November/December, 1972 Vol. 20 No. 1 MEDICAL GROUP MANAGEMENT Journal of the M.G.M.A. ‘Medical City Dellas Dolls, Texas Iston—p, 28) ARTICLES PAGE © Change and the Challenge for Associations .. ‘ © Price and Wage Controls and the Economics of the Health Care Industry .. 9 © What's New with Professional Corporations . © The Super Bill .BRUCE W. McKINNON @ THE SUPER BILL the mombership. of M.GM.A- icles I emt ‘concep? ipesition™ can ‘be. token. The following Inovetive approach to the billing of third parties BRUCE W. McKINNON graduated from Hamline University in St. Paul, Minnesota with a B.A. degree in 1964, majoring in history and political science, He worked as a claims adjuster and Medicare office unit supervisor for Travelers Insurance Company jor five years, He joined the Medical Education and Research Foundation at St, Paul Ramsey Hospital, a hospital based group practice of medicine, in June of 1960, as Assistant Director. In March of 1972 he became Administrator of the Hattiesburg Clinic, P.A. of Hattiesburg, Mississippi. Mr. McKinnon was the former chairman of the “Clinio—Third Party Billing Procedures Committee” of Minnesota Medical Group Management Association and has recently been appointed to the “Clinic Procedures Committee” of MG.MA. © One bill — “THE SUPER BILL” — for all billing, from all doctor's offlees (solo or group), to all patients and to all ‘third party carriers (local, state and federal; Medicare, Medicaid, welfare, commereial insurance companies, indus- ‘rial, efe') . . . one code — and only one — for services rendered . ... one code — and only one— for diagnosis the elimination of physician and patient signature require: ments, ‘This is the big 1973 project for the CLINIC PROCEDURES, COMMITTEE: Borrowing a theme from the M.G.M.A, Na- tional Conference in Atlanta this year, we intend to be “visible and physieal” with the new concept on your behalf If successful (and we intend. to be), the Super Bill concept could well save millions of dollars in health care costs an- ually. “Goodbye, Gertrude” (see MGM, July, 1969) was the first step in this’ direction. Now it is time for “The Super Bill”, ‘Most administrators are aware that there are numerous state cline manager organizations, TLE.W., HIC, AMA, the Blues, and others working on (or have completed) standard insurance claim forms and procedure coding systems. Cer. tainly, thls Is a step in the right direction, but whose form, or what system, are we going to adopt? Will these creations ‘cut across statelines and will there be universal acceptance? What we see in the future is a battle over “pride of author. ship," but not necessarily any solutions. Therefore, in pre- paring this article, your Clinic Procedures Committee has borrowed what we feel are the best ideas from such states ‘as Washington, Wisconsin, Minnesota, and California and ‘have summarized them into a new concept called the “Super Bll” We are asking for your comments, pro or con, in de- veloping this concept, rather than putting the “eart before the horse” and developing yet another form, ‘The following outline details for you the idea we have in ‘mind; that js, the abolishment of all insurance claim forms nd the substitution of a statement which will satisfy the needs of third parties. This eoncopt would allow all options assignment, nomassignment, federal or commercial insur- “ance, but mast of all, just 2 bill. In other words, all doctors Dills are automatically insurance claim forms whether the patient does or does not have insurance, The ingredients are (Q) common language, (2) common format, (3) complete elimination of all signature requirements replaced by legal falsification notices, (4) versatility in completion by any process, and (5) the right for the physician to bill the pa- tient and/or third party direct, according to individual prefer- I. Adoption of a “Standardized Bill” (one piece of paper) Which can serve as a Dill or balance forward state- ‘ment to the patient, or, as @ natural byproduct, would serve the needs of the insurance industry, welfare, Medicare, and other third parties, ‘The adoption of the standard bill eliminates the cost of storing and completing varied third party payor forms and internal forms such as bills and separate balance forward statements. This allows for physician business office billing manually, or via typewriter, ookikeeping machine, and off-line or on-line computer systems. Immediate ‘savings are extended to third arty payors since one piece of paper is completely interchangeable and the need to supply policyholders with “physicigns claim forms” is virtually eliminated, since any doctor's bill is automatically the claim form. IL, Universal Standardization of Billing Format, Certain basic information for billing to the patient, responsible party, and/or third parties should be generated rou- finely’ through the physician's accounting system and presented on the bill in the following manner. ‘A. Deseription of services via the 19 CRVS (or other nationally accepted publications) and two Gigit modifier, when applicable, with an abbrevi ated description. 1. At present the 1969 CRVS is the most widely. used medical deseription publication in the United States (the AMA CPT is virtually a copy of this publication) 2, The 1969 CRVS includes an additional 2,000 pro- cedural deseriptions not indicated in the 1964 November/Decomber 1972 21CRYS. The California Medical Association ad- vises that there will be no digits added to the 1969 CRVS number or modifier codes, which lends to ease in adoption of future revisions. Tt is imperative that the system be designed to keep up with the new techniques and discoveries within the field of medicine, as opposed to lock- ing into a system guaranteed to become archaic 8. The 1969 CRVS provides the use of modifier codes which enables the physician to designate his eustomary fee in those cases where his fee is reduced or increased. More importantly, other modifier codes indicate multiple or biv lateral procedures, assistant surgeons, team sur- gery, professional components, ete, eliminating the need for correspondence between third party payors and the provider requesting clarification Future additions of the CRVS could expand the modifiers to include break down between doctor and supervisory anesthesiology, hospital and professional components for ancillary services, injection procedures by attending physicians or radiologists. The modifier codes coupled with the CRVS number, guarantee accuracy in third party pro files and easily lends to accurate national sta tistical studies, since all third party payor sta tisties would be in a common language which is interchangeable, 4. The contention that the 1969 CRVS is inflationary or that it promotes the breakdown of services in order to increase the total charge is invalid. In view of the Wage-Price Freeze and Phase IT of the present program, physicians are unable to increase their prices beyond 25% overall. In ‘other words, for physicians to adopt the 1969 CRYS into their system, they are restricted to identifying the CRVS number to the services which they presently render and charge their current fees. Secondly, Blue Shield “fee schedules,” all editions of the CRVS, and the CPT have recog- nized the billing of nowincidental multiple pro- cedures at 50% Future revisions of the CRVS could place more emphasis upon differentiating Detween incidental and non-ineidental multiple services. If there has been a problem in this area, it has been due to the lack of understand: ing and national direction rather than the use of the 1969 CRVS or an attempt on the part of Physicians to defraud the public ‘Note: While we believe the 1969 CRVS is pres- ently the best coding system in use, the number- Ing system lacks codes for injections, supplies, orthopedic appliances, eye glasses, contact lenses, aphakia lenses, ambulances, many lab and xray procedures, and a multitude of other {ng system) could be used for description, At pres: ent, the medical record in most linies must be reviewed by clorical personnel in order to extract this information, Since the physician generally is not directly involved in the placement of the diag- nosis on a claim form, insurance companies pres: ently may be receiving inaccurate information, while the physician's business office operating costs are ever increasing due to the necessity of having to pull the medical record, The revolution in pre-printed “‘charge tickets” provides the solu. tion since @ checkoff system is provided on the front of the ticket for the service which the physi cian renders, a simple, time saving technique, A portion of the ticket is preprinted with the ICDA codes unique to that physlclan's speciality. The physictan simply checks the diagnosis descrip. ‘ion(s) pertaining to that patient’s treatment, (Or hhe can select the proper code from a list, then write it on the’ charge ticket.) Only the diagnosis code number will print on the standard bill — not the description, This is ab- solutely essential since the samo piece of paper (the statement/claim form) goes both to third par- fies and to the patient, should the patient have in- surance, (Whether the patient files his own claim of it is done by the doctor is irrelevant) Place of service via the Medicare codes Dates of service — Inpatient services of a like kind (ie, one procedure code such as follow-up hospital visits may be lumped together), showing total charge and the first date and last date of serviee. It is understood that there will be no lump- ing together of unlike services, sueh as the initial ‘exam and follow-up hospital visits, Identification of patient by name, date of birth, and patient status (adult male, adult female, dependent male, dependent female.) Date of birth and patient status are options, dependent upon how the clinic handles insurance Tientifieation of Medicare, Welfere, insurance or other third party contract ‘holder by name, policy number, subscriber number and/or contract num: ber. Accurate and efficient identification cannot be achieved until doctors, hospitals, and third parties begin using a standard for individual identiication, ‘This will involve a carefully disciplined syntax for the name and agreed number — most likely the Social Security number, It is feasible and neces sary, but its accomplishment will require several years of cooperative effort and is not necessary for the approval of this concept, Blanks would be al- lowed within tho format to indicate this informa- tion, Note: This information would be provided by the patient rather than by the elinie in those eases where the patient insured will be filing his own claim (see Roman numeral VD. 6 ‘ancillary items which must he billed by many IIL. Other information needed by third party. The bill will clinics. It is imperative that future revisions of ritGyltelal ace far nace har 2 Gs tape tars the CRVS take these items into consideration, Plleable and if available by the doctor's otfiee or the B. Diagnoses via the latest ICDA codes. Use of the patient, dependent upon the option chosen by the clinie total coding system is preferable and Is encouraged. for billing However, the “Massachusetts” codes (which iden. ‘A.Is condition employment related? tify captions of the sections of the total ICDA eod- ‘An answer of “NO” is automatic since the pro- 22 Medical Group Management