HIM a. LCD error is present and there IS an ABN for the services: a. HIM will add the GA modifier b. Select Refresh Claim

Transcription

1 The Physician Order Addendum Workflow will be completed by PFS and HIM. The exception is AIC and CTC. When the error is for a patient located at AIC or CTC, please contact Barb Hartman (CTC) or Kirstin Carson/Peggy Regas (AIC). These contacts will complete the review or advice as they are aware of the orders for their patients. Instead of doing this process below, we might want to call the physician office and/or the coding team. We ask that this process be performed using all of our resources prior to sending a letter to the providers. If the charges are high dollar or for a surgery, use Michelle Lavoie as a resource or talk with Karen Block (HIM) to see if they can send a new query to the physician. HIM a. LCD error is present and there IS an ABN for the services: a. HIM will add the GA modifier b. Select Refresh Claim c. If the error is satisfied, the error message will be removed from the account d. Nightly processing the claim will be sent appropriately b. LCD error is present and there NO ABN on file for the services: a. HIM will select Account Activities b. 596 Physician Order Addendum Request c. Double click on the activity to open d. Enter an account note e. NOTE: Billing Indicator will be placed on the account Page 1

2 f. Click Accept g. This activity will drive the account to workqueue 6599 (HB - PHYSICIAN ORDER ADDENDUM REQUEST) and to WQ 6604 (HB CODING ERROR - PENDING PHYSICIAN ORDER ADDENDUM) **If the account has a new code that still does not meet medical necessary, complete the following steps: a. HIM will select Account Activities b. 211 Failed MN after POA c. Double click on the activity to open d. Enter an account note, if necessary e. NOTE: Billing Indicator will be placed on the account. h. Click Accept i. This activity will drive to WQ 6604 (HB CODING ERROR - PENDING PHYSICIAN ORDER ADDENDUM) PFS a. Open Account Workqueue 6598 (Reg Physician Order Addendum Request) b. Double click to open the patient account c. Review the claim edit to see which CPTs are not passing medical necessity. a. Status Summary Tab b. Under Claim Error c. Expand the drop down arrow to review the claim errors Page 2

3 k. Go to the TX Inquiry Tab and click Select All under charge. l. Copy the code description for the CPT code that failed. m. Review the information coded and question why do they not match. Is the code that was coded not on the order or was it on the order but not coded? n. Select Account Activities o. Enter 597 Physician Order Addendum Mailed/Faxed in the search bar p. Double click on the activity; n. The letter is selected already o. Select Edit Letter p. Review the letter to ensure information is not missing from the letter. Verify if the doctor is correct. If not, change the physician name on the letter. If the letter is to an RMG physician, we need to work on correcting and not sending through the mail. Please review and question everything before sending the letter out q. Scroll down to the second page r. In the Test Ordered field, paste the code description. Page 3

4 r. Select the printer to be printed s. NOTE: Billing Indicator POAD Mailed/Faxed is added to the account t. Enter an account note u. Click Accept v. Fax the letter to the physician office b. Open a denial record r. Select the liability bucket s. Select log denial/remark/correspondence t. Complete the form u. Denial/Remark v. Date w. Source = ABN/POAD x. Enter Reason Code = 167 (CO167) y. Enter the dollar amount of the CPT z. Override action: 3 aa. Enter a comment bb. Accept cc. Select Created in the insurance bucket Page 4

5 dd. Place a check mark next to the denial that was created ee. Select Update ff. Update New Status to Completed gg. Enter a comment, if necessary hh. Complete all fields as possible ii. If the department is known, please enter jj. Root Cause select: 1013 POAD Physician Order Addendum kk. Enter the CPT Code ll. Accept mm. Upon accepting the denial is closed Physician Order Addendum is received: 1. The physician order will be sent to the PFS Cashier i. Is the physician order addendum blank? 1. If yes, do not send/scan 2. Perform an account activity 197 Create Account Note a. POAD returned no new information 3. Override the Claim edit a. Liability bucket b. Bucket action button on insurance line c. View Claim d. Override claim error Page 5

6 2. If the physician order addendum has changes, follow the below steps: 3. PFS Cashier will scan the document to the Document Table a. Select GO TO > Registration b. Select documents c. Select the document type of Physician Order Addendum d. Scan the documents e. Update the status to Received f. Enter Date Received with today s date Page 6 g. PFS Cashier will review the accounts billing indicators under the Account Summary i. If billing indicator Physician Order Addendum Complete & Failed MN after POA is present on the account, please remove. 1. Perform an account activity 196 Removing Billing Indicator 2. Select the billing indicator 3. Click on accept

7 h. After scanning, the document will move the account to workqueue 6599 HIM Answered Physician Order Addendums. i. Coding will review and update coding i. Coding will perform an account activity 598 Physician Order Addendum Complete j. Provided the LCD error is satisfied the error will remove from account and bill appropriately No completed Physician Order Addendum is received within 18 days from date of letter: DO NOT HOLD ANYTHING LONGER THAN 18 DAYS 1. If no letter is received after 18 days the account will be sent to workqueue No Answered Physician Order Addendums > 18 Days a. Go to the Liability Bucket i. Select the Bucket Action Button ii. View Claim iii. Override 300 Error Message b. PFS will perform an account activity 598 Physician Order Addendum Complete i. Enter an account note > NO POAD Returned 1. If one is returned later it will go to coding for review ii. Click Accept Page 7

8 Claim Edit Workqueue 6604: HB Pending Physician Order Addendum When an account is returned to coding that does not meet medical necessity, the account will be send to wq PFS will override the error to allow the claim to be billed to the payor. 1. Open Account Workqueue 6604 (HB Pending Physician Order Addendum) 2. Double click to open the patient account 3. Go to Acct Summary a. Does the account have a billing indicator of Failed MN After POA? i. If YES, go to the claim edit tab ii. Override the Code 300 error message iii. Enter comment Overriding error message due to failed MN iv. Refresh Claim b. If NO, skip the claims. The remaining claims should be dropping out throughout the POAD process. 4. Perform Account Activity a. PFS will perform an account activity 598 Physician Order Addendum Complete NOTE: When coding re-opens coding it is going to account workqueue 6623 Page 8