unintelligible speech is diagnosed with language impairment and verbal apraxia. ICD-9 code: (apraxia) Verbal apraxia tests confirm this diagnosis. CPT code: (speech-lang. eval.)

60 Coding Example Case: Auditory rehabilitation for a 66 y/o female. ICD-9 code: 389s (Hearing Loss) CPT code: (auditory rehabilitation post-lingual hearing loss)

61 Coding Example Case: Patient has normal hearing. Q. How do you code the diagnosis? A. Code the referring diagnosis. (For example, /tinnitus; 389.9/unspecified hearing loss)

62 Coding Example Case: Patient seen for bedside swallowing assessment. ICD-9 code: (dysphagia) CPT code: (evaluation of oral/pharyngeal swallow function)

63 Coding Example Case: SLP performs a speech-language evaluation and treatment on the same date of service. What would you code? Answer: Eval (92506) and treatment (92507) are now allowed on the same date of service with modifier -59 (distinct procedural service performed on same day).

64 Coding Example Case: SLP participates in fiberoptic endoscopy but does not actually insert the endoscope. What would you code? Answer: (bedside swallow) because SLP did not actually insert the endoscope.

65 A Great Resource ASHA s Billing and Reimbursement Web Site: Coding for Reimbursement Private Health Plans Medicare Medicaid

66 Questions Billing questions? Coding questions? Fee questions?