Billing Matters: December 15, 2017, Issue 001

December 15, 2017

In this issue:

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Encounter Numbers

Accurately recording encounter numbers on your claims allows the payment system to apply payment rules appropriately. In reviewing the physician billing data, the PRC notes that there are some billing practices where a new encounter number appears to be generated each time a patient is seen. In some cases this may be legitimate but when the practice is repeated multiple times, it may be a misunderstanding of the rules. This type of billing practice can lead to inappropriate payment of multiple surcharge benefits on a single patient on one date of service or overpayment of minor procedures and visits when billed on the same day. For example, PRC reviewed data that demonstrated the following billing practice:

Case study

Claims for HSC 03.05A, ICU services, a physician claimed multiple encounters with the same patients over the course of the day. Each encounter was recorded separately and a surcharge modifier was applied. An analysis of the data suggests that over the course of a one year period, nearly $200K in surcharge payments to one physician occurred as a result of changes to encounter numbers. This type of billing practice would put this physician at high risk for audit.

Focus on Education

The Schedule of Medical Benefits general rules defines “encounter” as the following:

GR 1.14 Unless otherwise stated, the term "encounter" used in this Schedule means each separate and distinct time a physician provides services to a patient in a given day as defined in GR 1.19. To be recorded as separate encounters, multiple services provided to a patient may not be initiated by the physician, or may not be a continuation of a service which began earlier in the day. An example of continuation of services is the time spent with a patient to review x-ray or laboratory results ordered during an examination of the patient earlier in the day. If the patient initiates the second and subsequent encounter(s) or the physician is requested to attend the patient by hospital or nursing home staff, additional encounters may be claimed.

But what does this actually mean?

A few examples might help to demonstrate the application of the rule:

1. A patient presents early in the day for a suspected ulcer. You send them for diagnostics; receive the results in the same day and follow up with the patient in person.

  • In this case, the service would be claimed using only one encounter and the total time providing patient management services for both interactions would be claimed using complex modifiers or prolonged consult/visit codes as appropriate.

2. A patient presents with a migraine headache. You treat the patient and send them home. Later in the day, the patient returns, on their own, with a worsened condition, you see the patient for the second time.

  • In this case two separate encounter numbers would be recorded.

3. A physician in the ICU sees multiple patients multiple times throughout his/her shift.

  • ICU visits (03.05A) are billed on a cumulative basis therefore only one encounter for each patient applies. The total time spent providing visit services should be apportioned appropriately to each patient using the calls field where every call represents 15 minutes.

4. A physician sees a patient for a laceration and examines the wound and the patient prior to stitching the wound closed. It is a small wound and the total time managing the patient's care is 30 minutes.

  • In this case the physician must only claim one service - either a visit OR the laceration. HSC 98.22A – laceration closure code is a minor procedure and may not be claimed in addition to a visit, where the visit and the procedure have related Dx codes.

How can you apply this to your practice?

  • Double check your billing software to ensure that a new encounter number isn’t generated every time you insert a second billing line for the same patient on the same day as it isn’t always appropriate.
  • Double check your billings to determine if your claims are each being submitted as a new encounter number when multiple services are claimed on a single patient at the same encounter. If you are not certain, pull a report from your billing software and review your statement of assessment from Alberta Health. This gets mailed (yes, paper mail) from Alberta Health.
  • Ensure that you have an understanding of how time-based codes work, services that are billed on a cumulative basis should be billed as one encounter number. Only in very rare instances would a second encounter apply.
  • Remember, if you call the patient back in the same day or are dealing with the same condition as you were earlier in the day, it is a continuation of the first service and only one encounter applies.

Claiming Surcharges

PRC’s Findings

Did you know that only one surcharge benefit may be applied per patient encounter? As mentioned in the article on Encounter Numbers, changing the encounter number in order to apply a surcharge modifier is inappropriate practice unless ALL of the criteria are met.

Focus on Education

Surcharge modifiers (EV, NTPM, NTAM, WK) may only be claimed in regional facilities,(non–rotation duty emergency rooms, physicians’ offices within the regional facilities are excluded). Surcharges may only be claimed when all of the following criteria are met:

  • A special call for attendance is made on the patient’s behalf
  • The physician responds to the call on an unscheduled basis outside of his/her normal working hours
  • The patient is attended on a priority basis
  • There is direct attendance by the physician

Surcharge modifiers may not be claimed for any of the following:

  • Any situation where the criteria above are not met
  • A change in encounter numbers where a second encounter by definition did not occur
  • Scheduled services that are provided after hours (e.g., weekend rounds of your patients in hospital)

Some examples

1. A physician gets called to the emergency department, and responds to a patient on a priority basis at 9:30 p.m. During the consultation, it is determined that the patient needs emergency surgery. The physician takes the patient to the OR and performs the procedure.

  • In this scenario, only one surcharge benefit applies, even if there is a break between the time of the consultation and the procedure. The surcharge should be claimed based on the time the encounter commences, in this case it would be the EV surcharge even though the procedure itself took place in the NTPM period (10 p.m. – 12 a.m.).

2. The physician sees the patient in his/her office, it is determined that the patient will need a procedure that is not performed in the physician’s office. The physician schedules the procedure at 6 p.m. at the hospital.

  • In this scenario, no surcharge benefit may be claimed as the service was scheduled in the after-hours period.

Questions? Comments? Please direct any inquiries to our new Peer Review Committee email address:

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