In audits, as well as at the Reference Committee, we often see physicians using inappropriate fee codes when there isn’t a fee item that fits the work they are doing.
In audits, as well as at the Reference Committee, we often see physicians using inappropriate fee codes when there isn’t a fee item that fits the work they are doing. This may occur in relation to infrequently performed procedures for which a fee code has not been established, or when there has been a change in the standard of care. In these cases, practitioners usually unilaterally choose what they believe is a similar or related fee code, and the tendancy is to choose the fee code that pays the higher amount. This is referred to as “upcoding.”
Rather than trying to make the Payment Schedule fit what you are doing, in order to bill correctly and get paid appropriately, you should bill a miscellaneous fee item (***99) in equity. See Section C.4 of the MSC Payment Schedule Preamble, included in part below.
Preamble C.4, Miscellaneous Services
This section relates to services not listed in the MSC Payment Schedule that are:
– New medically necessary services generally considered to be accepted standards of care in the medical community currently and not considered experimental in nature.
– Unusually complex procedures, for established but infrequently performed procedures.
– For unlisted “team” procedures.
– For any medically required service for which the medical practitioner desires independent consideration to be given by MSP.
Claims under a miscellaneous fee code will be accepted for adjudication only if the following criteria are fulfilled:
– An estimate of an appropriate fee, with rationale for the level of that fee (should be included in the note field of your billing).
– Sufficient documentation of the services (such as the operative report) to substantiate the claim.
The Medical Services Plan will review the fee estimate proposed and the supporting documentation, and by comparing the service provided with comparable services listed in the MSC Payment Schedule will determine the level of compensation. While an application for a new fee item is in process (as per Section C.2.), MSP will pay for the service at a percentage of a comparable fee until the new fee item is effective. Should it be determined that a new listing will not be established due to the infrequency of the unlisted service, payments will be made at 100% of the comparable service.
Contact your section representative
Proposals for new fee items, amendments to existing items, or deletion of existing items must be initiated by the applicable section and approved by the section executive.
If you are not a member of your section, consider becoming a member. That will ensure you have access to the most up-to-date information on the latest section issues, news, or policies affecting physicians.
While billing miscellanous fees may result in a longer adjudication process until you receive payment for a single service, it may be of great benefit if you are audited. Additionally, if you disagree with the level of compensation determined by MSP, you may bring the issue to the Reference Committee for further review, as outlined in Section C.12 of the Preamble.
—Lorne Verhulst, MD
Chair, Patterns of Practice Committee
This article is the opinion of the Patterns of Practice Committee and has not been peer reviewed by the BCMJ Editorial Board. For further information contact Juanita Grant, manager, audit and billing, Physician and External Affairs, at 604 638-2829 or firstname.lastname@example.org.
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Halpern SD, Ubel PA, Caplan AL, Marion DW, Palmer AM, Schiding JK, et al. Solid-organ transplantation in HIV-infected patients. N Engl J Med. 2002;347:284-7.
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