Accurate medical billing is crucial for emergency room physicians for fair compensation and compliance with OHIP guidelines. However, ER billing is complicated, with many potential areas for errors and lost revenue.
To help you avoid errors with special visit premiums (SVPs) and critical care codes and better understand how to maximize billings for assessments and procedures, our billing team has answered your most frequently asked questions regarding the most common ER billing challenges and how to overcome them.
Frequently Asked Questions
What are the most common areas ER physicians miss out on optimizing billings?
One of the most common mistakes we see with physicians is using the wrong special visit premiums for a specific time or day. Beyond this, doctors often forget to add these premiums to their claims, leaving money on the table.
The most common rejection codes for critical care and procedure codes seen by physicians are M4 errors, which physicians receive on the error report if the maximums for those codes have been exceeded.
For H-prefix assessment codes, a common error that physicians sometimes encounter is billing a weekend and holiday assessment on a weekday or vice versa, resulting in a V4 error code.
Lastly, we see physicians not challenging some of the rejections they receive. Rejections can be fixed with a manual review and by providing supporting documentation. For example, including multiple fractures on different limbs or when a physician provides an assessment and critical care on the same day for the same patient.
Do you do billing for individual doctors in an ER department, or does it have to be for the whole group?
We do both! If the ER is AFA (Alternate Funding Arrangement), then the ER is the client, and we bill for every doctor in that ER. If the ER is FFS (Fee-for-Service), then individual doctors are responsible for their own billing. We call these “solo clients,” as in this case, the physician is the client. There are pros and cons to being AFA vs FFS, which is a decision that the ER makes as a group. The more clients we have in any given group/ER, the easier it is on everyone, as we have greater visibility throughout the ER.
I have a lot of manual reviews for my claims. Do doctors still have six months to submit them, or is it three months now with the new changes?
You have three months from the date of service to submit a claim for the first time, manual review or not. The goal is to get it onto a Remittance Advice (RA) before it becomes a stale claim. Once a claim is on an RA, you have seven months to submit an inquiry for the first time.
If there is evidence that the claim was originally submitted within the three-month window, but it has become stale before getting onto an RA (for example, it bounced back on an error report and is too stale to resubmit), you may have options for submitting it to the MOH as a stale claim. However, this is a lot of extra work, so we encourage our clients to submit their work as regularly as possible.
What codes can be billed with the consultation H065/H055? For example, can we bill a Form 1, critical care, and procedures codes such as fracture or suturing?
Form 1 (K623) can be paid with a consultation (H055/H065) if the diagnoses differ significantly. The diagnostic code billed alongside the consultation cannot be 799/796 as they are too vague. Billing the consultation with 781 and the K623 with 300, is correct.
A consultation can be paid with critical care for the same patient on the same day, as long as the times for both visits are provided in a manual review. For example, “H065 at 2:00 p.m. for headache. Called back STAT at 4:30 p.m. for critical care following seizure.” In this situation, these separate visits should have separate diagnoses.
Consultation codes can be paid alongside those for fractures or suturing. If premiums E412/E413 apply, be sure to add them!
Can you clarify if H-prefix codes and K-prefix codes can be billed together?
You can bill ER H-prefix assessments (H065, H123, etc.) with mental health codes (K005, K015, K623, etc.) as long as they have significantly different diagnoses (diagnostic codes cannot be 799/796). K623 is not covered in the Schedule of Benefits, but K015/K005 can be corrected/argued retroactively (see page GP58 and A17 in SOB). Other K-codes, such as home care application (K070) or phone calls/consultations (K733/K734/K735) are usually allowed.
You cannot bill ER assessments (H065, H123, etc.) with any special visit premiums, including H-prefix special visit premiums or K-prefix special visit premiums. You must use general assessments (A005, A003, etc.) instead.
Are special visit premiums (SVPs) submitted as shadow billing or outside of the AFA?
All billing done within the ER can be billed through the AFA using H-prefix special visit premiums and K-prefix special visit premiums.
All “calls to the floor,” also called “shadow billing,” are considered fee-for-service/solo billing. This is for critical care only, and are billed as inpatients with C-prefix special visit premiums codes. These are not billed through the AFA, and you are entitled to 100% of the service fee. This must be billed separately from your group billing, either as locum billing or through a separate “code blue group” that the ER manages.
Do you see billing rejected more commonly from AFA or FFS sites?
It is easier to troubleshoot problems when we have full visibility within an ER, as in the case of the AFA groups we manage. This is because we have visibility into what other physicians in the group have billed and can better determine why something is not being paid.
The automated rejections on error reports do not differentiate between AFA and FFS.
There are ER departments in remote areas which are staffed by telemedicine. Do you help with billing for that?
We can help bill telemedicine codes and phone/video appointments using modifiers implemented during the pandemic. The codes K300 and K301 are still used, as outlined in the Schedule of Benefits.
What is required for the comprehensive billing codes: H102, H122, H132 & H152?
The definition in the Schedule of Benefits states: Comprehensive assessment and care is a service rendered in an emergency department or Hospital Urgent Care Clinic that requires a full history (including systems review, past history, medication review and social/domestic evaluation), a full physical examination, concomitant treatment, and intermittent attendance on the patient over many hours as warranted by the patient’s condition and ongoing evaluation of response to treatment.
It also includes the following as indicated:
- interpretation of any laboratory and/or radiological investigation; and
- any necessary liaison with the following: the family physician, family, other institution (e.g. nursing home), and other agencies (e.g. Home Care, VON, CAS, police, or detoxification centre).
I don’t use an EMR and submit my billings on day sheets. How do you work with this type of billing?
We ask that you submit your billing sheets promptly—unless you have time-sensitive codes, weekly is a best practice. We prefer you email your billing sheets as it is the fastest way to receive them and get them to your agent as securely as possible. However, at this time, fax, mail, and courier are also options that can be discussed on a case-by-case basis.
If you send us originals through the mail or drop them off, you can request that they be returned to you or made available for pick up. Otherwise, we securely shred any printed copies after three months.
I receive a lot of errors from my billing. Can Trillium help with this?
We can! We will reconcile every rejection you receive from the MOH, from error reports to your remittance advice. Most of this is done automatically, with minimal involvement from the doctor. We will reach out if we need supporting documentation, or if any resubmission requires input (such as a code change).
What is the benefit of having Trillium oversee our department’s billings?
The main and most important benefit is reducing the administrative load on you and your team, allowing you to focus more on providing exceptional patient care. Additionally, by letting us manage your billing, you will ensure that your errors and rejections are minimized and that your billing is optimized to maximize your revenue potential. Our billing specialists will regularly review your billing to identify opportunities to maximize revenue.
Resources
We have created additional resources to help doctors navigate the complexities of Emergency Department billing:
A Guide to ER Special Visit Premiums
We’re happy to help!
Contact us today to book a meeting with one of our expert team members!
