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Insurance Abstract
A method, system and computer program product for generating an
electronic bill having optimized insurance claim items based on
an insurance carrier of a patient are provided. The method includes
receiving insurance carrier data which identifies a patient's insurance
carrier and patient data which identifies a patient. The method
also includes receiving treatment data which identifies a drug administered
to the patient and a procedure performed on the patient on a date
of service. The treatment data is processed to obtain nurse documentation,
such as treatment and/or flow sheets. An electronic bill is automatically
generated having optimized reimbursable insurance claim items including
predetermined codes based on the treatment data and the insurance
carrier data to facilitate approval of the bill by the insurance
carrier.
Insurance Claims
1. A computerized method for generating an electronic bill having
optimized insurance claim items based on an insurance carrier of
a patient, the method comprising: receiving insurance carrier data
which identifies a patient's insurance carrier and patient data
which identifies a patient; receiving treatment data which identifies
a drug administered to the patient and a procedure performed on
the patient on a date of service; processing the treatment data
to obtain nurse documentation, such as treatment or flow sheets
or drug inventory and reorder forms; and automatically generating
an electronic bill having optimized reimbursable insurance claim
items including predetermined codes based on the treatment data
and the insurance carrier data to facilitate approval of the bill
by the insurance carrier.
2. The method as claimed in claim 1, wherein the treatment data
also identifies at least one of: a drug dosage, time spent in administering
the drug and supplies used in administering the drug.
3. The method as claimed in claim 1, wherein the treatment sheet
includes at least one of: route taken to administer the drug, the
names of the drugs in the same concurrent infusion and time spent
to administer the drug.
4. The method as claimed in claim 1, further comprising applying
an appropriate modifier to at least one claim item on the bill.
5. The method as claimed in claim 1, further comprising adding
at least one predetermined code required for reimbursement of the
drug or the procedure.
6. The method as claimed in claim 1, further comprising verifying
that HCT level is recorded and meets a minimum level required for
reimbursement of the drug by the insurance carrier.
7. The method as claimed in claim 1, further comprising generating
remarks containing at least one of: a predetermined code, drug name,
drug dosage, drug waste and route taken in administering the drug.
8. The method as claimed in claim 1, further comprising generating
remarks to document when the patient provides the administered drug
to ensure reimbursement for administration of the patient-provided
drug.
9. The method as claimed in claim 1, wherein the drug is a chemotherapy
or non-chemotherapy drug administrated to the patient and wherein
the method further comprises issuing the appropriate code for the
administration of the chemotherapy or non-chemotherapy drug.
10. The method as claimed in claim 1, further comprising applying
a predetermined code to distinguish between types of administrations
and any concurrent infusions.
11. The method as claimed in claim 1, further comprising determining
a correct set of codes and respective quantity fields to bill the
correct representation of infusion times, drug quantities, including
waste and administration counts.
12. The method as claimed in claim 1, further comprising disallowing
multiple drug administrations unless a predetermined code is included
on the bill.
13. The method as claimed in claim 12, further comprising generating
a claim item with an associated predetermined code wherein a total
dosage of the drug is substantially equal to a sum of the dosages
of the multiple drugs.
14. The method as claimed in claim 1, further comprising ordering
the claims and sequencing the claim items of the claims in a manner
to facilitate approval of the bill by the insurance carrier.
15. The method as claimed in claim 14, wherein related administered
drugs and their respective predetermined codes are grouped together
in a single claim.
16. The method as claimed in claim 1, further comprising issuing
prompts for supplies by insurance carrier, issuing prompts for office
visits and tracking of chemo follow-up visits.
17. The method as claimed in claim 1, further comprising precisely
estimating drug waste.
18. The method as claimed in claim 1, further comprising collecting
and generating documentation in the treatment sheet to corroborate
the claim.
19. The method as claimed in claim 1, further comprising monitoring
and issuing alerts pertaining to elapsed infusion times, supplies,
drug package and vial sizes, and other services.
20. The method as claimed in claim 1, further comprising generating
various reports with the application of different fee schedules
and the usage of drugs by package and vial sizes.
21. A system for generating an electronic bill having optimized
insurance claim items based on an insurance carrier of a patient,
the system comprising: a processor operable to execute computer
program instructions; a memory operable to store computer program
instructions executable by the processor; and computer program instructions
stored in the memory to perform the steps of: receiving insurance
carrier data which identifies a patient's insurance carrier and
patient data which identifies a patient; receiving treatment data
which identifies a drug administered to the patient and a procedure
performed on the patient on a date of service; processing the treatment
data to obtain nurse documentation, such as treatment or flow sheets
or drug inventory and reorder forms; and automatically generating
an electronic bill having optimized reimbursable insurance claim
items including predetermined codes based on the treatment data
and the insurance carrier data to facilitate approval of the bill
by the insurance carrier.
22. The system as claimed in claim 21, wherein the treatment data
also identifies at least one of: a drug dosage, time spent in administering
the drug and supplies used in administering the drug.
23. The system as claimed in claim 21, wherein the treatment sheet
includes at least one of: route taken to administer the drug, the
names of the drugs in the same concurrent infusion and time spent
to administer the drug.
24. The system as claimed in claim 21, wherein the instructions
perform the step of applying an appropriate modifier to at least
one claim item on the bill.
25. The system as claimed in claim 21, wherein the instructions
perform the step of adding a predetermined code required for reimbursement
of the drug or the procedure.
26. The system as claimed in claim 21, wherein the instructions
perform the step of verifying that HCT level is recorded and meets
a minimum level required for reimbursement of the drug by the insurance
carrier.
27. The system as claimed in claim 21, wherein the instructions
perform the step of generating remarks containing at least one of:
a predetermined code, drug name, drug dosage, drug waste and route
taken in administering the drug.
28. The system as claimed in claim 21, wherein the instructions
perform the step of generating remarks to document when the patient
provides the administered drug to ensure reimbursement for administration
of the patient-provided drug.
29. The system as claimed in claim 21, wherein the drug is a chemotherapy
or non-chemotherapy drug administrated to the patient and wherein
the instructions perform the step of issuing the appropriate code
for the administration of the chemotherapy or non-chemotherapy drug.
30. The system as claimed in claim 21, wherein the instructions
perform the step of applying a predetermined code to distinguish
between types of administrations and any concurrent infusions.
31. The system as claimed in claim 21, wherein the instructions
perform the step of determining a correct set of codes and respective
quantity fields to bill the correct representation of infusion times,
drug quantities, including waste and administration counts.
32. The system as claimed in claim 21, wherein the instructions
perform the step of disallowing multiple drug administrations unless
a predetermined code is included on the bill.
33. The system as claimed in claim 32, wherein the instructions
perform the step of generating a claim item with an associated predetermined
code wherein a total dosage of the drug is substantially equal to
a sum of the dosages of the multiple drugs.
34. The system as claimed in claim 21, wherein the instructions
perform the step of ordering the claims and sequencing the claim
items of the claims in a manner to facilitate approval of the bill
by the insurance carrier.
35. The system as claimed in claim 34, wherein related administered
drugs and their respective predetermined codes are grouped together
by the instructions in a single claim.
36. The system as claimed in claim 21, wherein the instructions
perform the steps of issuing prompts for supplies by insurance carrier,
issuing prompts for office visits and tracking of chemo follow-up
visits.
37. The system as claimed in claim 21, wherein the instructions
perform the step of precisely estimating drug waste.
38. The system as claimed in claim 21, wherein the instructions
perform the step of collecting and generating documentation in the
treatment sheet to corroborate the claim.
39. The system as claimed in claim 21, wherein the instructions
perform the steps of monitoring and issuing alerts pertaining to
elapsed infusion times, supplies, drug package and vial sizes, and
other services.
40. The system as claimed in claim 21, wherein the instructions
perform the step of generating various reports with the application
of different fee schedules and the usage of drugs by package and
vial sizes.
41. The method as claimed in claim 1, further comprising generating
various fee schedules to accommodate data entry into a billing software
system and to facilitate financial analysis of patient encounters.
42. The method as claimed in claim 1, further comprising tracking
of drug usage in order to maintain inventory and to activate the
ordering of drugs for the practice.
43. A computer program product for generating an electronic bill
having optimized claim items based on an insurance carrier of a
patient, the product comprising: a computer readable medium; and
computer program instructions recorded on the medium and executable
by a processor for performing the steps of: receiving insurance
carrier data which identifies a patient's insurance carrier and
patient data which identifies a patient; receiving treatment data
which identifies a drug administered to the patient and a procedure
performed on the patient on a date of service; processing the treatment
data to obtain nurse documentation, such as treatment or flow sheets
or drug inventory and reorder forms; and automatically generating
an electronic bill having optimized reimbursable insurance claim
items including predetermined codes based on the treatment data
and the insurance carrier data to facilitate approval of the bill
by the insurance carrier.
Insurance Description
BACKGROUND OF THE INVENTION
[0001] 1. Field of the Invention
[0002] The present invention relates to methods, systems and computer
program products for generating an electronic bill having optimized
insurance claim items.
[0003] 2. Background Art
[0004] Currently, oncology physicians record the services for the
treatment of a patient on a paper checklist. This paper is often
called an: Encounter Form; a Superbill; or, in the case of hospital
and office examination visits, a Face Sheet. These items are checked
off and blanks are filled in to record the therapy and services
provided during a patient visit. The sheets of paper tend to be
incomplete and prone to errors. They are passed on to human medical
billers specialized in oncology billing, who translate the information
into a series of medical codes and billing quantities in order to
obtain reimbursement from insurance carriers. The codes and requirements
change frequently and vary significantly among the different carriers.
The ordering of these codes obtain affects timely reimbursement.
[0005] The U.S. patent to Rensimer et al. (U.S. Pat. No. 6,154,726)
discloses a system that allows the ability to record, transfer,
or save medical data from a portable system to a database system.
Also disclosed is a means of archiving patient information and generating
clinical status codes that can be used for reimbursements from insurance
companies.
[0006] The U.S. patent to Evans (U.S. Pat. No. 6,347,329) discloses
a system comprising a pen-based portable computer with wireless
access to electronic patient records. The system may incorporate
legacy files, such as paper files, from a patient's chart.
[0007] The U.S. patent to Gilbert (U.S. Pat. No. 6,381,576 B1)
discloses a database program employing diagnostic and treatment
information data structure that contains both clinical and financial
information permitting effective filtering and analysis of Current
Procedural Technology (CPT) codes as to accuracy and appropriateness.
[0008] The U.S. patent application publication to Porterfield (2002/0077854)
discloses a system for determining the best possible billing scenario,
in order to maximize reimbursements.
[0009] The U.S. patent application publication to Ibok et al. (2002/0116219)
discloses a method for wireless accessing a medical record via a
PDA, laptop, personal computer (PC) or other telephony device. Also
disclosed is a method for secure information transmission using
an authentication scheme. The system also includes an interface
with existing legacy information.
[0010] U.S. patent application publication 2003/0074228 discloses
an electronic medical record that is directed towards use in chemotherapy
applications.
[0011] Electronic medical records in billing scenarios are shown
by the following U.S. patents and publications: U.S. Pat. Nos. 6,223,164;
6,655,583; 2002/0091540; 2002/0120466; 2003/0083903; 2004/0204961;
2004/0199404; 2004/0128163; 2002/0123907; 2002/0087358; and 2002/0022972.
SUMMARY OF THE INVENTION
[0012] An object of the present invention is to provide an improved
method, system and computer program product for generating an electronic
bill having optimized insurance claim items.
[0013] In carrying out the above object and other objects of the
present invention, a computerized method for generating an electronic
bill having optimized insurance claim items based on an insurance
carrier of a patient is provided. The method includes receiving
insurance carrier data which identifies a patient's insurance carrier
and patient data which identifies a patient. The method also includes
receiving treatment data which identifies a drug administered to
the patient and a procedure performed on the patient on a date of
service. The treatment data is processed to obtain nurse documentation,
such as treatment or flow sheets or drug inventory and reorder forms.
An electronic bill is automatically generated having optimized reimbursable
insurance claim items including predetermined codes based on the
treatment data and the insurance carrier data to facilitate approval
of the bill by the insurance carrier.
[0014] The treatment data may also identify at least one of: a
drug dosage, time spent in administering the drug, and supplies
used in administering the drug.
[0015] The treatment data may also identify at least one of:
[0016] whether the patient brought in a drug, drug name and route
of administration;
[0017] oncology office visits (especially chemo follow-up visits);
[0018] other services (lab work, port flush, etc.);
[0019] patient answers to questions, comments and progress notes,
ECOG and Karnofsky values;
[0020] patient vitals, blood work, and symptoms;
[0021] vial size used and actual waste quantities; and
[0022] date of service and cycle and day/week.
[0023] The treatment sheet may include at least one of: route taken
to administer the drug, the names of the drugs in the same concurrent
infusion, and time spent to administer the drug.
[0024] The treatment sheet may also include at least one of:
[0025] any of the treatment data items;
[0026] patient name, date of birth, total chemotherapy infusion
time, total non-chemotherapy infusion time, signature lines for
the doctor and nurse, insurance carrier, primary and secondary diagnosis;
and
[0027] doctor name and practice.
[0028] The method may further include applying an appropriate modifier
to at least one claim item on the bill. However, it is possible
that a claim may not need any modifiers.
[0029] The method may further include adding at least one predetermined
code required for reimbursement of the drug or the procedure. For
example, both the J-Code and sometimes a DX2.
[0030] The method may further include verifying that HCT level
is recorded and meets a minimum level required for reimbursement
of the drug by the insurance carrier.
[0031] The method may further include generating remarks containing
at least one of: a predetermined code, drug name, drug dosage, drug
waste and route taken in administering the drug.
[0032] The method may further include generating remarks to document
when the patient provides the administered drug to ensure reimbursement
for administration of the patient-provided drug.
[0033] The drug may be a chemotherapy or non-chemotherapy drug
administrated to the patient. The method may include issuing the
appropriate code for the administration of the chemotherapy or non-chemotherapy
drug.
[0034] The method may further include applying a predetermined
code to distinguish between types of administrations and any concurrent
infusions.
[0035] The method may further include determining a correct set
of codes and respective quantity fields to bill the correct representation
of infusion times, drug quantities, including waste and administration
counts.
[0036] The method may further include disallowing multiple drug
administrations unless a predetermined code is included on the bill.
[0037] The method may further include generating a claim item with
an associated predetermined code. A total dosage of the drug may
be substantially equal to a sum of the dosages of the multiple drugs.
[0038] The method may further include ordering the claims and sequencing
the claim items of the claims in a manner to facilitate approval
of the bill by the insurance carrier.
[0039] Related administered drugs and their respective predetermined
codes may be grouped together in a single claim.
[0040] The method may further include tracking of chemo follow-up
visits.
[0041] The method may further include precisely estimating drug
waste.
[0042] The method may further include collecting and generating
the appropriate documentation in the treatment sheet to corroborate
the claim.
[0043] The method may further include suggesting charges via prompts.
[0044] The method may further include tracking of elapsed infusion
times.
[0045] The method may further include tracking cycle-day/week and
providing default dosages.
[0046] The method may further include generating various fee schedules
to accommodate data entry into a billing software system and to
facilitate financial analysis of patient encounters.
[0047] The method may further include the tracking of drug usage
in order to maintain inventory and to automate the ordering of drugs
for the practice.
[0048] Further in carrying out the above object and other objects
of the present invention, a system for generating an electronic
bill having optimized insurance claim items based on an insurance
carrier of a patient is provided. The system includes a processor
which is operable to execute computer program instructions. The
system further includes a memory which is operable to store computer
program instructions executable by the processor. Computer program
instructions are stored in the memory. The computer program instructions
receive insurance carrier data which identifies a patient's insurance
carrier and patient data which identifies a patient. The computer
program instructions receive treatment data which identifies a drug
administered to the patient and a procedure performed on the patient
on a date of service. The computer program instructions process
the treatment data to obtain nurse documentation, such as treatment
or flow sheets or drug inventory and reorder forms. The instructions
automatically generate an electronic bill having optimized reimbursable
insurance claim items including predetermined codes based on the
treatment data and the insurance carrier data to facilitate approval
of the bill by the insurance carrier.
[0049] The treatment data may also identify at least one of: a
drug dosage, time spent in administering the drug and supplies used
in administering the drug.
[0050] The treatment sheet may include at least one of: route taken
to administer the drug, the names of the drugs in the same concurrent
infusion and time spent to administer the drug.
[0051] The instructions may apply an appropriate modifier to at
least one claim item on the bill.
[0052] The instructions may add a predetermined code required for
reimbursement of the drug.
[0053] The instructions may verify that HCT level is recorded and
meets a minimum level required for reimbursement of the drug by
the insurance carrier.
[0054] The instructions may generate remarks containing at least
one of: a predetermined code, drug name, drug dosage, drug waste
and route taken in administering the drug.
[0055] The instructions may generate remarks to document when the
patient provides the administered drug to ensure reimbursement for
administration of the patient-provided drug.
[0056] The drug may be a chemotherapy drug administrated to the
patient, and the instructions may issue the appropriate code for
the administration of the chemotherapy drug.
[0057] The instructions may apply a predetermined code to distinguish
between types of administrations and any concurrent infusions.
[0058] The instructions may determine a correct set of codes and
respective quantity fields to bill the correct representation of
infusion times and administration counts.
[0059] The instructions may disallow multiple drug administrations
unless a predetermined code is included on the bill.
[0060] The instructions may generate a claim item with an associated
predetermined code wherein a total dosage of the drug is substantially
equal to a sum of the dosages of the multiple drugs.
[0061] The instructions may order the claims and sequence the claim
items of the claims in a manner to facilitate approval of the bill
by the insurance carrier.
[0062] Related administered drugs and their respective predetermined
codes may be grouped together by the instructions in a single claim.
[0063] Still further in carrying out the above object and other
objects of the present invention, a computer program product for
generating an electronic bill having optimized insurance claim items
based on an insurance carrier of a patient is provided. The computer
program product includes a computer readable medium. The computer
program product further includes computer program instructions recorded
on the medium and executable by a processor to: receive insurance
carrier data which identifies a patient's insurance carrier and
patient data which identifies a patient; receive treatment data
which identifies a drug administered to the patient and a procedure
performed on the patient on a date of service; process the treatment
data to obtain nurse documentation, such as treatment and/or flow
sheets; and automatically generate an electronic bill having optimized
reimbursable insurance claim items including predetermined codes
based on the treatment data and the insurance carrier data to facilitate
approval of the bill by the insurance carrier.
[0064] The above object and other objects, features, and advantages
of the present invention are readily apparent from the following
detailed description of the best mode for carrying out the invention
when taken in connection with the accompanying drawings.
BRIEF DESCRIPTION OF THE DRAWINGS
[0065] FIGS. 1-79 are screenshots generated by a computer programmed
with one embodiment of a computer program product of the present
invention.
DETAILED DESCRIPTION OF THE PREFERRED EMBODIMENTS
Improve Cash Flow by Expediting Claim Approval
[0066] An objective of the computer application is to increase
cash flow. Two avenues pursue this: expediting claim approval and
maximizing reimbursement. The first is by striving to obtain the
approval of claims during an insurance adjudicator's initial review;
thereby, avoiding additional intervention. Namely: resubmissions,
phone calls, and Statuses. The computer application pursues this
by consistently: [0067] 1. Applying the appropriate Modifier to
claim line items. A 25 Modifier is necessary for Office Visits on
the same day as chemotherapy or non-chemotherapy, except if the
insurance is Blue Cross. A 25 Modifier is also required for Level
I Office Visits to Medicare when there are no other services provided
on the same day. A 59 Modifier is required for Hydration unless
it is the primary procedure for the day. Refilling and maintenance
of portable pump (96520) and Introduction of needle or intracatheter,
vein (36000) always require a 59 Modifier. Medicare requires a 59
Modifier for Phlebotomy, therapeutic (99195). A 76 Modifier is required
for the reimbursement of Introduction of needle or intracatheter,
vein (36000) to multiple sites. [0068] 2. Verifying the coding of
the proper primary diagnosis code for certain procedures. For example,
a Phlebotomy, therapeutic (99195) requires Hemochromatosis (2750)
or Polycythemia Vera (2384). [0069] 3. Providing a secondary diagnosis
code for certain procedures that demand one for reimbursement, e.g.,
Urinalysis (81000) in an oncology setting requires a secondary diagnosis
code of 7910 (Proteinuria). The user defines this relationship in
ProcsAndCodes.
[0070] 4. Including a secondary diagnosis code, when it is required
for the reimbursement of a drug. The application allows the user
to optionally define one secondary diagnosis per drug (or procedure)
in ProcAndCodes. Some drugs require a different secondary diagnosis
codes depending upon the primary diagnosis of the patient, which
the application accommodates through logic within the program code.
TABLE-US-00001 Program Logic for Procrit (Q0136) and Aranesp (J0880)
SECONDARY If DX1 Description DX2 DIAGNOSIS 1400 to Cancer 28522
Anemia in Neo- 20497 plastic Disease 28529 Anemia of Chronic Disease
2859 Anemia 585 Chronic Renal Failure 2859 Anemia 2387 Myelodysplastic
Syndrome 2859 Anemia
[0071] TABLE-US-00002 Suggested Secondary Diagnosis Entries in
ProcsAndCodes DRUG J-CODE DX2 SECONDARY DIAGNOSIS Cimetidine J3490
78701 Nausea with Vomiting Atropine J0460 78791 Diarrhea Prochlorperazine
J0780 78701 Nausea with Vomiting Dexamethasone J1100 78701 Nausea
with Vomiting Diphehydramine J1200 78701 Nausea with Vomiting Anzemet
J1260 78701 Nausea with Vomiting Filgrastim/ J1440 2880 Agranulocytosis
Neupogen Filgrastim/ J1441 2880 Agranulocytosis Neupogen Polygam/
J1563 27903 Oth Selective Gammunex Immunoglobulin Defic Kytril J1626
78701 Nausea with Vomiting Iron J1750 2809 Anemia/Iron Deficient
Mannitol 25% J2150 59582 Irradiation Cystitis Sandastatin Lar J2353
78791 Diarrhea Oprevelkin/ J2355 2874 Secondary Neumega Thrombocytopenia
Zofran J2405 78701 Nausea with Vomiting Pamidronate/ J2430 1985
Malignant Neoplasm Aredia Bone & Bone Marrow Aloxi J2469 78701
Nausea with Vomiting Neulasta J2505 2880 Agranulocytosis Metocloropramide
J2765 78701 Nausea with Vomiting Solumedrol J2930 78701 Nausea with
Vomiting B-12 J3420 2810 Folate Deficiency Anemia Zometa J3487 1985
Malignant Neoplasm Bone & Bone Marrow Lupron J9217 1985 Malignant
Neoplasm Bone & Bone Marrow Faslodex J9395 1985 Malignant Neoplasm
Bone & Bone Marrow
[0072] 5. Ensuring that the HCT Level is recorded and meets the
required minimum level (38.5 or less), as necessitated for the reimbursement
of certain drugs, such as: Procrit (Q0136) and Arenesp (J0880).
[0073] 6. Creating Remarks containing J-Code, Drug Name, Amount
Used (Dosage plus Waste), Route (Injection, IV, or Push), and NDC
Number for drugs, which do not have their own unique J-Code assigned
to them and now share J3490 or J9999 with other drugs. [0074] 7.
Generating the necessary Remarks to document a patient bringing
their own drug, assuring reimbursement for the administration of
that drug. The computer application includes: J-Code, Dosage, and
Route in the Remarks. [0075] 8. Issuing the appropriate G-Code for
chemotherapy injections to distinguish between Hormonal and Non
Hormonal Agents among the chemotherapy J-Codes. At this time, Faslodex,
Lupron, and Zoladex comprise the set of Hormonal Chemotherapy Injections.
[0076] 9. Applying the proper G-Code to distinguish between: Chemotherapy
Injections, Pushes, and Infusions; and Non-Chemotherapy Injections,
Pushes, Sequential Infusions, and Concurrent Infusions. Also, determining
the correct set of G-Codes with their respective quantity fields
to bill the correct representation of infusion times and administration
counts. [0077] 10. Providing the proper coding for 5FU pump administration.
To infuse the drug 5FU for more than eight hours, pumps are used.
Usually, the patient receives a Push followed by either a Pump Refill
or Pump Initiation procedure. Generally, Medicare only allows one
administration code per drug per day of service, but pumps are an
exception to this rule. The computer application disallows multiple
5FU administrations unless a pump administration code is included.
Then the billing algorithm generates three claim lines: the code
for Push, the code for the pump administration; and the J-Code for
the 5FU with a total quantity representing the sum of both dosages.
The application records both dosages next their respective routes
in the Treatment Sheet for the patient's chart. The billing algorithm
applies a 59 Modifier to Pump Refills. [0078] 11. Building claims
and sequencing claim line items in a logical fashion to facilitate
adjudication, accommodating the most restrictive format, the HFCA
1500 six-line claim.
[0079] The application contains a billing algorithm, which subdivides
a patient encounter into Units for Approval, exhibited to an insurance
adjudicator as packets of claim lines. Each packet begins with one
or more closely related procedure codes pertaining to the same specific
administration and technique followed by the J-Codes of the drugs
administered by that method.
[0080] Instead of a deluge of haphazard codes, the adjudicator
views an orderly series of services separated into Chemotherapy
Infusions, Pushes, Injections, Therapeutic/Diagnostic Infusions,
Pushes, and Injections; as well as Hydrations and Pump Administrations.
Immediately, after each of these techniques, follow the administered
drugs. This assists the adjudicator by presenting coherent groups
easily recognized as being complete and appropriate with all the
necessary secondary diagnosis codes and modifiers. They appeal to
the insurance adjudicator's need to easily decipher the required
prerequisites, increasing the likelihood of approval. If rejected,
the biller can more easily reprocess them, since they form distinct
and cohesive subsets.
[0081] E.g., Hydration as: 36000 Introduction of needle or intracatheter,
vein followed by G0346 Hydration followed by J7030 Saline. Note:
For clarity, the algorithm places Introduction of needle or intracatheter,
vein (36000) before the associated hydration, infusion, or push
that flows through it.
[0082] E.g., A non-chemotherapy infusion as: G0348 Intravenous
infusion, for therapy/diagnosis; each additional hour, up to eight
hours with a quantity of three followed by Intravenous infusion,
for therapy/diagnosis; G0349 Additional sequential infusion, up
to one hour with a quantity of one followed by J2150 Mannitol.
[0083] E.g., Chemotherapy pushes as: G0358 Chemotherapy administration,
intravenous; push technique with a quantity of three followed by
J9040 Bleomycin, J9000 Adriamycin, and J9360 Vinblastine.
[0084] One could consider a Port Flush to be a Unit for Approval,
but currently, there are no reimbursable J-Codes to accompany it.
In addition, Office Visits and Lab Procedures do not have J-Codes
associated with them. Since, these procedure codes have no contextual
relationships with other claim lines, sequencing them is not important.
They occupy the last lines of the last claims for the patient encounter.
Likewise, the algorithm places saline (except when the insurance
is Blue Cross) and other supplies among the final lines for the
encounter.
[0085] The algorithm endeavors to present the Units for Approval
on separate six-line HFCA 1500 formats for the sake of clarity to
the adjudicator, but not at the expense of generating extra claims
needlessly. For example: An Injection procedure code with its accompanying
drug only consumes two claim lines, which would result in four blank
HFCA 1500 lines. Another Unit for Approval could fit on the same
claim.
[0086] For non-chemotherapy drugs, the billing algorithm insures
that there are not more than three unique Secondary diagnosis codes
on the claim. The HFCA 1500 Claim format has a limit of four unique
diagnosis codes per claim. Since one must be primary, only three
remain for use as unique secondary diagnosis codes.
[0087] The billing algorithm encodes the Units for Approval for
a specific Date of Service constructing a series of packets packaged
into claims. Each Unit of Approval is discernable as there are one
or more procedure codes at the beginning followed by one or more
J-Codes at the end, resulting in all drugs in proximity to their
respective techniques and administration. Within the same claim,
a G-Code always has at least one of its related J-Codes following
it. However, because a procedure may administer many drugs, the
algorithm may have to split some of the drugs to the beginning of
the next six-line claim. The algorithm splits off the least expensive
drugs in the packet.
[0088] Generally, all chemotherapy items would be on the first
and second claims; followed by non-chemotherapy items flowing into
additional claims and Laboratory, Office Visits, and Supplies would
appear on the last claims. Together all of the claims represent
the complete patient encounter for the Date of Service.
[0089] While this describes the overall strategy of the billing
algorithm, the first claim for a patient encounter demands some
specific tactical ordering of claim lines: [0090] 1) An Initial
G-Code appears on the first line of the first Claim, except if there
is an Introduction of needle or intracatheter, vein (36000). The
procedure code 36000 always appears before the procedure using the
needle or intracatheter. Thus, the Initial G-Code would appear on
the second line. [0091] 2) If there are additional hours (G0360
or G0348), they appear next. [0092] 3) The most expensive drug administrated
by the preceding G-Codes follows. [0093] 4) If the encounter warrants
reimbursement for the Medicare Demonstration Project, then the three
G90nn-Codes fill the remaining lines of the first claim.
[0094] At this point, an adjudicator should readily approve the
Demonstration Project Codes for reimbursement. Answers to all three
of survey questions are readily apparent, as they are together in
one group. It is evident that the patient received chemotherapy
by a Push or Infusion, since one of these chemotherapy administration
G-Codes appears immediately before the administered chemotherapy
drug.
[0095] All of this is determined by looking at only one claim.
Because these line items make up such a simple claim (similar to
boilerplate), the entire claim is almost certain to obtain immediate
approval. Inclusion of the most expensive chemotherapy drug into
this first claim makes good sense because the adjudicator should
not find anything to doubt. [0096] 5) For claims to Blue Cross,
there are no Demonstration Project Codes to bill. In their place,
the billing algorithm generates claim lines for the Saline Supplies
because Blue Cross requires them to be in the same claim with the
Primary (Initial) Procedure Code. [0097] 6) If are at least two
available lines remain and there are more procedures to bill, the
algorithm generates another procedure code and drug(s). The algorithm
never generates a procedure code without at least one J-Code following
it. If there are still more J-Codes associated with the procedure,
they spill onto the beginning lines of the second claim. [0098]
7) If there are no more procedures to bill, the algorithm fills
the remaining lines of the first claim with supplies and/or Office
Visits/Labs/Misc. [0099] 8) The billing algorithm then resumes its
overall strategy of generating claims and claim lines for the remaining
services.
[0100] The method described is subject to modification as better
strategies become apparent or as reimbursement criteria changes,
e.g., Medicare eliminates the Demonstration Project Codes.
Improve Cash Flow by Maximizing Reimbursement Revenue
[0101] The second avenue to improve cash flow is maximizing reimbursement
revenue. The application accomplishes this by reminding the user
of additional expense items eligible for reimbursement, that are
not generally well known, often because they vary by insurance.
For example: [0102] 1. Medicare currently pays for the Demonstration
Project Codes, but only if the patient received chemotherapy administered
by a Push or Infusion and answered all three of the Survey Questions.
The doctor can insist that the application always bill for the Demonstration
Project, which results in the computer application forcing the user
to answer all three of the Survey Questions when the Date of Service
qualifies for the reimbursement. The application does not force
answers or bill the Demonstration Project Codes for patients that
received chemotherapy by Injection or for patients that do not have
a cancer diagnosis. For example, Multiple Sclerosis (340) patients
receiving Mitoxantrone/Novantrone (J9293). [0103] 2. Carriers will
reimburse for drug waste. The computer application provides a Waste
field next to the dosage of each drug administered. If the treatment
resulted in Waste, recorded by the nurse or estimated by the application,
it is included as part of the reimbursement quantity. The application
currently uses the HCPS Billing Quantity to provide a minimum estimate
for Waste. However, it can under report much of the entire amount;
Proper entry by the nurse is important. The application is able
to store the actual vial sizes in ProcsAndCodes. By subtracting
the entered dosage from the drug and vial size selected by the nurse,
the application can obtain a precise Waste estimate; covering most
instances involving Single-Use Vials. [0104] 3. Medicare will not
provide for the reimbursement of 99211 (Level I Office Visit) on
the same day that a patient receives chemotherapy or non-chemotherapy,
but most insurance carriers will. When a patient receives chemotherapy
or non-chemotherapy and the insurance will reimburse for an office
visit on that same day, the computer application prompts the user
for a Level I Office Visit (99211). The user can accept or deny
this charge or issue a higher level of Office Visit. Hence, the
application issues prompts offering 99211 for Blue Cross, Blue Care
Network, Medicaid, Other Insurances, and PPOM, but not for Medicare.
The Application strives to reduce the volume of Explanation Of Benefits
(EOB) error messages to prevent important messages from being lost.
Thus, the application blocks the user from billing a Nurse Charge
to Medicare on Dates Of Service with chemotherapy or non-chemotherapy,
thereby avoiding the denial messages. [0105] 4. Blue Cross will
pay for up to three Chemotherapy Follow Up Visits within thirty
days of the last date of chemotherapy with no co-payment to the
patient. The application tracks these visits and notifies the user
when the patient is eligible for reimbursement of a Chemo Follow
Up Visit. If the user issues an Office Visit Charge and the computer
application determines that this visit qualifies as a Chemo Follow
Up, the computer application prompts the user for confirmation.
If the user concurs, the billing algorithm generates the Office
Visit Charge with a V672 secondary diagnosis code, preventing a
co-payment bill to the patient. The billing algorithm ensures that
a 25 Modifier is not present, since it would result in a rejection
by Blue Cross. [0106] 5. Blue Cross will not pay for Saline Supplies
unless they are in the same claim as the primary procedure code.
Therefore, for Blue Cross, the billing algorithm places charges
for Saline Supplies in first claim, since it always contains the
Initial G-Code. [0107] 6. A Port Flush does not normally qualify
for reimbursement, since the procedure and its supplies are almost
always bundled with other services. If a nurse provides a port flush
with no other procedures other than Labs on the same day, a Port
Flush (G0363) is reimbursable. The supplies, i.e. Saline Sterile
5 cc and either Heparin or Heplock, are bundled into the Port Flush
procedure. G0363 pays more than a Nurse Charge (99211) will, even
if you include the fees for the Saline and either Heparin or Heplock,
which are no longer reimbursable anyhow.
[0108] The computer application lists any Selected port flush supplies
in the Patient Treatment Sheet, but never bills them because they
are always bundled expenses. They are not reimbursable. They only
result in adding to the volume of rejection messages in the EOB,
making it more difficult to identify inappropriately denied revenue.
[0109] If the user selected a Port Flush and services other than
Labs were performed, the application records the Port Flush in the
Treatment Sheet, but does not bill it because it is not reimbursable.
[0110] If the user selected port flush supplies, i.e. Saline Sterile
5 cc and either Heparin or Heplock with no other services, except
Labs and the user did not select G0363 (Port Flush), the application
issues a prompt suggesting a Port Flush.
[0111] When the computer application identifies an encounter with
port flush supplies along with a Nurse Visit (99211) and no other
services, except for Labs, the computer application suggests the
alternative charge. [0112] 7. For Blue Care Network, PPOM, and Other
insurances (That is--not Blue Cross, Medicaid, or Medicare), if
the Introduction of needle or intracatheter, vein occurred, the
practice can receive additional reimbursement by billing procedure
code 36000. The computer application queries for this procedure
on every Infusion, Push, and Hydration. The application records
the procedure in the Patient Treatment Sheet regardless of insurance,
but only bills it to Blue Care Network, PPOM, and Other. For Blue
Care Network, PPOM, and Other, the application queries for a second
site. If there were two separate IV Sites for this patient, the
application includes a 76 Modifier with the second 36000. [0113]
8. Blue Care Network, PPOM, and Other insurances will pay for Chemo
Kits, when billed as 99070 for PPOM and A4221 for Blue Care Network
and Other. Blue Cross, Medicaid, and Medicare insurances consider
the kits to be bundled and will reject the charges. If the insurance
is Blue Care Network, PPOM or Other and the patient received chemotherapy
or non-chemotherapy by a Push or Infusion; the computer application
offers the billing of 99070 or A4221. For PPOM, which requires Remarks
accompanying the charge, the computer application generates a Remarks
Field containing "Chemo Kit". [0114] 9. Drugs Etoposide
(J9181 & J9182), Taxotere (J9170) and Taxol (J9265) require
special Non-PVC Tubing (S1016). This is a Bundled Expense to Blue
Cross, Medicaid, Medicare, and PPOM. Because Blue Care Network and
Other commercial insurances will reimburse this as a separately
expensed item, the computer application detects these drugs and
when the insurance is Blue Care Network or Other, offers to bill
for the tubing. [0115] 10. Huber Needles (A4212), used during Port
Flushes, are a Bundled Expense to Blue Cross, Blue Care Network,
Medicaid, Medicare, and PPOM. However, Other commercial insurances
will reimburse this as a separately expensed item. The computer
application monitors the use of 5 cc of Saline with either Heplock
or Heparin. If the insurance is Other, the application prompts for
the billing of a Huber Needle (A4212). [0116] 11. There are Pump
Supplies (A4222) used in the Initiation or Refill of a Pump. Blue
Cross, Medicaid, Medicare, and PPOM consider these expenses bundled.
However, it is payable by Blue Care Network and Other insurances.
Therefore, the computer application checks for pump administration
codes and issues a prompt suggesting the billing of Pump Supplies
(A4222) if the insurance is Blue Care Network or Other. [0117] 12.
Allowable reimbursement items change over time and vary by region,
which will result in changes to the application as needed.
[0118] Another endeavor of the computer application to maximize
reimbursement revenue is to validate that the user has entered the
proper amounts of drugs, supplies, and times into the computer application.
[0119] To ensure that the practice is obtaining full compensation
for all of the infusion times, the computer application checks the
actual infusion times against the expected infusion times. Actual
times that are lower than expected would cause the computer application
to query the user, asking if the entered time is indeed what was
desired.
[0120] There is a tendency for nurses to record infusion time as
the time stated in the Protocol. The Protocol specifies infusion
times in quarter hour or half hour increments. Medicare billing
units are to the nearest hour with 30 minutes or less to be `rounded
down`. In addition, Medicare defines Infusions of 15 minutes or
less to be Short Infusions, requiring the biller to bill them as
a Push. However, the Medicare billing units are for Actual time.
It is very possible that the Actual time will differ from the stated
Protocol time.
[0121] The computer application offers the user the option to enter
the actual start and stop times from which the computer application
can calculate the elapsed time. These serve as journal entries,
logged in the Patient Treatment Sheet for supporting documentation.
In addition, the user can use the application in real time for Hydration
and Infusions. Auto Start and Auto End Buttons serve as a stopwatch.
[0122] For Infusions close to billing unit thresholds, the computer
application alerts the user, notifying that a `rounding down` of
an Additional Hour of Infusion Time is about to occur or that an
Infusion is going to be billed as a Push. This gives the user an
opportunity to confirm that the correct Actual elapsed time has
indeed been entered and allows the user to make corrections and
to record specific time of day entries if desired.
[0123] The nurse must infuse a drug for more than 90 minutes in
order to bill for an Additional Hour. The program notifies the user
when it cannot generate an Additional Hour of Infusion Time because
the infusion time is close to, but not greater than 90 minutes.
[0124] For "Short Infusions", the application notifies
the user, with a message, Warning: Infusion times of 15 minutes
or less will be billed as pushes. The application reports this as
an Infusion on the Treatment Sheet, but bills it as a Push.
[0125] The computer application offers the user the option to enter
Cycle-Day/Week for each patient chemotherapy encounter. The computer
application provides a list of patient encounters with the Cycle-Day/Week.
Omissions in the Cycle-Day/Week series are evidence of missing patient
encounters. Perhaps, they were misplaced or forgotten. This would
result in lost revenue if not discovered.
[0126] Because of the effort to remember every treatment item,
the computer application offers the ability to select a previous
patient encounter using Cycle-Day/Week as a guide and copy it with
a new Date Of Service. This saves keystrokes, but also the listed
drugs, supplies, and procedures serve to remind the user of what
to bill. The application does not copy the patient Vitals and Comments,
since they are likely to change.
[0127] This will be by deducting the error from a future claim,
causing confusion for the billing department, and wasting more staff
time.
[0128] To facilitate accurate data entry of individual claim lines
into the billing software, the computer application generates a
total dollar amount for each claim in the Superbill. The computer
application assigns a dollar amount to each claim line according
to the fee schedule established by the practice in ProcsAndCodes.
It is highly recommend that these dollar amounts be identical to
the fees in the billing software for the practice. Upon completion
of data entry for a claim, most billing software products show a
dollar total. If the fee schedule of the computer application is
identical to the fee schedule in the billing software these totals
should agree. Thus, the biller can conclude that the claim items
have been transferred into the billing software accurately.
[0129] The computer application allows multiple fee schedules to
be established. This allows the practice to maintain a fee schedule
of allowed amounts for each carrier. The user can direct the computer
application to apply different sets of fees to the Superbill. Hence,
the practice can see the expected revenue for each patient encounter
by insurance carrier. If the practice also creates a fee schedule
with the practice's estimated cost of each claim line, the user
can generate a `variable cost` report. That is--a report showing
the estimated variable cost for each encounter. When compared to
the expected revenue for the encounter, an estimate of marginal
profit per encounter can be determined.
[0130] The computer application tracks the usage of pre-mixed drug
bags and drug vials in order to maintain inventory for the practice.
In ProcsAndCodes, each drug has an associated: Items on Hand; a
minimum and maximum threshold for ordering; and a reorder quantity.
The application produces a report showing the usage of drugs during
a date range. For practices that perform "just in time inventory
controls", the usage of drugs by vial size during the previous
week can be used to determine the anticipate order to be placed
for the following week. The computer application provides for the
update of number of Items on Hand as drug shipments are received.
Improve Office Productivity
[0131] The computer application instantly improves office productivity
because it eliminates the necessity of a chemotherapy nurse to translate
the patient's chart into a superbill by hand. The nurse does not
have to learn medical reimbursement coding rules and procedures.
The nurse merely records the patient treatment, as a matter of normal
charting necessity.
[0132] However, the success of any computer application depends
upon the accuracy and completeness of the data entered. Using a
computer keyboard and mouse does require extra effort over hand
written notes. The computer application makes every attempt to maximize
the utility of the entered data by automating other tasks, normally
performed by the nurse. The strategy is that the more the nurse
is "rewarded" through the elimination of laborious and
tedious tasks, the more conscientiously the nurse will embrace the
use of the computer application.
[0133] Toward this end: [0134] 1. The computer application allows
the nurse to enter the dosages only in the appropriate unit of measure
for the patient's chart rather than the HCPS Billing Units that
are required for billing. [0135] a. For example, the nurse will
enter the Mannitol dosage in grams. The billing algorithm automatically
converts it to HCPS Billing Units of 50 ml. [0136] b. The nurse
will enter Aloxi in multiples of 0.25 mg. The billing algorithm
converts the dosage to the equivalent HCPS Billing Units of 25 mcg,
resulting in a Billing Quantity of 10 or multiples thereof. [0137]
c. The nurse will enter Kytril as milligrams. The billing algorithm
converts this into the HCPS Billing Units of 100 micrograms. Thus,
a dosage entry of 1 mg results in a HCPS Billing Quantity of 10.
[0138] d. The nurse administers certain drugs and fluids (5FU, Mannitol,
Mesna, Procrit, Saline, Vidaza) multiple times. If the drug's definition
in ProcsAndCodes indicates Multiple entries allowed, the program
permits the reporting of multiple drug entries. The application
lists each entry in the Treatment Sheet in the sequence reported
by the nurse. The billing algorithm generates a claim line with
one J-Code, summing the multiple dosages to calculate the appropriate
HCPS Quantity. [0139] e. The nurse can select the package size of
drugs or supplies, such as Saline, that have multiple J-Codes to
designate different package sizes. The application reports the total
dosage in the Treatment Sheet, but bills the multiple J-Codes with
their respective HCPS Quantities.
[0140] 2. In ProcAndCodes, the user can provide default dosages.
This is especially useful for drugs that have the same dosage regardless
of patient BSA. The application also provides a default dosage per
BSA for certain drugs. TABLE-US-00003 Suggested Default Dosages
in ProcsAndCodes DRUG J-CODE DOSAGE MEASURE Anzemet J1260 100 mg
Neupogen J1440 300 ug Neupogen J1441 480 ug Kytril J1626 1 mg Aloxi
J2469 .25 mg Neulasta J2505 6 mg
[0141] 3. From ProcsAndCodes entries, the application knows which
drugs are Single Use Vials. The application estimates the minimum
Waste for Single Use Vials by subtracting the Dosage from the product
of the HCPS Billing Quantity times the HCPS Billing Units. The application
pre-fills the Waste field with this estimate, which is often close
enough. The nurse modifies the estimate as necessary. (For Multiple-Dose
Vials, the Waste field remains blank, until the nurse enters an
amount.) The application also allows for the selection of different
vial sizes for drugs that have multiple Single-Use Vial sizes, but
only one J-Code. This allows the application to provide a precise
Waste value, accurate in most cases, to relieve the nurse of calculating
Waste with by hand. [0142] 4. The application generates a Treatment
Sheet, which itemizes for a patient Date of Service: Drugs Administered,
Dosages, Waste, Routes of Administration, and Times for both chemotherapy
and non-chemotherapy Infusions. Also, included are the patient's
name and primary diagnosis. For Medicare patients, the application
also includes the answers to the Survey Questions. Blank signature
lines for the nurse and doctor appear at the bottom. This comprises
the beginning of an Electronic Medical Records (EMR) System to which
the practice can augment additional patient chart entries. With
the additional entries, the application holds a significant variety
of patient data, capable of answering simple questions. Querying
the application instead of searching and pulling patient charts
saves the practice a significant amount of time. For example, the
nurse can order drugs for next week's treatments solely by accessing
the application without the pulling of individual patient charts.
The more times the practice views each data item, the more they
can attest to its accuracy. [0143] 5. If the patient received chemotherapy,
the application prompts for Cycle-Day/Week, as optional input from
the user. When entered, the application includes them in the Treatment
Sheet. The application does not permit duplicate Cycle-Day/Week
entries nor does it assign a Cycle-Day/Week to a Date of Service
when there was no chemotherapy performed. [0144] 6. The computer
application allows the user to enter Progress Notes for each patient
encounter and patient Vitals (Blood Pressure, Temperature, Pulse,
ECOG and Karnofsky Performance Status). In addition, the nurse can
enter Height and Weight, from which the DuBois and Dubois Body Surface
Area (BSA) is calculated. When provided, these are included in the
patient Treatment Sheet. The nurse can place the Treatment Sheet
into the patient's chart, eliminating the task of consolidating
other notes and slips of paper. Sometimes carriers demand progress
notes, which the application can store in its database. The nurse
or biller can merely print them and avoid retrieving the patient's
chart. This is especially valuable when the biller is off site.
The application is able to store blood laboratory results and patient
symptoms, including them as part of the Treatment Sheet. The application
provides a Blood Work Tab and a Symptoms Tab for data entry. The
application checks the blood work values for reasonableness, rejecting
absurd values and highlighting abnormal values. The application
provides the user with the ability to define a standard set of values
for seven different symptoms (nausea/vomiting, diarrhea/constipation,
pain, fatigue, numbness, shortness of breath, and mucositis). For
example, the patient often describes pain values on a scale of one
to ten. [0145] 7. The computer application generates Flow Sheets
automatically. These are sheets of paper illustrating patient progress
resulting from chemotherapy and the administration of therapeutic
drugs. Essentially, this is a one-page summary of the drugs administered
over a series of days to compare against subsequent blood results
for the patient. For each Date of Service, this contains the Cycle-Day/Week
and each drug administered with Dosage. Also, included for each
day are the patient's Vitals, Symptoms, and Blood Work. The application
allows the user to designate a series of individual Dates of Service
from a list annotated with corresponding Cycle and Day/Week entries.
The application prints the selected entries on the Flow Sheet. To
accommodate the vast number of different blood tests, the application
only prints results with non-blank values of the Flow Sheet. [0146]
8. Because many patients receive the same chemotherapy regimen,
the computer application allows the user to copy the encounter of
one patient to another patient. If the patient encounters are similar,
the user avoids data entry time for most of the encounter. Again,
the application copies the drugs and administrations, but not Infusion
Times, or Vitals.
[0147] An objective of this application is to minimize the total
number of rejection messages that appear on EOBs. Of significant
concern are rejections that are superfluous, not requiring follow-up
or rebilling. These typically result when a practice attempts to
maximize revenue by billing for items that are not reimbursable
in all instances. A practice might bill the Medicare Demonstration
Project for every Medicare patient encounter, resulting in rejections
for Dates of Service that do not qualify, i.e., patients that did
not receive chemotherapy, patients that received chemotherapy by
Injection or Multiple Sclerosis patients receiving chemotherapy.
[0148] It is difficult for the staff to remember the few exceptions
as to when this charge is not appropriate; so, they bill it for
all Medicare encounters. However, this results in legitimate rejection
messages from Medicare. These additional rejections tend to obfuscate
the truly important rejections that the biller needs to recognize
as soon as possible for prompt follow-up. In addition, the Accounts
Receivable becomes deceiving because the illegitimate expenses overstate
the expected revenue stream. The biller must apply numerous Write-Offs
to the billing software during the posting of payments, reconciling
invalid charges. If Medicare mistakenly approves these charges,
Medicare will later seek to reclaim the money. This will be by deducting
the error from a future claim, causing confusion for the billing
department, and wasting more staff time.
Operating Environment
[0149] Currently, the computer application runs as a Stand Alone
Windows Application with no prerequisite software. It can run on
Windows 98, Windows 2000, or Windows XP (Home or Professional).
The user can install the software on any PC, but most will prefer
to have the computer application located on a workstation located
in the nurse's area. Because this area is usually quite small and
cramped, we have found it advantageous to implement the computer
application on a small laptop with a 12-inch screen. In order to
reduce incidents of virus and spy ware corruption, it is also desirable
for the workstation to be dedicated only to this computer application.
[0150] For these reasons, plus the desire to have a limited set
of hardware/software operating system environments, SOS-Medical
Software provides both the hardware and the software as part of
the product package. At this time, the operating environment consists
of a 12-inch screen laptop with a laser printer to be entirely dedicated
to running the computer application. It may be desirable to have
the work station connected to the internet or at least to a telephone
line, so that a remote access program, such as PC Anywhere can allow
remote maintenance and error correction.
[0151] For larger practices and clinics, a networked configuration
will be required. Larger users will have several nurses performing
treatment on any patient arriving for treatment. Therefore, each
nurse will require each laptop to be able to access any of the patients.
The simplest approach will be to establish one laptop as the server
with the other laptops operating as clients.
[0152] While we are entertaining the possibility of 10-inch screens
or even PDA devices, the small resolution somewhat prohibits these
implementations. However, redesign of the screen layouts may eventually
facilitate these options. A clinic that desires real time collection
of treatment data at each patient chair would motivate this implementation.
Each device would then be part of a network with a central server.
[0153] The current backup plan uses the hard drive, preformatted
CD-R/W or DVD-R/W Discs, and a USB Jump Drive. The application initiates
its own daily backup to the hard drive automatically, then mirroring
a daily backup to the USB Jump Drive when it is present. Backups
are archived after encryption and compression to the Discs. The
user should place the Jump Drive in a safe that is both fireproof
and waterproof each evening and reinserted at the beginning of each
workday.
[0154] A Web environment is advantageous for the implementation
of the application, since this would eliminate many of the logistical
issues with software updates and back up complexities. The data
for each doctor is stored and backed up at the remoter server. With
updates only occurring at the server, the code and the database
structures would always be current.
[0155] FIG. 1 shows the Icon the user will click to start the application.
This document illustrates the implementation using the 12-inch laptop
implementation.
[0156] The workstation is password protected by a Windows password.
A password in the System BIOS, can add further security to the application.
[0157] The user merely double clicks on the Computer Application
Icon near the middle of the screen to start the application. Returning
to the desktop and double clicking on the computer application icon
again can start subsequent instances of the application. This would
be desirable if a nurse wanted to record information for multiple
patients in real time.
[0158] The laptop facilitates privacy by closing the top of the
laptop between sessions. When the user reopens the laptop, Windows
requires the user to enter the password. After entering the password,
the desktop reappears with the set of application windows that were
present when the user closed the laptop.
[0159] FIG. 2 is a screenshot of a Patient Information Window.
This is the first window presented to the user, typically a chemotherapy
nurse. It serves as the "Main Menu" for the application.
At the top are buttons to maintain the supporting tables of the
application: DXcodes; ProcsAndCodes; DoctorsAndFees; and BillingReports.
The contents of these tables will become evident during the explanation
of the main functions of the application.
[0160] Also, at the top is: SurveyOnOff. If there is a practice
that does not want to bill for the Medicare Demonstration Project,
this button allows the billing feature to be turned off. The button,
BillingReport, leads to report functions of the application. In
DoctorsAndFees, the user can enter or edit the Doctor Name and/or
the Practice Name. The fee schedule for the practice is also loaded
and updated here.
[0161] Find by name: allows the user to select a patient already
in the application's database. The user Left clicks on Find by name:
resulting in a drop down list of patients that exist in the database.
The drop down list presents: Patient Last Name; Patient First Name;
and Date of Birth. The user can scroll down and select the patient
name or type the beginning letters of the last name. The application
will present the first patient that matches the character string
entered. When the desired patient is located, the application fills
the fields to the left with the database contents for this patient.
[0162] An alternate selection method is available with Find by
acct #: This allows the user to select a patient by the patient's
account number that is used by the doctor's internal record keeping
system; most likely the office's medical billing system. We have
also found that some practices like to use this field to store the
Social Security Number of the patient. Find by acct #: presents
a drop down list with type ahead searching similar to that of Find
by name:
[0163] After the user selects a patient, clicking on the Make Changes
button allows modifications to the patient fields. There is also
a button to Delete Patient. If the patient does not exist in the
database, the Add Patient allows the user to enter a new patient.
[0164] When adding a patient to the database, the following fields
are relevant: [0165] 1. Key is for internal use only by the application.
[0166] 2. Patient Last Name and First Name are required. [0167]
3. Account Number is optional. [0168] 4. Insurance is required.
A drop down box allows the user to select either: [0169] a. Blue
Care Network. [0170] b. Blue Cross. [0171] c. Medicaid. [0172] d.
Medicare. [0173] e. PPOM. [0174] f. Other. [0175] g. Unknown. If
Unknown is selected, the claims are not be generated because the
application does not know what rules to apply. Unknown only serves
as a `place holder` allowing the entry of treatment data, while
awaiting the correct insurance entry. [0176] h. County Health Plan.
These are patients with a `promise` of obtaining Medicaid. Since,
Medicaid is the anticipated insurance, Medicaid reimbursement rules
are applied. The application suggests that the practice assign this
insurance to these patients, so that a practice knows how exposed
they are when Medicaid coverage is delayed. If the patient obtains
Medicaid insurance, the practice should update the field to Medicaid.
[0177] 5. DX1 is the Primary Diagnosis for the Patient. The user
selects from a drop down list containing an alphabetical sequence
of Diagnosis Codes and Descriptions defined by the user. Upon selection
of a particular Diagnosis, the application displays the accompanying
Diagnosis Code in the adjacent field to the right. If the Diagnosis
is not in the list, the user can define a new Diagnosis Code with
a Description "on the fly". Currently, the application
uses the ICD-9-CM Codes, but will use the new international ICD-10
Codes, when they become required. [0178] 6. DOB is optional. This
field differentiates patients that have the same name (e.g. Robert
Smith). In order to abbreviate the amount of patient data that the
user enters, the application does not require Social Security Number,
which is the normal method to uniquely identify patients. The application
calculates the patient's age, which it displays to the right to
assist in identifying the patient. The computer application also
includes a photographic image of the patient (not shown). [0179]
7. Referred by is optional. [0180] 8. Last Date of Chemo is sometimes
required in the Remarks section of a claim; Chemo Follow Up Visits
to Blue Cross being one example. The application automatically generates
and updates this field. However, the biller can enter an initial
value if this is an existing patient to the practice, but new to
the application. [0181] 9. Comments for the patient are optional.
Typically, this would pertain to insurance or billing information.
[0182] 10. Height and Weight, when provided, allow the application
to perform the Dubois and Dubois Body Surface Area (BSA) calculation.
[0183] Clicking the Save Record button commits these fields into
the database. The Cancel button allows the user to abort any changes
made or the addition of a new patient. The application presents
both of these buttons during Add Patient and Make Changes.
[0184] After the user has added or selected a patient, they may
proceed by clicking on Enter Treatment Sheet or Enter Billing Info.
Both of these buttons proceed to allow the entry of treatment data
for a particular Date of Service.
[0185] Enter Billing Info is oriented for billers working from
a conventional paper superbill. A typical superbill lists various
drug and administration codes under different sections of a preprinted
form. The application provides a series of input screens as tabs
attempting to match the most common layouts for superbills. Hence,
a biller can tab quickly to Survey, Fluids, Non-Chemo, Chemo, or
Office Visits/Labs/Misc. The application sequences the drugs in
the drop down boxes by J-Codes, which billers are intimately familiar
with, allowing the biller to quickly reach the drug they are looking
for. Upon completion of input, the generated Superbill is directly
viewable.
[0186] Enter Treatment Sheet is oriented for nurses. Instead of
Fluids, Non-Chemo, and Chemo tabs, there is one Treatment Sheet
tab. Within this tab, the nurse enters the services performed. Since,
the application lists them in the Patient Treatment Sheet in the
order of entry by the nurse, reporting the services in the actual
administration sequence is preferred. Upon completion of input,
a Treatment Sheet is directly viewable.
[0187] Nurses will typically enter data by way of the Enter Treatment
Sheet button. Billers or Billing Agencies that use the standard
paper superbills would enter data by way of the Enter Billing Info
button.
[0188] List All Bills provides a list of patient encounters from
which the user can view saved patient encounters for editing and
printing purpose. In addition, it allows the user to copy a patient
encounter to another Date of Service.
[0189] Copy Bill From Other Patient provides the ability to copy
encounter data from one patient to another.
[0190] FIG. 3 is a screenshot illustrating the start of data entry
for a Medicare patient. This window resulted from clicking on Enter
Treatment Sheet from the Patient Information Window. The window
has the text, `CLICK FOR: [patient name]`, in order to locate it
on the Windows Task Bar at the bottom of the screen. As mentioned
previously, the application has the capability to allow entry of
patient treatment data in real time. To accommodate multiple patients
in real time, users can start subsequent instances of the application.
Each patient's window is readily located on the Windows Task Bar
and clicked when it is time to enter real time data for a particular
patient.
[0191] The top portion of the window repeats some of the identifying
characteristics of the patient from the previous window. The application
displays the patient's age to assist in identifying the patient.
The computer application also accommodates a photographic image
of the patient for further identification (not shown).
[0192] The bottom left of the upper section of the screen allows
for Cycle-Day/Week entries, as optional input from the nurse. If
the nurse recorded chemotherapy data, but did not enter Cycle-Day/Week,
the application will issue a prompt, encouraging their entry, which
the nurse may decline. The application prevents the entry of duplicate
Cycle-Day/Week values for a patient. If the nurse entered values
for these fields and there was no chemotherapy performed, the application
will reject the values, as Cycle-Day/Week only applies to chemotherapy.
[0193] The application displays a calendar to the right of the
window. The application does not allow the entry of future dates.
The application highlights tomorrow's date to force the nurse to
overtly select a date. Although the application can participate
in a real time environment, where there is an advantage to default
to the current day, most of the nurses seem to be using the application
after the treatment has concluded. It is typical for the nurses
in many practices to do their charting at the end of the week, increasing
the likelihood for incorrect date entries. Hence, the application
forces the nurse to select the Date of Service (DOS) on every encounter.
If the nurse has not entered a date and clicks View Treatment Sheet,
the application will issue a message stating, "You must enter
a Date of Service".
[0194] After the user clicks the DOS, the application displays
the DOS field at the top right of the window in mm/dd/yyyy format.
Clicking on the date causes the calendar to reappear, which allows
the date to be changed. If the DOS already exists in the database,
the application issues: This patient already has a bill for this
DOS will appear after clicking View Treatment Sheet.
[0195] The content of the upper portion of the window remains fixed
throughout the selection of the various tabs. The user can change
the contents of the modifiable fields (DOS and Cycle Day/Week) at
any time.
[0196] The remainder of the window consists of a series of tabs
containing logical groupings for patient treatment data. This window
opened at the Survey Tab because Mary Medicare has Medicare insurance
and the doctor's practice has elected to participate in the Medicare
Demonstration Project. The nurse may enter the Survey answers at
this point or click on one of the other tabs and return to this
tab later. There is no required order for entry of any of the tabs
and the entries do not have to be complete because the nurse can
always return to a tab making additions, deletions, or changes to
the data. The application is persistent in its quest to maximize
reimbursements. If the nurse had forgotten to return to the Survey,
the application will remind the nurse that the Survey is incomplete
and force the nurse to return to the tab and complete the answers.
[0197] FIG. 4 is a screenshot of the Survey tab. Here you can see
that the nurse selected a DOS of Sep. 21, 2005, since it appears
to the right of DOS in the upper right corner of the window and
the Calendar has disappeared. To change the date, the user clicks
the DOS causing the Calendar to reappear.
[0198] At this point, the nurse may select the appropriate survey
answers by selecting from the drop down box for each Survey question.
The application checks to verify that there are answers to all three
questions after the nurse clicks the View Treatment Sheet button.
If the nurse did not answer all three questions, the application
presents the Survey tab, instructing the nurse to complete the Survey.
If for some reason, the nurse desires to waive the Survey, the nurse
may deactivate the Survey by clicking on SurveyOnOff at the top
of the window. Clicking SurveyOnOff a second time reactivates the
Survey.
[0199] FIG. 5 illustrates entry of treatment data when selecting
a drug or fluid. Here the nurse has selected the Treatment Sheet
tab. At the left, the nurse can select from the drugs and fluids,
predefined in ProcsAndCodes. Because they appear in alphabetic sequence
by Drug Description, the drugs should be given names familiar to
the nurse. In this case, entering the letter r, positioned the drop
down to the first entry beginning with r, Rituxan.
[0200] FIG. 6 illustrates entry of treatment data when selecting
an administration. The patient is to receive Rituxan by Infusion.
The drop down box shows the default Admin choices available for
a drug. These choices can be limited per drug by settings in ProcsAndCodes.
Some Drugs can only be administered by: (Push or Pump only); (Injection
or Infusion only); (Injection only); (Push or Infusion only); (Push
only); or (Infusion only). The default is (Infusion or Push or Injection).
[0201] FIG. 7 illustrates entry of treatment data when selecting
an infusion. Because the nurse selected Infusion, this prompt appears.
The application is about to display an Infusion Clock for the nurse
to establish the Infusion Time. The nurse proceeds by clicking on
OK.
[0202] FIG. 8 shows a treatment screen with an Infusion Clock.
The nurse has clicked the OK button, which displays the Infusion
Clock. The nurse can click on Auto Start to start a stopwatch for
real time recording of the infusion. When the infusion is completed,
the nurse would click on Auto Stop. Then when the user clicks Set
Inf Time From Clock, the elapsed time is calculated and recorded
as the Inf Time for the Infusion.
[0203] As an alternative, the nurse can enter the Start Time and
End Time in Military Time as log entries. Again, when the nurse
clicks Set Inf Time From Clock, the elapsed time is calculated and
recorded as the Inf Time for the Infusion.
[0204] The third alternative is for the nurse to enter Inf Time
as hh:mm and Click on Set Inf Time Manually, resulting in hh:mm
as the Inf Time for the Infusion.
[0205] FIG. 9 shows a treatment screen with an Infusion Clock and
waste for a Single Use Vial drug. The nurse has entered 1:35 in
Inf Time (hh:mm) and clicked on Set Inf Time Manually. The application
assigns the time of 01:35 to the Infusion for Rituxan, since it
is the highlighted drug. The application transfers the 01:35 to
the Rituxan line in the column Inf Time. The application clears
the 01:35 in the Inf Time (hh:mm) box to accommodate the next Infusion
or Hydration time entry.
[0206] Had the nurse entered 1:30, the application would have notified
the nurse: Rounding Down additional hour of Infusion Time because
Time is 1:30. Infusion time of 1:31 would Round Up. Rounding Down
will be done for billing purpose only. The time you enter is still
recorded as is. Confirm the Infusion Time is actual and accurate.
[0207] Rituxan comes in 100 mg and 500 mg Single Use Vials. The
nurse cannot use any remaining portion on another patient or encounter.
The remainder is reimbursable when included in the billing quantity.
Both vial sizes have the same J-Code (J9310) with a HCPS Billing
Unit of 100 mg. The application estimates the Waste by presuming
the vial size is the same as the HCPS Billing Unit. In this case,
the application has estimated seven vials to provide 675 mg, leaving
25 mg as Waste. Therefore, the total amount of drug expended is
700 mg. When dividing by the HCPS Billing Units of 100 mg, the billing
algorithm determines a HCPS Billing Quantity of seven. The FeeAmount
in DoctorsAndFees is $600 per HCPS Unit yielding a Charge of $4200.00.
The application highlights the estimated Waste in red to catch the
nurse's attention in case the nurse needs to modify the amount of
waste.
[0208] However, if the vial size were actually 500, the Waste would
be 325 mg, yielding a Charge of $6,000.00, a significant difference
in reimbursement, illustrating how important it is for the nurse
to monitor this field. To improve the estimate of Waste, the program
application also provides the ability to select the drug by vial
size.
[0209] At this point, you can see the Total Charge is $4200.00,
as displayed in the upper right portion of the window. However,
this does not include the administration fees because parsing of
the applicable Medicare G-Codes has not taken place, yet. Nor should
they be, because the entire encounter needs to be examined in its
entirely before the Initial G-Code can be determined, which significantly
affects the Total Charge.
[0210] FIG. 10 shows a treatment screen with a subsequent chemotherapy
drug and administration. The patent received 45 mg of Fludarbine
by Infusion over a one-hour period. The nurse entered the appropriate
quantity. Since the Infusion Clock was already in the window, the
prompt stating: Infusion clock is being displayed . . . does not
appear again. The application highlights Fludarbine after the nurse
selects it. Therefore, any clock entries made will apply to this
drug. If the nurse forgets to make the time entry and clicks View
Treatment Sheet, the application issues an error message.
[0211] Fludarbine comes in a Single-Use Vial. There is only one
vial size of 50 mg, which is equal to the HCPS Billing Unit. The
application estimate of 5 mg is probably accurate, but the nurse
can modify the Waste if necessary. Perhaps the nurse spilled the
previous vial or the previous vial had expired and the manufacturer
will not provide for an exchange.
[0212] Notice that the Fee for Fludarbine is $400.00 and Total
Charge is now $4600.00. Remember Admin Fees will not be determined
until the nurse clicks View Treatment Sheet.
[0213] FIG. 11 shows a treatment screen with a non-chemotherapy
drug and administration. The nurse reported that the patient received
25 mg of Diphehydramine by Infusion. It occurred over a 30-minute
period. Hence, the nurse entered 00:30 into the Inf Time (hh:mm)
box. Clicking on Set Inf Time Manually would transfer it to the
Diphehydramine line.
[0214] Note: Medicare defines an Infusion Time of 15 minutes or
less as a Short Infusion and requires the practice to bill it as
a Push. When this is about to occur, the application will inform
the nurse: Infusion times of 15 minutes or less will be billed as
Pushes.
[0215] Diphehydramine comes in a Single-Use Vial. There is only
one vial size of 50 mg, which is equal to the HCPS Billing Unit.
Therefore, the application estimate of 25 mg is probably correct,
but the nurse could modify the Waste. Notice the Total Charge increased
by $5 to $4605.00.
[0216] Had the patient brought in his own drug and had it administered,
the nurse would have clicked the Rx radio button, indicating that
the application should not bill the J-Code representing the drug
charge to Medicare. Common examples are: J1750 (Iron); Q0136 (Procrit);
J3487 (Zometa); and J2505 (Neulasta).
[0217] In the column labeled Conc is a drop down list that defaults
to Sequential, but the user can select Concurrent. The Medicare
G-Code system requires a different administration code for a non-chemotherapy
drug when it is infused simultaneously with another drug, i.e.,
Concurrent with any other chemotherapy or non-chemotherapy infusion.
The field only appears when a non-chemotherapy Infusion is being
reported. Here, the nurse has reported that the patient was administered
Diphehydramine as a sequential infusion.
[0218] FIG. 12 is a treatment screen with fluids. The nurse reported
the bags of Saline used during the chemotherapy session. The nurse
administered 500 ml of Normal Saline to the patient followed by
250 ml and then another 500 ml. Both bags served as a Dilutant to
the administered drugs. The application reports each bag on the
Treatment Sheet in the order administered. The billing algorithm
bills the two 500 ml bags as one J7040 with a quantity of two.
[0219] Dilutant is the default Admin for bags of Saline. The other
value is Hydration; described in detail later. The application's
billing algorithm will not generate G-Codes for the Saline because
there is no reimbursement for its administration, except during
Hydration. The application tallies the Fees for the Saline itself
in the Charge column.
[0220] The Port was flushed with a dosage of 500 units of Heplock.
Since the HCPS Quantity is in units of 10, the billable HCPS Quantity
is 50. In DoctorsAndFees, the Fee to be charged was defined to be
$0.10 per HCPS Quantity resulting in a line item charge of $5.
[0221] Insurance carriers do not provide reimbursement for Heplock,
Heparin, or the 5 cc of Saline. These supplies are bundled. The
application reports them in the patient's Treatment Sheet, but does
not bill for them. The application calculates the supply fees because
they once were reimbursable and might be again in the future.
[0222] The port flush administration is also bundled. It is not
reimbursable, except in one very narrow circumstance. This is when
a nurse performs a port flush and there are no other services for
the day, except for Labs. The nurse selects the Port Flush administration
in the Office Visit/Labs/Misc tab; so, there is no need to have
Admin values for the port flush supply J-Codes. Hence, the Admin
values for the port flush supplies are all blank, as you can see
in their drop down boxes.
[0223] The computer application can determine when a port flush
is reimbursable and offers G0363 (Port Flush) if the nurse has not
already selected it. If the nurse has selected 99211, OV Brief (Nurse
Visit) instead of Port Flush, the application offers G0363, Port
Flush, in its stead.
[0224] This is the end of the Treatment Sheet entries. Although,
there appears to be only one more line for data entry, there is
a scroll bar to the right that can be used to access more lines
on the form.
[0225] FIG. 13 illustrates the entry of Vitals/Comments. The nurse
has jumped over to the Vitals/Comments tab. The nurse recorded the
patients Blood Pressure, Temperature, and Pulse. The nurse also
made entries for the Karnofsky and ECOG performance status. In addition,
the nurse entered Progress Notes. This can be especially handy to
the billing department when a carrier denies a claim and demands
to see Progress Notes. There does not have to be any manual searching
through patient charts. As we will see, the application can print
them out in the Treatment Sheet for the patient's chart or for forwarding
to the insurance carrier.
[0226] FIG. 14 illustrates the entry of Office Visits/Labs/Misc.
The nurse has clicked on the Office Visits/Labs/Misc tab and selected
an OV Brief (99211). The nurse is also reporting a Complete blood
count. You can see all of the choices for Labs/Misc near the bottom
of the form. Total Charge now appears as $4706.00. Since this seems
to complete the patient encounter, the nurse clicks on View Treatment
Sheet.
[0227] FIG. 15 shows a treatment screen with missing infusion time.
The nurse forgot to click Set Inf Time Manually after entering the
30 minutes for the Infusion of Diphehydramine. The application discovered
this, issuing the prompt and highlighting Diphehydramine for correction.
The nurse clicks OK and then clicks on Set Inf Time Manually to
transfer the 30 minutes from the clock to the Infusion time for
Diphehydramine. The nurse proceeds by clicking on View Treatment
Sheet.
[0228] FIG. 16 shows a prompt noting missing Cycle-Day/Week values.
The application suggests the recording of the Cycle and Day/Week.
This is probably a good idea because the nurse can add it to the
patient's chart by printing the Treatment Sheet that the application
is about to produce. In addition, the application displays a list
of Superbills with the included Cycle-Day/Week entries. Any omissions
in the series could mean a Superbill is missing. Perhaps an encounter
was misplaced and not entered into the application. The nurse enters
the Cycle and Day and clicks on OK.
[0229] FIG. 17 shows a prompt forcing the user to enter missing
Survey questions. The application has detected that the doctor's
practice has decided to participate in the Medicare Demonstration
Project, but apparently, the nurse did not answer all of the Survey
Questions. Had the patient not received a Chemotherapy Infusion
or Chemotherapy Push, the application would not have issued this
prompt because the Demonstration Project only reimburses in those
instances. In addition, the patient must have a cancer as a primary
diagnosis. The nurse clicks the OK.
[0230] FIG. 18 illustrates that the application presented the Survey
Tab to the user in order to complete the Survey questions. The nurse
forgot to answer the question regarding Fatigue. All three questions
must have answers in order to receive any reimbursement; so, the
nurse enters Quite a bit and clicks on View Treatment Sheet.
[0231] FIG. 19 shows the blocking of a 99211 charge for a Medicare
patient. This prompt appeared because Medicare does not pay for
a 99211 if there is chemotherapy or non-chemotherapy on the same
DOS. This will result in a rejection message in the Explanation
of Benefits. One of the objectives of this application is to minimize
the number of rejections, especially those that are innocuous. The
application seeks to reduce the deluge of messages in the EOBs in
order not to lose sight of rejections, requiring prompt follow up.
Even if by chance Medicare makes payment on the charge, it is only
a matter of time before Medicare discovers the mistake and seeks
to reclaim the money. This will be by deducting the error from a
future claim, causing confusion for the billing department and end
up costing more in the long run. Probably the most negative aspect
is that they will overstate the Accounts Receivables, falsely indicating
revenue that is not there.
[0232] Note: Medicare only denies payment for 99211 Level I (Nurse)
Office Visit Brief. Medicare allows Higher-level Office Visits when
billed with a 25 Modifier.
[0233] After clicking on OK, another prompt appears.
[0234] FIG. 20 shows a prompt asking the nurse if they used a peripheral
IV. The computer application always asks the nurse if there was
a peripheral IV. Although, Medicare will not reimburse for this
service and the application will not attempt to bill Medicare, the
question is relevant for complete documentation in the patient's
Treatment Sheet. There was no administration of a peripheral IV,
so, the nurse clicks on No.
[0235] FIG. 21 is a screenshot of the top half of a Treatment Sheet.
The Treatment Sheet generated for the encounter appears for review
by the nurse. It has been broken into two parts here to paste it
into this document. It shows the services performed, as well as
the recorded Vitals and Comments. The Treatment Sheet records the
waste for all of the drugs here.
[0236] FIG. 22 is a screenshot of the bottom half of a Treatment
Sheet showing signature lines for the doctor and nurse. At this
point, the nurse may print the Treatment Sheet and put it into the
patient's chart. Notice there are two lines. One is for the doctor's
signature and the other is for the nurse to sign.
[0237] FIG. 23 shows the selected radio button to release the Superbill
for billing. When the nurse clicks on Close, the application presents
this window. The nurse elects to take the default action and clicks
Done.
[0238] FIG. 24 shows a prompt confirming that the computer application
saved and released [the Superbill] for billing. The Treatment Sheet
is stored for later printing at any time. Because the nurse released
the Superbill to billing, no further changes should take place to
the encounter. The application locks the encounter, preventing any
further changes until the user intentionally unlocks the encounter.
After the nurse clicks OK, the Patient Information Window appears.
[0239] FIG. 25 shows the Patient Information Window. Notice the
application updated the Last Date of Chemo. While not relevant for
a Medicare patient, it is applicable for the billing of Chemo Follow-Up
Visits for Blue Cross patients. Let's have the nurse click on List
All Bills.
[0240] FIG. 26 shows all of the saved encounters for Mary Medicare.
The application presents all the saved patient encounter records
to the nurse. The application has set the Status for the last encounter
to Billed with the Date and Time when the nurse last released it.
[0241] For the biller to obtain the Superbill, under Options to
the right of Bill, the biller clicks on Print/View.
[0242] If the insurance for the patient has been changed in the
Patient Information Window, the user must Change Status to Open
the bill and then Edit followed by View Superbill to generate a
new Superbill with the rules for the new insurance.
[0243] FIG. 27 is a screenshot of the top half of the Superbill.
This is the Superbill for the patient's Date of Service (DOS). The
billing algorithm parsed the Treatment data. G0359, Chemotherapy
administration, intravenous infusion technique; up to one hour,
single or initial substance/drug was determined to be the Initial/Primary
Procedure. The billing algorithm parsed the remaining Admin's and
generated the following G-Codes with their respective quantities.
[0244] For Claim # 1, G0359, Chemo IV infusion, single/initial
hour drug, 1st hour (abbreviated description for G0359 from ProcsAndCodes)
is listed first because it is the Initial G-Code. Each additional
hour of Chemo infusion up to 8 hrs (abbreviated description for
G0360) immediately follows. The G0360 has a quantity of one, since
the G0359 accounted for the first hour and the billing algorithm
rounded up the additional 35 minutes yielding the additional hour.
[0245] The most expensive chemotherapy drug, Rituxin, is right
behind the two G-Codes that represent its administration. Its dosage
of 675 mg resulted in seven HCPS Billing Units. The application
has already documented the 25 mg of waste in the Treatment Sheet.
[0246] The three Demonstration Codes are next because if they are
not in the same claim as a chemotherapy infusion or push, Medicare
will not provide for their reimbursement.
[0247] There can only be six lines per HFCA 1500 Claim; so, the
application calculates a Claim charges subtotal to assist the biller
with verification of correct data entry into the billing software.
When the biller enters the first claim into the billing system,
the billing system should agree with the Claim charges subtotal
of $4,657.00. Otherwise, a data entry error probably occurred during
data entry or the Fees are different in the billing system. It is
recommended that the Fees be identical between this application
and the billing system in order to verify data entry. The application
then generates the next claim.
[0248] Not every billing software system limits data entry to six
lines to mirror the HFCA 1500 Claim Format. Some will accept more
than six lines for data entry. The computer application also generates
the accumulated Bill Charges for the entire encounter, which can
serve as balance total for the biller to verify data entry.
[0249] FIG. 28 is a screenshot of the bottom half of the Superbill.
The second claim begins with G0362, Chemotherapy administration,
intravenous infusion technique; each additional sequential infusion,
(different substance/drug) up to one hour followed by the additional
chemo drug, Fludarbine. The dosage equated to a HCPS Billing Quantity
of one.
[0250] Next is G0349, Intravenous infusion, for therapy/diagnosis
(specify substance or drug); additional sequential infusion, up
to one hour. The infused non-chemotherapy drug, Diphehydramine,
follows with a HCPS Billing Quantity of one. In addition, the billing
algorithm knows that a secondary diagnosis of Nausea with Vomiting
(78701) is a prerequisite for its reimbursement. The required secondary
diagnosis code for this drug is set in DrugsAndProcs.
[0251] Because Port Flush Services and Supplies are bundled expenses,
the billing algorithm does not bill the J-Codes for the Heplock
and the 5 cc of Sterile Saline. The billing algorithm has listed
the bags of Saline with a quantity of two for the 50 ml bags and
a quantity of one for the 250 ml bag. The Claim Charges for Claim
# 2 total $597.00.
[0252] Last is the charge for the Complete Blood Count. Since,
all billable expenses are now complete, another Claim charges total
appears, as well as the Bill charges for the patient encounter.
This should balance with the billing system with a total for $17.00
for the third claim and a complete total for the entire encounter
for $5,271.00. Like the Treatment Sheet, the user can print the
Superbill at this point. There is another option to print the Superbills
by a range of Bill Release Dates (Invoked through BillingReports).
Close returns to the prior window.
[0253] FIG. 29 shows the two encounters for Mary Medicare again.
The application shows that the bill was originally released for
billing on Sep. 22, 2005 at 10:40 PM. When a user clicks on Change
Status and confirms by clicking Yes, the application copies the
date and time to the Original Release Date. The next Submit for
Billing revises the Status with the new Release Date. From the time
stamp, the nurse and biller can determine if they can simply swap
the new bill with the old bill. If there is a substantial difference
in the dates, the biller will immediately see the need to rebill
for any added, deleted, or modified charges that appear on the new
Superbill.
[0254] Close returns to the Patient Information Window.
[0255] FIG. 30 illustrates selecting another patient from the Patient
Information Window. The nurse has returned to the Patient Information
Window. The nurse entered the letters hy to the right of Find by
name: In our small "Sandbox" database, the fictitious
patient with a last name of Hydration appears. In a real setting,
more characters of the last name might be necessary. At this point,
the nurse presses the Enter key with the following result:
[0256] FIG. 31 shows the selection of Heidi Hydration. Heidi Hydration
appears with her basic patient information. Let us pretend the user
this time is a biller. Thus, the biller clicks, Enter Billing Info
and is positioned at the Fluids tab. The application does not present
a Survey tab because Heidi is not a Medicare patient. The application
presented the Calendar for the DOS and the biller clicked on the
day representing Sep. 19, 2005.
[0257] FIG. 32 shows the Fluids Tab after the user has selected
Hydration. Let us pretend the biller is working off a standard paper
superbill, not this application's Superbill, but one drafted by
the doctor's practice. This practice documents the actual start
and stop times recorded by the nurse on the superbill. In addition,
on this superbill, the nurse has checked off services for Hydration,
Phlebotomy, and Venipuncture, but forgot to communicate the administration
of a Peripheral IV.
[0258] The biller has already selected an Admin of Hydration (The
default of Dilution was overridden by selecting Hydration from the
Drop Down Box) for J7040 with a Dosage of 500 ml. Hydration has
a billable G-Code based on duration. The application is about to
display a Hydration Clock for the user to establish the Start Time
and End Time. Notice the Total Charge of $15.00 to the left of View
Treatment Sheet. The application has begun to tally the total charges
for this patient encounter. ProcsAndCodes has a Fee of $15.00 for
J7040.
[0259] FIG. 33 shows the Hydration Clock. The biller has clicked
the OK button resulting in the display of the Hydration Clock. The
Hydration Clock acts just like the Infusion Clock explained before.
Here it is more obvious that the clock is for Hydration because
this entire tab is devoted to Hydration. With the Treatment Sheet
method of data entry, the user knows the clock is for Hydration
when the application highlights a line with an Admin of Hydration
in the light blue, we saw before.
[0260] FIG. 34 shows the entered Start Time and End Time for the
Hydration. The biller has entered the logged Hydration Times and
clicked Set Inf Time From Clock to calculate and record the elapsed
time, which now appears under Total Time. Next, the biller clicks
on Office Visits/Labs/Misc.
[0261] FIG. 35 shows the rejection of a Phlebotomy (99195) by the
computer application. Because the nurse had marked Phlebotomy, the
biller selects it [99195] while in this tab. The biller is going
to have to consult with the nurse or the doctor regarding the primary
diagnosis code. To ensure proper billing, the biller has to: Remove
the Phlebotomy entry; View Superbill; Close; and Save, do not Submit
for Billing to return to the Patient Information Window. After confirming,
which of these conditions is appropriate, the biller will click
on Make Changes to update the DX1 for the patient. After clicking
on Save Record, the biller clicks on List All Bills and then clicks
on Edit to get back to the DOS. As you can see, things are bound
to go faster with the Treatment Sheet performed by the nurse. The
biller, again, selects Phlebotomy from the drop down and then clicks
on View Superbill.
[0262] FIG. 36 shows the prompt asking if the nurse administered
the patient through a peripheral IV. Presumably, the biller was
finished with data entry in the other tabs, but not necessarily.
A user can always return to reenter data. Regardless, the Billing
Algorithm started to analyze the data entered so far and detected
that a Push or Infusion or Hydration occurred in one of tabs. The
application issued a prompt to determine if the administration was
via a peripheral IV. Because Insurance is Other, if the biller responds
with Yes, the application will respond with another prompt asking
if there were [multiple sites accessed]. If the user responds in
the positive, the billing algorithm bills a second 36000. The billing
algorithm will automatically apply a 59 Modifier to the first 36000
and a 76 Modifier to the second 36000 on the claim lines.
[0263] Because the nurse forgot to record this on the practice's
superbill, the biller should consult with the nurse again. There
is the temptation to decline the expense, since chemotherapy patients
usually receive administration through a Port. However, some oncology
patients do receive treatment via Peripheral IV, as do as a variety
of Hematology patients. We hope that all billers make confirmation
with the nurse before they decline the billing of the 36000. Again,
here is another illustration of the desirability of charge capture
by the nurse. After consulting with the nurse a second time, the
biller responds to the prompt by clicking Yes.
[0264] FIG. 37 shows the screenshot for the Superbill for the hydration
through a peripheral IV. The computer application generated this
Superbill. A Bill Release Date does not appear because the biller
has not yet released the Superbill. The biller realizes that Venipuncture
was on the practice superbill, but forgot to select it. To add more
items to the patient encounter, the biller clicks on Close at the
top left corner of the window. What appears next is:
[0265] FIG. 38 illustrates how to make changes to the treatment
data. Instead of taking the default, Save and Submit for Billing,
the biller clicked on the radio button to the left of Make changes
to data. The biller knows that a service for this encounter is missing.
Afterwards, Done is clicked. The application returns the biller
to the Fluids Tab. The biller clicks on the Office Visits/Labs/Misc.
[0266] FIG. 39 shows the Office Visits/Labs/Misc tab. After selecting
Venipuncture from the drop down list, the biller again clicks on
View Superbill.
[0267] FIG. 40 shows the peripheral IV prompt that appears repeatedly.
The application asks the question again because there is no drop
down box for 36000 and the biller's answers could be different.
The biller agrees to bill the charge by clicking Yes.
[0268] FIG. 41 is a screenshot of the Superbill with the additional
service. The application displays the Superbill, showing the appropriate
G-Codes, generated with their respective quantities.
[0269] Normally, an Initial G-Code occupies the first line of the
first claim. Although, Hydration is the Initial/Primary Procedure,
it benefits the insurance adjudicator to immediately show that the
Saline administration occurred through a vein. Therefore, a 36000
with a 59 Modifier precedes the Initial Hydration G-Code.
[0270] Next, the Initial G-Code, G0345, Intravenous infusion, hydration;
initial, up to one hour is generated, followed by G0346, Intravenous
infusion, hydration; each additional hour, up to eight (8) hours.
If there were three hours of Hydration, the quantity for G0346 would
have been two. Since the patient received no chemotherapy or non-chemotherapy,
G0345 and G0346 do not require a 59 Modifier. The J-Code for the
Saline is next, accompanied by the required secondary diagnosis
code 2765.
[0271] Finally, we see the procedure codes for the Phlebotomy and
the Venipuncture.
[0272] The total for the claim is $250. After the biller enters
these charges into the billing software, the balances should match,
verifying that the biller has made the correct entries.
[0273] There is only one claim for this encounter. Therefore, the
Claim charges and the Bill charges are both $250.00, established
according to the Fee Schedule in DoctorsAndFees.
[0274] If the BillingReport Function had generated this claim,
the Grand Total would equal the sum of all of the Superbills in
the Date and Time Range specified by the user. At this point, the
biller may print this Superbill, immediately or wait for completion
of data entry for all of the patients. This may not occur until
the end of the week. Let's presume the biller is going to wait until
later. Therefore, the biller clicks Close located at the top left
corner of the screen.
[0275] FIG. 42 shows the prompt, which confirms that the computer
application has released the bill for billing. Clicking on Close,
results in this window presented. The biller elected to take the
default action and clicked Done, resulting in the Bill saved and
released for billing message. The Superbill is stored for later
printing. The application locks the encounter; preventing any further
changes unless the user specifically unlocks it. After the biller
clicks OK, the Patient Information Window appears.
[0276] FIG. 43 illustrates the resulting return to the Patient
Information Window. The biller clicks on List All Bills.
[0277] FIG. 44 shows there is only one encounter for Heidi Hydration.
The application displays all of the saved Superbills to the biller
for this patient. The application set the Status for Heidi Hydration's
Superbill to Billed with the date and time when the user last released
the encounter.
[0278] For the biller to obtain the Superbill, the biller clicks
Print/View under Options and to the right of Bill. We have already
seen what the Superbill looks like. Therefore, there is no need
to show it again. However, let us see what happens if the user clicks
on Print/View Treatment Sheet.
[0279] FIG. 45 shows the screenshot that results when clicking
on Print/View Treatment Sheet. Here is the result of Print/View
Treatment Sheet for the patient encounter. Even though the nurse
has not entered data for the patient through Enter Treatment Sheet,
the application will still provide a Treatment Sheet. After printing
the Treatment Sheet, the Nurse and/or Doctor can review, sign, and
put into the patient's chart. The nurse can add information by Editing
the Treatment Sheet. Note that the supplies and procedures are not
in the actual sequence that they were performed, which is why entry
by a nurse is preferred. The user can print this Treatment Sheet
at this point. There is another option to print the Treatment Sheets
by a range of Bill Release Dates. Close returns to the prior window.
[0280] FIG. 46 illustrates the unlocking of a bill. The user has
clicked on Change Status. The prompt requests verification to unlock
the record.
[0281] FIG. 47 shows the result of clicking Yes. Now the record
has an Open Status. The Edit buttons will proceed to provide modifications
to the encounter. Edit to the right of Bill under Options will offer
View Superbill. Edit to the right of Treatment Sheet under Options
will offer View Treatment Sheet.
[0282] Notice, the Original Release Date contains the date when
the user first released the Superbill for billing. This serves as
a flag to the biller that this Superbill could already be in the
billing system. The biller will need to evaluate if any extra ordinary
effort will be required to reconcile the practice's billing system.
For example, the biller could have already transmitted the claim
to the clearinghouse requiring rebilling.
[0283] Let's jump ahead where the application has already started
another patient and the recording of information on the patient
encounter is already in progress.
[0284] FIG. 48 shows treatment data for hydration, non-chemotherapy
drugs, and fluids. This patient received a two-hour Hydration. To
record this, the nurse selected 0.9 Normal Saline 1000 ml. Then
the nurse changed the Admin from Dilutant to Hydration. This caused
the Clock to appear, allowing the nurse to enter 02:00 into Inf
Time. After the nurse clicked on Set Inf Time Manually, the application
recorded 02:00 under Inf Time on the line containing the 1000 ml
bag of Saline.
[0285] Next, the nurse reported the Zofran Infusion. The nurse
entered 00:30 into Inf Time (hh:mm) and clicked on Set Inf Time
Manually. As a result, Inf Time shows 00:30. The nurse made the
same entries for the Cimetidine, resulting with 00:30 on its line.
[0286] The manufacturer packages both drugs in either Single-Use
or Multiple-Dose vials. Therefore, the user has defined them in
DrugsAndProcs as Multiple-Dose Vials. This prevents the application
from attempting to estimate Waste. If Waste did occur, the nurse
should enter the amount in the Waste field. When the packaging of
the drug is consistently Single-Use, it behooves the practice to
allow the application to estimate the waste. Because these two non-chemotherapy
drugs were not administered Concurrent to each other, the nurse
left the Conc fields at their default value of Sequential.
[0287] Finally, the patient's port was flushed with Heparin and
Saline. In addition, the nurse selected Complete blood count in
the Office Visits/Labs/Misc tab.
[0288] After the nurse clicked View Treatment Sheet, the prompt
for Cycle-Day/Week appeared and the nurse elected not to make the
entries.
[0289] FIG. 49 shows a prompt for a 99211 Office Visit charge.
Medicare will not reimburse for a 99211 if chemotherapy or non-chemotherapy
was performed on the same Date of Service. Typically, 80% of an
Oncology practice consists of Medicare patients. As a result, nurses
often forget to charge for a 99211. Because the insurance for this
patient is not Medicare, the application issues this reminder. The
nurse can click Yes if she has met the requirements for billing
a Level I Office Visit Brief. A confirmation, 99211 OV has been
generated will appear next. After clicking Yes, the nurse declined
the [ . . . peripheral IV . . . ] prompt.
[0290] FIG. 50 shows a prompt to offering to bill a Chemo Kit to
PPOM. Because the Insurance is PPOM rather than Blue Care Network,
Blue Cross, Medicaid, or Medicare, the application offers a Chemo
Kit as a billable expense. Had the insurance been Other, the application
would have issued the same prompt, but with A4221. The nurse agreed
to issue the charge by clicking on Yes.
[0291] Next, the Treatment Sheet appeared for review. Let's presume
it is complete and the patient encounter is ready for billing. The
nurse clicked Close and accepted [Save and submit to billing] and
clicked Done.
[0292] Here is what the Superbill looks like:
[0293] FIG. 51 is a screen shot of the generated Superbill. The
billing algorithm has parsed the Treatment data and determined Intravenous
infusion, for therapy/diagnosis (specify substance or drug); initial
up to one hour to be the Initial/Primary Procedure Code (Abbreviated
as Initial hour IV infusion, non-chemo in ProcsAndCodes). Therefore,
it appears on the first line of the first claim followed by the
most expensive drug administered by non-chemo infusion, Zofran.
From ProcsAndCodes, the billing algorithm knows that Zofran requires
a secondary diagnosis code of 78701. The dosage for Zofran was 32
mg, which is a HCPS Billing Quantity of 32. Neither the application
nor the nurse entered any waste value.
[0294] The patient received Cimetidine infused as a second non-chemotherapy
drug. Thus, the billing algorithm generated, G0349, Intravenous
infusion, for therapy/diagnosis (specify substance or drug); additional
sequential infusion, up to one hour. The quantity for G0349 is one,
but would be two is there was a third non-chemo drug infused. Following
G0349 is the second infused non-chemo drug, Cimetidine, which requires
a secondary diagnosis of 78701. Following this line are Remarks
preceded by * * * . During data entry into the medical billing software,
the biller should copy this string of characters into the Remarks
box for the claim.
[0295] Cimetidine does not yet have its own unique J-Code. It is
an Unspecified Drug with a shared J-Code of J3490. J3490 and J9999
drugs must appear with a HCPS Quantity of one. Billers must document
them in the Remarks box of the claim with J3490 or J999 followed
by Drug Name, Route, Amount Used (Dosage plus Waste), and the NDC
Number. Because the user did provide an NDC Number for Cimetidine
in ProcsAndCodes, the number does not appear in this example.
[0296] For J3490 and J9999 drugs, ProcsAndCodes provides for the
entry of an NDC Number. For J3490 and J9999, the application generates
the contents of Remarks as: * * * followed by either J3490 or J9999
followed by the Drug Name (As defined in ProcsAndCodes) followed
by the Route of Administration followed by the Amount Used (Dosage
plus Waste) followed by the NDC Number (Also, defined in ProcsAndCodes).
The application displays the generated line after the line in the
Superbill containing the J-Code with the HCPS Quantity equal to
one.
[0297] Next, the application lists the G-Code for Hydration. Unlike
the patient encounter for Heidi Hydration, Hydration is not the
Primary Procedure for this patient. Thus, the application has issued
a G0346, Intravenous infusion, hydration; each additional hour,
up to eight (8) hours to correctly bill for Hydration. Because there
was non-chemotherapy during this encounter, a 59 Modifier is required
for the G0346.
[0298] Finally, we have the 99211 for the Nurse Charge. Because
the patient received non-chemotherapy, a 25 Modifier must be included.
[0299] There are two claims for the biller to balance to during
data entry. Claim #1 totals $619.00 and Claim #2 totals $120.00.
The total for the encounter is $739.00.
[0300] FIG. 52 shows the entry of treatment data for a J9999 non-hormonal
injection. This is a very simple patient encounter illustrating
that the user does not need to remember which drugs are hormonal
versus non-hormonal. The patient received an injection of the chemotherapy
drug Vidaza. It comes in 100 mg Single-Use Vidaza. The application
has accurately estimated that there was zero waste during this treatment.
[0301] FIG. 53 is a screenshot of the generated Superbill. The
application has listed the J9999 drug to convey the necessary information
to the biller in order to document the Remarks correctly. The HCPS
Quantity is one and the billing algorithm generated the necessary
values for Remarks, listed in a format that works. There was zero
waste during the administration. If there were waste, it would have
been included in the total. The NDC Number has a defined value in
ProcsAndCodes; so, it can appear here.
[0302] Notice, the billing algorithm generated G0355, Chemotherapy
administration, subcutaneous or intramuscular; non-hormonal anti-neoplastic
as opposed to G0356, Chemotherapy administration, subcutaneous or
intramuscular; hormonal anti-neoplastic or G0351, Therapeutic or
diagnostic injection (specify substance or drug); subcutaneous or
intramuscular. In ProcsAndCodes, the user defines each drug (or
saline) as Fluid, Chemo, or Non-Chemo with an administration type.
For the Chemo drugs administered by injection, the user also specifies
whether the drug is Hormonal or Non-Hormonal.
[0303] FIG. 54 shows the entry of treatment data for Taxotere to
a patient with Other insurance. The nurse administered Kytril by
a Push. Kytril comes in both Single-Use and Multiple-Dose vials.
The user has defined it as Multiple-Dose in ProcsAndCodes. This
precludes the application from estimating the waste, relying entirely
upon the nurse for any value. The application allowed the nurse
to enter the convenient dosage value of 1 mg and converted it to
the HCPS Quantity of 10 billable units.
[0304] The nurse infused 42 mg of Taxotere for one hour. Taxotere
comes in Single-Use vial sizes of 23.6 mg and 94.4 mg including
overfill. The nurse dilutes them into injection concentrates of
20 and 80 mg, respectively. The practice has defined Taxotere as
Single-Use in ProcsAndCodes. The application has estimated the Waste
as 18 mg by assuming the vials size to be the same as the HCPS Billing
Units. The nurse has an opportunity to modify this estimate, but
has left it as is.
[0305] After the computer application obtains the ability to store
vial sizes, it may make sense to avoid entering the vials sizes
for Taxotere to avoid confusion resulting from Taxotere's use of
overfill. For proper waste calculations, the stored vial sizes would
have to be 20 and 80 mg rather than the actual package volumes of
23.6 and 94.4. Since, use of 80 mg concentrate is infrequent, it
is probably easier to continue to use the HCPS Billing Unit as the
estimate for vial size.
[0306] The nurse infused 35 mg of Vinorelbine for 10 minutes and
received a warning. The ten minutes is the actual time; so, the
nurse has left the time entry as it is.
[0307] Vinorelbine comes in 10 mg and 50 mg Single Use Vials. The
nurse cannot use any remaining portion on another patient or encounter.
The remainder is reimbursable when included in the billing quantity.
Both vial sizes have the same J-Code (J9360) with a HCPS Billing
Unit of 1 mg. The application estimates the Waste by presuming the
vial size is the same as the HCPS Billing Unit. A HCPS Billing Unit
of one will always result in a waste estimate of zero. The nurse
has made an entry of 5 mg, which is the expected waste when 10 mg
vials are used.
[0308] However, if the vial size were actually 50, the Waste would
be 15 mg, a yielding a $100.00 increase to Charge of $400.00, again
illustrating how important it is for the nurse to monitor this field.
To improve the estimate of Waste, the program application provides
the ability to select the drug by vial size. The application may
automatically provide the entry of 5 mg of waste (not shown).
[0309] The patient received Aranesp. Because ProcAndCodes has Arenesp
defined with an Administration type of Injection Only, the drop
down box only offers Injection, reducing the possibility of a keystroke
error. The practice has established the Arenesp Default Dosage in
ProcAndCodes to 300, which the application has automatically entered
into the Dosage field, resulting in a HCPS Billing Quantity of 60.
[0310] Aranesp comes in Single-Use vials in sizes of {25, 40, 60,
100, 150, 200, and 300} mcg. All use the same J-Code (J0880), which
has a HCPS Billing Unit of five mcg. In this example, the user defined
it as a Multiple-Dose vial in ProcsAndCodes, leaving any entry for
waste entirely up to the nurse, who has left it blank. The future
application enhancement to store vial size, would not likely by
of much assistance, since the waste is usually going to be zero.
[0311] Because Aranesp requires the patient's HCT Level for reimbursement,
a box to enter the value has appeared. Notice what happens if the
nurse clicks on View Treatment Sheet and forgets to enter an HCT.
[0312] FIG. 55 shows the result of not entering a HCT value for
a drug that requires one. Now see what happens if the nurse enters
an HCT value that is too high.
[0313] FIG. 56 shows the result of entering a HCT value that does
not warrant reimbursement for the drug. The application notifies
the user that the HCT Level does not warrant reimbursement. In real
time, this could have prevented a loss. However, in this case, it
was just an input error and the nurse corrects it. The nurse has
already entered a Complete blood count in Office Visits/Labs/Misc.
In addition, the nurse made entries in Vitals/Progress Notes. The
nurse clicks on View Treatment Sheet.
[0314] FIG. 57 shows a prompt offering to bill a 99211 Office Visit.
The nurse spent considerable time education the patient, documenting
this in the Progress Notes. However, because the practice is mostly
comprised of Medicare patients, the nurse forgot that her time is
billable because this patient has Other Insurance. The nurse clicks
Yes.
[0315] FIG. 58 shows a prompt querying whether the nurse used a
Peripheral IV. The nurse clicks No.
[0316] FIG. 59 shows a prompt offering to bill the special tubing.
Because the patient received Taxotere and the insurance is Other,
the special tubing is reimbursable. The nurse clicks, Yes.
[0317] FIG. 60 shows a prompt offering to bill for a Huber Needle.
The application has detected that the use of 5 cc of Saline with
either Heparin or Heplock. This indicates that the nurse performed
a Port Flush, expending a Huber Needle. Since the patient has Other
Insurance, it is reimbursable. The nurse user clicks yes to bill
this supply.
[0318] FIG. 61 shows a prompt offering to bill a Chemo Kit. Because
the patient received an Infusion and has Other Insurance, a Chemo
Kit is reimbursable. Therefore, the application issues this prompt.
The nurse clicks Yes and then clicks View Treatment Sheet.
[0319] FIG. 62 shows the screenshot for the top half of the patient
treatment sheet. Notice, both chemotherapy drugs have their calculated
waste documented. The bottom half of the Treatment Sheet follows:
[0320] FIG. 63 shows the screenshot for the bottom half of the
patient treatment sheet. After the nurse saves the Treatment Sheet,
the Superbill is available for viewing.
[0321] FIG. 64 shows the screenshot for the top half of the Superbill.
This bill has been broken up into two parts in order to paste it
into this document. In Claim #1, we see G0359 for Chemotherapy administration,
intravenous infusion technique; up to one hour, single or initial
substance/drug. The billing algorithm has appropriately identified
the chemotherapy infusion as the Primary Procedure for this encounter.
[0322] Taxotere (J9170) was the only chemotherapy drug administered
by the infusion. The billing algorithm has placed J9170 immediately
after its infusion code and calculated a HCPS Quantity of three.
[0323] Another chemotherapy administration occurred, not determined
to be the Initial Procedure for the encounter. Therefore, the algorithm
encoded it as G0358, Chemotherapy administration, intravenous; push
technique, each additional substance/drug.
[0324] Because the patient received only one chemotherapy drug
by a push, G0358 has a quantity of one. The administered drug, J9390,
Vinorelbine immediately follows with a HCPS Billing Quantity of
four.
[0325] Next the billing algorithm encoded G0354, Therapeutic or
diagnostic injection (specify substance or drug); each additional
sequential intravenous push. Since the nurse only pushed one non-chemotherapy
drug, the quantity is one. The drug was Kytril (J1626) with a dosage
of 0.1 mg, converted to a HCPS Billing Quantity of 10. Reimbursement
for Kytril requires a secondary diagnosis code of 78701 (Nausea
with Vomiting), which the billing algorithm obtained from ProcsAndCodes.
The billing algorithm has filled all six lines of the first claim;
so, it calculates the total. The Claim charges total of $2375.00
provides the biller with a number to balance to during data entry
into the billing system.
[0326] FIG. 65 shows the screenshot for the bottom half of the
Superbill. In Claim # 2, the first line is G0351 (Therapeutic or
diagnostic injection (specify substance or drug); subcutaneous or
intramuscular) for the non-chemotherapy drug Arenesp (J0880). The
dosage is 300 ug, which the billing algorithm converted to a HCPS
Billing Quantity of 60.
[0327] When the patient has a cancer diagnosis (1623 in this case),
a secondary diagnosis code of 28522 (Anemia in Neoplastic Disease)
is required for reimbursement. The HCT column of the claim must
indicate an HCT value less of 38.5 or less. In addition, the Remarks
section of the claim must also indicate the HCT value. The application
flags this with a line beginning with * * * .
[0328] Left remaining for the billing algorithm to bill is only
supplies, a laboratory procedure, and an Office Visit. Order for
these items is not important. Thus, the algorithm fills the remaining
lines in Claim #2 and calculates the Claim charges total to be $1,941.00.
[0329] The billing algorithm generates a third claim to accommodate
the last two items. A Grand Total for the entire encounter is also
calculated ($4,369.00).
[0330] FIG. 66 shows the entry of treatment data related to a pump.
The nurse infused 255 mg of Avastin for two hours. Avastin comes
in 100 mg and 400 Single-Use vials. The application estimated the
waste by assuming the HCPS Billing Unit to be the vial size. Since,
the HCPS Billing Unit is only 10 mg, the application vastly underestimated
the waste as 5 mg. The nurse actually dispensed the drug from a
400 mg vial, resulting in the true waste to be 145 mg. Had the nurse
not entered the correct waste, the charge would have been $1400.00
less.
[0331] The application also has the ability to store the vial sizes
with the drug in ProcAndCodes, which allows the nurse to select
Avastin with the vial size, resulting in the correct calculation
of waste.
[0332] The nurse also infused 140 mg of Oxaliplatin for two hours.
Oxaliplatin comes in 50 mg and 100 mg Single-Use vials. Both vials
have the same J-Code (J9263) with a HCPS Billing Quantity of 0.5
mg. Using the HCPS Billing Unit as the presumed vial size, the application
estimated zero waste. The nurse has entered the correct waste amount
of 10 mg, resulting in additional charge of $200.
[0333] The application also has the ability to store the vials
sizes with the drug in ProcsAndCodes, which allows the nurse to
select the drug with the 50 mg vial size, resulting in the correct
value for waste.
[0334] This encounter involves the Initiation of a pump. The 5FU
definitions in ProcsAndCodes provide for 5FU to have Pump (refill)
and Pump (initial) in its drop down box. In addition, in ProcsAndCodes,
5FU is marked for Multiple entries allowed. The nurse was able to
record the push of 660 mg of 5FU followed by a pump Initiation with
3960 mg of 5FU. The use has defined 5FU in ProcsAndCodes as a Multiple-Dose
drug. Thus, the application does not attempt to estimate any waste,
relying entirely upon the nurse for any value.
[0335] FIG. 67 continues the illustration of the patient treatment,
which involves a chemo pump. The nurse pushed Aloxi. The application
converted the convenient dosage entry of 0.25 mg to the HCPCS Billing
Units of 0.025 mg, resulting in a HCPS Billing Quantity of 10. Aloxi
comes in a 0.25 mg Single-Use vial. Obviously, this resulted in
zero waste.
[0336] Finally, the nurse infused 350 mg of Leucovorin Concurrently
with the other infusions. Thus, there is no entry of time against
Leucovorin. Leucovorin come in 50, 100, and 200 mg Single Use vials.
In this example, the user has defined Leucovorin as a Multiple-Dose
drug, resulting in no attempt by the application to estimate the
waste. The nurse has entered a waste value of 50 mg, which the application
used in the calculation of the HCPS Billing Quantity.
[0337] After the nurse clicks on View Treatment Sheet, a prompt
appears.
[0338] FIG. 68 shows a prompt for a 99211 Office Visit. Because
the patient has Blue Cross, the nurse can bill for a Level I Office
Visit. The nurse clicks Yes.
[0339] FIG. 69 shows a prompt offering to bill any Office Visit
during this for the Date of Service as a chemo follow up visit.
The patient has Blue Cross and the application has been keeping
track of the Chemo Follow-UP Visits and has determined that the
patient is eligible for such a visit, avoiding a co-payment from
the patient; so, this prompt appears. The nurse clicks Yes.
[0340] FIG. 70 is the prompt regarding a Peripheral IV that perpetually
appears. The nurse clicks No.
[0341] FIG. 71 is a screenshot for the top half of the treatment
sheet generated by the application. One can see the Progress Notes
and Vitals entered by the nurse, which was presented among the previous
screens. Notice that the Leucovorin has been labeled as a Concurrent
Infusion.
[0342] FIG. 72 is a screenshot for the top half of the Superbill.
The algorithm has identified the Chemotherapy Infusion as the Initial/Primary
Procedure Code; so it appears on the very first line of the first
claim. This is not to be confused with the pump Initialization,
which is not an Initial Code.
[0343] There were four hours of chemotherapy infusion. The G0359
accounts for the first hour. The G0362 accounts for another hour
and the G0360 accounts for the remaining two hours. The G0360 immediately
follows the G0359 and immediately precedes the most expensive infused
chemotherapy drug (Avastin) in the first claim. Since, Blue Cross
requires Saline supplies to accompany the Initial/Primary Procedure,
they also must appear in the first claim. The Initialization of
the pump is in the last line of the first claim.
[0344] Claim #2 line starts with the G0362 with an accompanying
chemotherapy infused drug (J9263). Next is G0358 for the Chemotherapy
Push Technique followed by the pushed chemotherapy drug (J9190).
The J9190 HCPCS Quantity includes the 5FU that went into the pump.
At the end of Claim #2 is the non-chemotherapy concurrent infusion
(G0350) followed by the infused non-chemotherapy drug (J0640).
[0345] FIG. 73 is a screenshot for the bottom half of the Superbill.
Claim #3 starts with a non-chemotherapy push (G0354) followed by
the pushed non-chemotherapy drug (J2469). The secondary diagnosis
code 78701 (Nausea with vomiting) appears because it is required
for reimbursement. The billing algorithm converted the Aloxi dosage
to the HCPCS Billing Quantity of 10. The nurse also did a Complete
Blood Count and the Nurse Office Visit follows with a V672 Primary
Diagnosis code to signal to Blue Cross that this is a Chemo Follow-Up
Visit with no co-payment to the patient. Blue Cross requires the
Remarks for the Chemo Follow-Up Visit to state the Last Date of
Chemo.
[0346] Referring now to the screenshot of FIG. 74, this version
of the computer application has the Automated Flow Sheet feature.
Notice there is a Print Flow Sheet button. First, let us look at
the tabs in Enter Treatment Sheet for this version of the computer
application.
[0347] Referring now to the screenshot of FIG. 75, notice there
are two additional tabs in this version of the computer application,
Blood Work and Symptoms. Here in the Blood Work Tab, the user has
made some entries.
[0348] Referring now to the screenshot of FIG. 76, here is what
the Symptoms Tab looks like. The drop down box for Pain illustrates
some values the user has defined through the Symptoms Tab at the
top of the screen. For this example, the user has not entered any
reported symptoms. After returning to the Patient Information Window
and clicking on View Flow Sheet, the following appears.
[0349] Referring now to the screenshot of FIG. 77, the computer
application has listed the patient's dates of service, which the
user can individually click. The Cycle and Day/Wk serve as a guide
to indicate which treatments would be of interest to appear on the
Flow Sheet.
[0350] Referring now to the screenshot of FIG. 78, here the user
has selected all of the dates of service. After selecting the desired
entries, the user can see the Flow Sheet results by clicking on
View.
[0351] Referring now to the screenshot of FIG. 79, here is the
resulting Flow Sheet. For the selected Dates of Service, the computer
application displays the patient's Vitals and Symptoms, as well
as any recorded blood work results. In this case, the user only
entered blood work for the last Date of Service and did not enter
any Symptoms for any day.
SUMMARY
[0352] A purpose of this computer application is to collect chemotherapy
treatment data on a particular patient for a specific date of service
from an oncology nurse in order to generate a superbill. The computer
application records the information and formats it, automating patient
charting to assist the nurse. Then the application translates the
administered drug and procedure data into a robust superbill, comprised
of the most effective combinations of medical reimbursement codes
to serve as input to medical billing software. The application performs
this in a manner to improve the productivity and efficiency of the
nursing and billing staff, while maximizing insurance reimbursement
and expediting cash flow.
[0353] Functions of the computer application are to collect the
minimum amount of billing data from the chemotherapy nurse at the
time of treatment while maximizing revenue, then parse, and encode
the data into sets of medical insurance claim lines heuristically
proven to yield prompt and maximum reimbursement.
[0354] Secondary functions of the computer application are to encourage
the use of the application by automating the record keeping and
documentation of patient treatment data.
[0355] While the computer application currently generates claims
using the Medicare G-Codes, it is able to accommodate any other
system of insurance codes. The American Medical Association and
Medicare have defined new CPT Codes, which the application is able
to handle.
Benefits
[0356] 1. It eliminates the necessity of the nurse to generate
a superbill. The nurse does not need to learn coding rules and nomenclature.
It insulates the nurse from bureaucratic changes to Medicare and
other insurances. [0357] 2. It provides a framework for the efficient
recording of patient treatment data, minimizing the amount of data
recorded by the nurse, but assuring the billing of all reimbursable
items. [0358] 3. It automates bill documentation and patient charting,
saving hours of nurse time. [0359] 4. It is self-auditing. It continuously
issues prompts and queries, while checking and validating entries.
It is insists upon required documentation. [0360] 5. It eliminates
the need for billing personnel to master the parsing of insurance
codes. Changes to encoding procedures are implemented instantly,
avoiding errors associated with going through a new learning curve
and the breaking of obsolete billing habits. With the saved encoding
time, the biller can spend more time reducing the outstanding accounts
receivable. [0361] 6. It constructs insurance claim lines optimized
to facilitate immediate approval by insurance adjudicators in order
to expedite cash flow and to decelerate the growth of outstanding
items in the accounts receivable. [0362] 7. It offers reimbursable
items to the user on an insurance basis for charges not generally
known to be reimbursable. [0363] 8. It builds an extremely robust
superbill; such that, personnel with limited billing expertise can
merely copy the claim lines into the doctor's billing software.
Thus, it provides back up for the billing staff in order to facilitate
vacation and sick time, without incurring an interruption in the
billing pipeline. The application can greatly enhance billing software
products that provide interfaces to accept the output of this application
as direct input, eliminating manual data entry.
[0364] While embodiments of the invention have been illustrated
and described, it is not intended that these embodiments illustrate
and describe all possible forms of the invention. Rather, the words
used in the specification are words of description rather than limitation,
and it is understood that various changes may be made without departing
from the spirit and scope of the invention. |