Elixir Medical Claims Management LLC

31/12/2014

11/12/2014

Back to Basic: All the Ways (Not) to Unbundle

A physician should not report multiple HCPCS/CPT codes when a single comprehensive HCPCS/CPT code describes these services. For example if a physician performs a vaginal hysterectomy on a uterus weighing less than 250 grams with bilateral salpingo-oophorectomy, the physician should report CPT code 58262 (Vaginal hysterectomy, for uterus 250 g or less; with removal of tube(s), and/or ovary(s)). The physician should not report CPT code 58260 (Vaginal hysterectomy, for uterus 250 g or less;) plus CPT code 58720 (Salpingo-oophorectomy, complete or partial, unilateral or bilateral (separate procedure)).

A physician should not fragment a procedure into component parts. For example, if a physician performs an upper gastrointestinal endoscopy with biopsy of the stomach, the physician should report CPT code 43239 (Upper gastrointestinal endoscopy …; with biopsy, …). It is improper to unbundle this procedure and report CPT code 43235 (Upper gastrointestinal endoscopy …; diagnostic, …) plus CPT code 43600 (Biopsy of stomach; …). The latter code is not intended to be utilized with an endoscopic procedure code.

A physician should not unbundle a bilateral procedure code into two unilateral procedure codes. For example if a physician performs bilateral mammography, the physician should report CPT code 77056 (Mammography; bilateral). The physician should not report CPT code 77055 (Mammography; unilateral) with two units of service or 77055LT plus 77055RT.

A physician should not unbundle services that are integral to a more comprehensive procedure. For example, surgical access is integral to a surgical procedure. A physician should not report CPT code 49000 (Exploratory laparotomy,…) when performing an open abdominal procedure such as a total abdominal colectomy (e.g., CPT code 44150).

18/11/2014

Dubai To Control Healthcare Cost Increases In Private Sector Hospitals

New regulations will cap the price increase for health services offered by the private sector at 4.22 per cent, the Dubai Health Authority said.

The Dubai Health Authority (DHA) has announced that it will implement a price regulation model for all health services offered by the private sector by 2015.

The new regulations will cap the price increase for health services provided by the private sector at 4.22 per cent, in line with the published rate of inflation by the Dubai Statistics Centre, the authority said in a statement.

As per the latest rules, a separate proposal is required for every service a health entity proposes to increase the fee for.

“This model essentially aims to regulate price increases of health services in the private sector,” said Essa Al Maidoor, director-general of the DHA.

“The price increase will be regulated in a calculated and transparent way so that it facilitates a sustainable health system.”

He added that the regulation will be applicable to all polyclinics, clinics and hospitals in Dubai and services provided to Dubai insurance policies.

“The aim of the price regulation model is to ensure balance between allowing price increases and protecting patient’s interest,” said Al Maidoor.

The DHA also said that all firms looking to increase prices should apply to the authority by the end of November.

“The price increase is applicable for 12 months and healthcare entities will not be able to increase prices for a year. This ensures sustainability, is fair towards providers and at the same time protects patient rights,” said Al Maidoor.

The DHA has urged all private providers to comply with the e-claims system, as it helps track the compliance of all financial transactions of the health sector.

“Through the e-claim link we can track the proper implementation of existing and approved price increases. In 2014, the e-claim portal received 900,000 claims per month and by the end of the year, the transactions will be worth approximately Dhs6 billion,” said Haider Al Yousuf, director of Health Funding at the DHA.

Almost 23 million services and eight million claims were recorded from the beginning of this year through the portal, the DHA said.

Healthcare service costs in the UAE have been skyrocketing over the last few years.

According to a research by the Cost Of Living report, consumers in the UAE spend the most among the GCC on healthcare with each person footing a bill of $1,200 on average every year.

The Emirates emerged as the most expensive country for consulting a general practitioner at an internationally certified hospital in the GCC.

The UAE also had the highest costs for routine, specialist and executive health check-ups and magnetic resonance imaging (MRI) scans in the region, the report showed.

committed - gulfnews

14/10/2014

Know how ICD-10-CM sequencing changes will affect rehabilitation services

ICD-10-CM guidelines Section II. Selection of Principal Diagnosis K. state that when patients undergo rehabilitation services, the principal diagnosis is the condition for which the rehabilitation is performed. Note that this is the opposite of ICD-9-CM guidelines, which require coders to report a code from category V57 as the principal diagnosis followed by a code to denote the condition for which the rehabilitation is performed.
Consider this ICD-10-CM scenario: A patient presents with left-sided (dominant) hemiplegia followed a cerebrovascular accident. Report I69.352 (hemiplegia and hemiparesis following cerebral infarction affecting left dominant side) as the principal diagnosis.
If the condition for which the rehabilitation is performed is no longer present, ICD-10-CM coding guidelines state that coders must report an aftercare code as the principal diagnosis.
Consider this ICD-10-CM scenario: A patient presents for rehabilitation services following a hip replacement. The patient underwent the hip replacement due to severe degenerative osteoarthritis that no longer exists thanks to the surgery. Report Z47.1 (aftercare following joint replacement surgery) as the principal diagnosis.
Coders must pay close attention to the specific diagnosis for which the rehabilitation services are performed and whether the patient still has this condition. Physician education is going to be very important for these cases.

12/10/2014

One License to practice all over UAE coming soon..

Dubai News (Zawaya). In a major move for the advancement of the health-care sector, medical licences will now be recognised across the UAE with effect from October 12, paving the way for medical professionals to work across the country.

The Dubai Health Authority is implementing an earlier agreement for unification of medical practitioners during the Arab Health Exhibition and Congress in January.

Dr Layla Al Marzouqi, acting director of Health Regulation Department at DHA, said it is excellent move. “ It’s like having a driving license that is recognised throughout the country. Doctors, nurses and healthcare professionals with licenses from the Health Authority of Abdu Dhabi ( HAAD ), Dubai Health Authority (DHA) and the Ministry of Health (MOH) will be covered under this. Which means a doctor from Dubai will be able to practice in Abu Dhabi without giving any additonal tests or adddtional primary verifications provided he applies for permissions, she said.

Eisa Al Maidour, Director-General of DHA, said that this move works as it seeks to unify medical practice and streamline the professional medical licensing process. “With the introduction of this process, all health-care professionals will be evaluated based on the same criteria across UAE,” she said.


For the time-being all professionals graduating from accredited local programmes within the UAE will be exempted from experience requirement so that they can begin practice in their field of medicine or nursing after completion of the medical programme and internship. For the first two years, they will work under supervision in a secondary or tertiary hospital.

Al Maidour also said that for certain certificate holders, the number of years required for a specialist physician/dentist to be a consultant has been reduced from eight to five years as a means to provide growth opportunities to medical professionals. He said that American board, Canadian board and Certificate of Completion of Specialist Training (CCST) certificate holders from UK will be eligible to be consultants directly.

05/10/2014

Are Technical Skills More Important than Leadership Qualities?

Technical Skills: Technical skills give you a base and the confidence to be an expert in the long term. Being the expert makes it difficult to delegate because you have to accept that your employees may or may not do it better than you. Leadership qualities are difficult to teach and incredibly subjective. I would be afraid if most of the professors I had in business school taught me leadership skills. - Marjorie Adams, AQB

Leadership Skills: While technical skills are nice, they're not essential for one to be an entrepreneur. Leadership skills, however, are paramount for success. As an entrepreneur, it's less important to know how to do everything and much more important to know how to outsource everything you can't do! - Alexis Wolfer,

03/10/2014

Understand pre-populated data risks / Copy paste of patient datas. If your physicians use templates
to document their services, make sure they understand the risk
of pre-populated data built in to their templates. A better option is
for the provider to enter the data at each visit. Often, this can be accomplished
with minimal typing by using a “point and click” functionality
that adds text to a note. For example, to document an ROS,
the physician would click on individual built-in phrases (e.g., denies
chest pain or positive shortness of breath with exertion) and that information
would be added to the clinic note. A process such as this is
not cloning because the provider must actively add the language, as
appropriate, for each patient encounter.