Billing Boot Camp I: Basic Training

1 2016 by the American Pharmacists Association. All rights Boot Camp IMary Ann Kliethermes, BS Pharm, PharmDSandra Leal, PharmD, MPH, FAPhA, CDEG loria Sachdev, BS Pharm, PharmD2 Billing Boot Camp I: Basic Training3 Disclosures Mary Ann Kliethermes is co-owner of Clinical pharmacy Systems Inc. [INSERT FACULTY NAME(S)] [INSERT THE FOLLOWING TEXT IF NO CONFLICTS EXIST: declare(s) no conflicts of interest, real or apparent, and no financial interests in any company, product, or service mentioned in this program, including grants, employment, gifts, stock holdings, and honoraria. OR LIST THE CONFLICTS ]The American Pharmacists Association is accredited by the Accreditation Council for Pharmacy Education as a provider of continuing pharmacy Target Audience: Pharmacists ACPE#: 0202-0000-16-012-L04-P Activity Type: Knowledge-based5 learning Objectives Explain Basic Billing terminology. Discuss the types of Billing opportunities for pharmacists services.

2 Explain general requirements for Billing patient care services in the health care system, including medicare . Identify the key Billing decision makers and their influence on pharmacists Billing services. Describe medication therapy management and Billing codes for incident to physician services and how these codes are used to bill for pharmacists patient care Codes 1 HCPC (Healthcare Common Procedure Coding System) that include the incident to Evaluation & Management codes which providers may use to support pharmacist by medicare Part B for Billing by the Resource-based Relative Value Scale (RBRVS) of the above 2016 by the American Pharmacists Association. All rights (Ambulatory Payment Classifications) Codes are used in which setting? Hospitals or health-systems for facility fee services in their ambulatory clinics Physician offices for diabetes education services Assisted living and group homes for clinical provider services For in-home services provided by medicare Part B providers8 Which one of the following statements is NOT a CMS criteria for Billing incident to physician in a hospital-based outpatient clinic?

3 Have an have Direct Physician have a continued physician relationshipD. Must be considered a recognized provider9 Which of the following is a TRUE Statement? CPT codes can be billed under medicare Part CPT codes can be billed under medicare Part is required by medicare to be provided by is an opt-in requirement of medicare prescription drug plans10 What are key opportunities for pharmacists to comment on impending medicare rules? is never an opportunity for pharmacists to comment on the Notice of Proposed the Interim Final the Final Rule is implement11 Je ne sais pa UnderstandingBilling LanguageMary Ann Kliethermes, BS Pharm, PharmDVice-Chair, ProfessorChicago College of PharmacyMidwestern University12 learning Objective Explain Basic Billing terminology Words and acronyms you should know and have a Basic understanding of what they mean 2016 by the American Pharmacists Association. All rights the languagePayerSite/typeCoding Services DiseaseForms Rules14 Whose language do we need to understand?

4 Federal MedicarePart A Part BPart CPart DStateMedicaidInsurance exchangesCommercial or PrivateEmployer basedGroupIndividual15 Commercial Health Insurance LanguageConventional indemnity plan Allows the participant the choice of any provider without effect on reimbursement. Reimburse as expenses are (Preferred provider organization) Coverage is provided through a network of selected health care providers. Enrollees may go outside network, but incur larger costs. EPO (Exclusive provider organization) A more restrictive type of preferred provider organization plan. Employees must use providers from the specified network. There is no coverage for care received from a non-network provider except in an emergency Model HMO Contracts with a single multi-specialty medical group, the group may only see HMO patients or it may also provide services to non-HMO patients. Staff Model HMO Closed-panel, members receive services only from providers who are HMO Model HMO Contracts with multiple physician groups to provide services to (Individual Practice Association) HMO A group of independent providers who maintain their own offices and band together to contract their services HMOs.

5 HMO (Health maintenance organization) Assumes financial risks associated with providing medical services & for health care delivery usually in return for a fixed, prepaid fee. Reimbursement only to HMO (Point-of-service) A POS plan is an "HMO/PPO" hybrid Resemble HMOs for in-network services. Outside of the network are reimbursed like an indemnity plan ( reimbursement based on a fee schedule or usual, customary and reasonable charges).PHO (Physician-hospital organization) Alliances between providers & hospitals to help providers attain market share, improve bargaining power & reduce administrative costs. Sell their services to managed care organizations or directly to Supplemental Plans Pays the medicare deductibles, copayments, and other expenses18 Demystifying the languagePayerSite/typeCoding Services DiseaseForms Rules 2016 by the American Pharmacists Association. All rights : Center for medicare and Medicaid Services(HCFA Health Care Financing Administration old name) medicare Part A Universal benefit Covers Hospitals, Health Systems Long term care Hospice and Home HealthMedicare Part B Must Opt out Must have contributed to Social Security Covers outpatient servicesMedicare Part C May opt in medicare Advantage Administered by commercial payersMedicare Part D May opt in Administered by commercial payers (PDPs)HospitalPDPsCommercialPayersProvid er20 medicare Part A Inpatient ServicesGoverned by IPPS (Inpatient Prospective Payment System) MS-DRGs (Medical Severity Diagnosis Related Groups) Over 700 clinically cohesive groups that demonstrate similar consumption of hospital resources and length of stay Example MS-DRG 007 liver transplant Revenue Codes (4 digits numeric) Example 0120 Room and Part BGovernance documents PFS (Physician fee schedule)

6 EHR Incentive Programs Meaningful use PQRS (Physician Quality Reporting System) HOPPS (Hospital Outpatient Prospective Payment System) for Part B and Outpatient Hospital ServicesGoverned by HOPPS (Hospital Outpatient Prospective Payment System) APC or Facility Fee Code Pays the hospital the costs of using the facility to provide services to the beneficiary Where hospital employees may bill for Part B Provider List Anesthesiology Assistants Audiologists Certified Nurse-Midwives Certified Registered Nurse Anesthetists Clinical Nurse Specialists Clinical Psychologists Clinical Social Workers Mass Immunization Roster Billers, individuals Nurse Practitioners Physical/Occupational Therapists in private practice Physicians (Doctors of Medicine or Osteopathy, Doctors of Dental Medicine; Dental Surgery; Podiatric Medicine; or Optometry) Physician Assistants Psychologists practicing independently Registered Dietitians or Nutrition Professionals Speech-Language Part CMust provide enrollees with all Part A and Part B servicesMay also provide Part DRules on relationships with providers Interfering with patient/provider relationship Incentives to providers Inclusion/exclusion of providers Cost sharingCMS Call 2016 by the American Pharmacists Association.

7 All rights Part D Governed by the CMS Call Letter CY 2016 Medication Therapy Management Program Guidance and Submission Instructions Memo the languagePayerSite/typeCoding Services DiseaseForms Rules27 Language of medicare Reimbursement medicare Coding System HCPCS (Healthcare Common Procedure Coding System) Level 1 CPT (Current Procedural Terminology codes) 5 numeric digits ex. 99605 Level 2 Codes for product supplies and services not covered under CPT (ambulance and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician's) Single alphabetical letter followed by 4 numeric digits28 Level 2 HCPC codes A-codes: Transportation, Medical Supplies, Experimental B-codes: Enteral & Parenteral tx C-codes: Temporary Hospital Outpatient Prospective Payment System D-codes: Dental Procedures E-codes: Durable Medical Equip. (DME) G-codes: Temporary Procedures & Professional Services H-codes:Rehabilitative Services J-codes: Drugs Administered Other Than Oral Method, Chemotherapy Drugs K-codes: Temporary Codes for DME Regional Carriers L-codes: Orthotic/Prosthetic Procedures M-codes: Medical Services P-codes: Pathology and Laboratory Q-codes: Temporary Codes R-codes: Diagnostic Radiology Services S-codes: Private Payer Codes T-codes: State Medicaid Agency Codes V Codes: Vision/Hearing Services29 APC (Ambulatory Payment Classifications) CodesPays for most clinic and emergency department visitsOutpatient payment groups based on HCPCS codes Similar clinical services Similar resource consumptionAPC for Outpatient E/M service Describe use of space and supplies Describe involvement of hospital employees APC code 5012(was 0634) with HCPCS code G046330 CPT.

8 Current Procedural Terminology codesNomenclature to report medical services & procedures for paymentMaintained and owned by the AMAC ategory 1 ( 3 categories) Evaluation and management (E&M): 99201 99499 Example 99211 incident to code Anesthesia: 00100 01999; 99100 99150 Surgery: 10000 69990 Radiology: 70000-79999 Pathology and laboratory: 80000 89398 Medicine: 90281 99099; 99151 99199; 99500 99607 Example 99605 99607 medication therapy management services 2016 by the American Pharmacists Association. All rights Relative Value Scale (RBRVS) A system for describing, quantifying, and reimbursing physician services relative to one another. three components of physician services physician work (time, technical skill & effort, judgment & stress) practice expense (rent, wages) professional liability insurance Relative value unit (RVU) is assigned to each RVU s are determined by AMA Committee from physician survey and passed on to CMS to approve and adopt Must be budget neutral Based on Conversion factor that estimates the sustainable growth rate (SGR) and Geographic Practice Cost Index 32 Why are RVUs importantWork RVU x GPCIP ractice expense RVU x GPCIProf liability RVU X GCPIT otal RVU.

9 Total RVU conversion factor$$ for a CPT Codes: International Classification of Diseases, 10th Revision For classifying diagnoses and reason for visits in all health care settings. Codes may be 3, 4, 5, 6 or 7 alpha/numeric characters Code or codes from through , 69,000 codesNPI number: National Provider Identifier a unique 10-digit identification number issued to health care providers 34 What you did: CPT code Why you did it: ICD 10 Who did it: NPI numberCoding for billingRVUS35 Demystifying the languagePayerSiteCoding Services DiseaseForms Rules36 Language of Forms формы Health Care Financing Administration 1500 form (HCFA 1500) The official standard form used by individual health care providers ( , physicians, nurse practitioners) when submitting bills or claims for reimbursement to payers Primarily a federal government form, but used universally Uniform Billing (UB 92- old) and the updated UB-04 also called the CMS-1450 (new) used by facilities or institutions ( , hospitals, long-term care facilities) when submitting bills Government payers use UB-04, but some private payers may still use UB-92.

10 2016 by the American Pharmacists Association. All rights 1500 the languagePayerSiteCoding Services DiseaseForms Rules40 CMS General Rules Medically necessary as services or supplies that are proper and needed for the diagnosis or treatment of a medical condition and are provided for the diagnosis, direct care, and treatment of the medical condition, meet the standards of good medical practice in the local area, and are not mainly for the convenience of the patient or the provider Usual /Customary/Reasonable is the amount paid for a medical service in a geographic area based on what providers in the area usually charge for the same or similar medical OpportunitiesMedicare Part A Governed by HOPPS regulations Hospital bills Billing codes: facility fee APC 5012, G0463 Chronic Care Management APC 5011, CPT 99490 medicare Part B Governed by PFS (Physician Fee Schedule) regulations E&M codes Incident to codes 99211-99215 TOC (Transition of Care) 99496, 99495 CCM (Chronic Care Management) 99490 HCPC Level 2 codes AWV (Annual Wellness Visits) G0438, G0439 Diabetes Education G0108, G010942 Billing OpportunitiesMedicare Part C Relationship/contracting with Commercial PayerMedicare Part D Relationship/contracting with PDP MTM codesCommercial or Private Payer Like medicare Relationship/contracting 2016 by the American Pharmacists Association.