Injured By a Spacecraft? There’s a Diagnostic Code for That

July 15, 2008 @ 6:09 pm
By Jacob Goldstein | The Wall Street Journal Health Blog

So we’ve got this patient here who was injured in this spaceship accident. You know, just a routine, uh, orbital mishap. But how do we account for that? Oh, right, it’s ICD-9 code E845 — “Accident involving spacecraft.”

Apropos of nothing in particular, this billing code popped up on a couple of medical blogs last week (KevinMD and Dr. Secretwave101). Intrigued, we did a little reporting.

This extended definition notes that the code includes “launching pad accident,” but excludes “effects of weightlessness in spacecraft,” which has its own code (E928.0).

ICD (International Classification of Diseases) codes are the basic international health codes that exist for just about everything (as this spaceship thing suggests). They’re used both for billing purposes and for tracking trends in public health.

A spokesman for the Centers for Medicare and Medicaid, one of the key agencies that deals with the codes in this country, told us that E845 was in the current version of U.S. ICD-9 code when it was first published in 1979. The code was created by the World Health Organization as part of ICD-9, the spokesman said. Other places in the world use ICD-10, we’ve stuck with ICD-9-CM.

A little creative Googling turned up a citation of the same code all the way back in 1966.

Just because a code exists, it doesn’t mean anybody’s ever used it. “Whether someone was injured [by a spacecraft] or not was immaterial because somebody thought, ‘What If?’ ” Sheri Poe Bernard, a VP at the American Academy of Professional Coders told us.

It didn’t take much to get Poe talking about all the strange things that have their own codes. Bite of a non-venomous arthropod. Dog bite. Rat bite. Scorpion sting. “A centipede has its own code — E905.4,” she said. “Accident caused by paintball gun, E922.5 Accident by fireworks, explosion, E923.0″

If you can think of a way to be killed or injured, there’s a code for it. “Terrorism has all kinds of codes associated, involving marine weapons, aircraft, explosions, conflagration,” she said. “Terrorism involving nuclear weapons, E979.5; biological weapons E979.6; chemical weapons E979.7.”

Uh, thanks Sheri. If you need us, we’ll be huddling under our desk, fearing for our lives. What’s the ICD code for that?

 

Healthcare groups use ads to lobby lawmakers on Medicare bill

July 03 2008 | McKnight’s Long Term Care News

Congress may be on break this week, but two industry groups launched ads spurring the Senate to take action on a Medicare bill that affects nursing home residents and other older adults when it returns from the Fourth of July recess.

The American Medical Association unveiled an advertising campaign to encourage passing the bill, H.R. 6331. Targeted towards opponents of the legislation, the ads say the issue boils down to a choice: insurance company profits, or seniors and disabled vets who will lose their access to healthcare. Meanwhile, insurance lobbyists are working on their own anti-H.R. 6331 advertising blitz. They argue that the cuts to Medicare Advantage plans that would fund the bill would limit choices, reduce benefits and pass on higher costs to seniors.

This week, two harmful actions went into effect: the expiration of the exceptions process for Part B outpatient therapy caps, and a freeze on Medicare physician payments. Therapy caps, which affect nursing home residents, impose a $1,810 limit on physical therapy and speech therapy combined and $1,810 on occupational therapy for nursing home residents. Residents in Medicare-certified beds at a skilled nursing facility will not have therapeutic services covered past $1,810, according to a note from the Centers for Medicare & Medicaid Services. Others who exceed the cap, however, may obtain medically necessary therapy services at a hospital.

 

AMA launches campaign to cut waste from chaotic insurance claims process, unveils new health insurer report card

Delayed and inaccurate insurance payments add cost, inefficiency to health care system

June 16, 2008

CHICAGO — To help reduce the substantial administrative burden of ensuring accurate insurance payments for physician services, the American Medical Association (AMA) today launched the Cure for Claims campaign to help heal the ailing system of processing medical claims with health insurers, and unveiled the first AMA National Health Insurer Report Card on claims processing.

“The goal of the AMA campaign is to hold health insurance companies accountable for making claims processing more cost-effective and transparent, and to educate and empower physicians so they are no longer at the mercy of a chaotic payment system that take countless hours away from patient care,” said AMA Board Member William A. Dolan, MD.

The inefficient and unpredictable system of processing medical claims adds unnecessary cost to the health care system, estimated as much as $210 billion annually, without creating value. Physicians divert substantial resources, as much as 14 percent of their total revenue, to ensure accurate insurance payments for their services.

“Eliminating the inefficiencies of the billing and collection process would produce significant savings that could be better used to enhance patient care and help reduce overall health care costs,” said Dr. Dolan. “To diagnose the areas of greatest concern within the claims processing system, the AMA has developed its first online rating of health insurers.”

The AMA’s new National Health Insurer Report Card provides physicians and the public with an objective and reliable source of information on the timeliness, transparency and accuracy of claims processing by health insurance companies. Based on a random-sample pulled from more than 5 million electronically billed services, the report card provides an in-depth look at the claims processing performance of Medicare and seven national commercial health insurers: Aetna, Anthem Blue Cross Blue Shield, CIGNA, Coventry Health Care, Health Net, Humana and United Healthcare.

Key findings include:

• Denials. There is wide variation in how often health insurers pay nothing in response to a physician claim (from less than 3 percent to nearly 7 percent), and in how they explain the reason for the denial. There was no consistency in the application of codes used to explain the denials, making it extremely expensive for physician practices to determine how to respond.
• Contracted payment rate adherence. Health insurers reported to physicians the correct contracted payment rate only 62 to 87 percent of the time. Additional analysis will be necessary to determine how often these errors were tied to inaccurate payment. When health insurers report an amount that does not adhere to the contracted rate, it adds additional, unnecessary costs to the physician practice to evaluate the inconsistency.
• Transparency of fees and payment policies. More than half of the health insurers do not provide physicians with the transparency necessary for an efficient claims processing system.
• Compliance with generally accepted pricing rules. There is extremely wide variation among payers as to how often they apply computer generated edits to reduce payments (from a low of less than .5 percent to a high of over 9 percent). Payers also varied on how often they use proprietary rather than public edits to reduce payments (ranging from zero to as high as nearly 72 percent). The use of undisclosed proprietary edits inhibits the flow of transparent information to physicians, adding additional administrative costs to reconcile claims.
• Payment timeliness. Prompt pay laws appear to have been effective in ensuring a relatively quick response to physician’s electronic claim. Further analysis will be necessary to determine the extent to which this response is accompanied by accurate payment if the claim.

The report card will be available for the first time today on the AMA Web site.

“Physicians want to focus on caring for their patients, not fighting health insurance red tape that may delay, deny or shortchanged payments for their services,” said Dr. Dolan. “The report card provides a useful snapshot of how each of the nation’s biggest health insurers can improve the process they use to pay their bills.”

The report card demonstrates the inconsistency and confusion that results from each health insurer using different rules for processing and paying medical claims. This variability requires physicians to maintain a costly claims management system for each health insurer.

The report card also suggests that both physicians and health insurers can help reduce unnecessary administrative costs if electronic transactions and full transparency are widely adopted. The costs of re-submitting claims can also be reduced if health insurers make better use of voluntary fields and reason and remark codes in electronic transactions to communicate crucial information to physicians about their claims.

The AMA Cure for Claims campaign will empower physicians to create a systematic approach to claims management so they spend less time and resources on payment hassles with health insurers. To help physicians submit timely and accurate claims, the AMA has created the Practice Management Center, an easy-to-use online resource offering physicians and their staff members tools for preparing claims, following their progress and appealing them when necessary.

The Practice Management Center’s library of education materials and practical tools are available online.

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For additional information, please contact:

Robert Mills,
AMA Media Relations
(312) 239-4991 or (312) 464-5970

Last updated: Jun 16, 2008
Content provided by: Media Relations

 

DATA OWNERSHIP ISSUES FOR THE PHYSICIAN PRACTICE AND A MEDICAL BILLING SERVICE

Article Date: April 4, 2008

Medical billing services assist physician practices in billing, coding, accounts receivables and management activities. By outsourcing to a medical billing service, a physician practice may realize increased profitability by decreasing the administrative time and expense involved in the billing process. The relationship between the physician practice and a billing service is an important and complex one. The issues are not limited to the billing service’s effectiveness in collecting payments. Both the physician practice and the billing service will benefit from a clear agreement, appropriately documented, as to all aspects of their relationship, including matters relating to data ownership of medical records and termination of the relationship.

Information technology systems are making it easier to rapidly transmit medical records and associated claims data while also reconfiguring and manipulating the data to exchange. To protect patient’s privacy and security, the American Medical Association (AMA) and the Healthcare Billing Management Association (HBMA) encourage physician practices and medical billing services to consider discussing, agreeing upon and including provisions in their contracts regarding software and proprietary information, claims data-ownership with respect to both original and copies of physician practice records and termination procedures. Physician practices are encouraged to consider the value the relationship will bring to the practice before entering into an agreement.

Typically, the physician practice will provide a medical billing service with a variety of records required for various billing, coding, accounts receivable, and management activities. A medical billing service may incorporate the records into proprietary forms, templates and other tools to prepare reports for the physician practice. This document will list topics for physician practices to consider addressing with prospective medical billing services prior to entering into an agreement.

Definition of Physician Practice Records

Typically, three categories of records belong to the physician practice: (1) patient records, claims, Explanation of Benefits (EOB)/Remittance Advice (RA) and other documents containing patient information, (2) managed care contracts, fee schedules and other proprietary information of the physician practice itself, and (3) final reports, such as accounts receivable (A/R) registers, prepared by the billing service for the physician practice.

Definition of Medical Billing Service Records

Typically, three categories of records belong to the billing service: (1) internal notes and work papers prepared by its employees, such as records of conversations with third party payers relevant to documentation needed for appeals, (2) papers relating to the billing service’s software and other proprietary or licensed tools, and (3) other proprietary information of the billing service, such as the forms and templates used to prepare reports furnished to the physician practice. The billing service may also have proprietary or confidential information regarding its operations.

Transfer of Documents and Electronic Records When Relationship Terminates

Prior to entering into an agreement, the medical billing service and the physician practice should agree on how to handle any termination of the relationship. Questions to consider include:

• What materials should be returned by the billing service to the physician practice or a successor billing service, subject to any transition agreement, for the practice or successor billing service to: (1) enter patient and charge data into its computer system, or (2) seek to collect pending billings on health plan claims for the physician practice.

• Who has custody of the documents relating to health care claims filed, which generally fall into three categories: (1) source documents, usually in the form of copies of visit or operative notes, (2) payer generated data, such as EOBs, and (3) reports that the billing service generates on billing and management activities for its clients. Occasionally, when discussing these questions, both the physician practice and billing service should realize that a billing service may have a legitimate need to retain copies of or at least a right of access to any records—even documents owned by the physician practice, as discussed above, in order to document their services, particularly if the billing service codes physician claims.

• What should the format and media for the return of physician practices records be?

• When and how will electronic records be returned to the physician practice?

(1) What information will be provided in file layout?

(2) What file codes and programming will be given?

(3) Which patient account data on the billing service’s computer system or software will be returned to the physician practice or sent to a successor billing service?

• Who will own documents that do not contain protected health information, such as the coding notes, and other work products of the billing service? Will it be the original or copies?

• Who keeps original records and who pays for any copies?

• Who pays the cost of locating or transferring hard copy or electronic records to the physician practice or to a successor billing service?

• Under what circumstance will the physician practice (or a successor billing service) have access to billing and claim denial notes and records made by the billing service as it provided services to the physician practice?

Record Retention and Access – Points to consider and discuss

At a certain point in time, retained records cease to be of any value, typically upon the lapse of the longest applicable statute of limitations for a third party payer audit or legal actions as to which the records would be relevant. In the case of patient records in the custody of a billing service, the patient records will be copies only, with the originals of the patient’s records at the physician practice or facility at which the underlying care was rendered. Some of the considerations in this section apply principally to original records.

• When the applicable time frame for retention of records in the custody of the billing service expires, will the records be destroyed or returned to the physician practice?

  • What are the state and federal laws pertaining to the period of time records are to be retained?

  • To the extent that the billing service is a business associate of the physician practice, a written HIPAA business associate agreement should be in place documenting among other things how protected health information (either in paper or electronic forms) must be either destroyed or returned to the physician upon termination of the agreement with the billing service. This language can also provide for other equally secure methods of protected health information management upon termination. Additionally, physician practices should ensure that the underlying agreement with their billing services provides for safeguards to the confidentiality, integrity and availability of the protected health information disclosed to the billing service and any other confidential information. These provisions should comply with any state law that is more stringent than HIPAA, and be consistent with guidance from the physician’s professional liability carrier.

• Due to the cost of storage of voluminous paper records, a billing service may scan original paper documents and store them electronically.

  • Will electronic copies of paper records be accepted as the original document?

  • Does the state the physician practices in accept a scanned medical record or other business record as an original as long as the accuracy of the scanned document can be reasonably substantiated?

  • Will the original paper records be destroyed after such records are scanned?

  • If, for some reason, electronic scanning is not permitted due to cost or availability, will the paper records be stored on the billing service’s premises or, especially after the termination of the agreement, in an offsite storage facility?

  • Will there be any costs charged to the physician practice for storage of paper records by the billing service during or after the termination of the agreement?

• Selection of offsite facilities. A storage facility off the premises of the billing service needs to be secure both for the integrity and availability of the stored records and for compliance with HIPAA and state medical records laws. Ultimately, this is the physician practice’s responsibility, although the selection may be delegated to the billing service.

  • Who will pay the cost of storage at offsite facilities during the term of the relationship?

  • After termination, will the physician practice be responsible for the costs of storage or scanning of records retained on behalf of the physician practice (as opposed to for the billing service’s own purposes)?

Audit and Litigation Assistance and Record Searches

Certain records searches and data assembly may be time consuming if the search requires manual review of stored records. This may be the case where, for example, a records search is conducted by date of service rather than by patient name. Physician practices should expect a reasonable level of support from their billing services during the term of the relationship as “part of the service”, but may also anticipate incurring additional costs for assistance which goes beyond that level.

• During the term of the relationship, the billing service and the practice need to determine if there is a component included in the basic service for searching records and otherwise assembling information for litigation or third party payer audits.

• For more extensive work, discussions should include the fee the billing company will charge for personnel and reimbursement for associated costs.

• For services during and after the termination of the relationship, discussions should include the fee and other costs that is the responsibility of the physician practice, such as if the billing service will be reimbursed for copies of records it provides to the physician practice.

For more information on medical billing services, as well as further questions that should be asked before contracting with a medical billing service, AMA members can visit the Private Sector Advocacy (PSA) Website at http://www.ama-assn.org/go/psatools and download the complimentary flyer “What is a medical billing service?”

Prepared by the American Medical Association, Practice Management Center, along with the Healthcare Billing and Management Association, December 2007.

Questions or concerns about practice management issues? AMA members and their practice staff can email the AMA Practice Management Center at practicemanagementcenter@ama-assn.org for assistance.

Contact the AMA-PSA unit:

• Call (800) 262-3211 and ask for AMA-PSA.

• Fax information to (312) 464-5541

• Visit http://www.ama-assn.org/go/psa to access the AMA-PSA Web site.

Contact HBMA:

• Call (877) 640-4262 and ask for HBMA’s Billing Resource Center

• E-mail requests to info@hbma.org

• Visit www.hbma.org

This educational flyer was developed through a cooperative effort between the Healthcare Billing and Management Association and the American Medical Association. © Copyright 2007 American Medical Association. All rights reserved.