Rpsgt, RST, CSE. Subtitle Here. Clinical Coordinator Crittenton Hospital Sleep Center Decoding Prior Authorization in Your Practice
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1 Lorraine Title Here Brierley Rpsgt, RST, CSE Subtitle Here Clinical Coordinator Crittenton Hospital Sleep Center Decoding Prior Authorization in Your Practice
2 x
3 YOU CAN MAKE A DIFFERENCE At the conclusion of this course, attendees should be able to understand the ICD-10 and CPT codes most commonly used in sleep medicine. I will give some simple methods for ensuring patients are getting the most out their sleep study
4 SIMPLE MEASURES Get access to the Insurance Websites visit often Read their newsletters Know their individual quirks there are many Plan ahead on clinic day
5 KNOW YOU CODES
6 WHEN CURRENT I PROCEDURAL LIVED IN ENGLAND TERMINOLOGY I AKA CPT CODES WORRIED ABOUT MY PSG Polysomnography; 4 Parameters CPAP Polysomnography; HEALTH 4 Parameters w/cpap also Split Night NOW MSLT Multiple Sleep Latency Test HST Home Sleep Test I WORRY ABOUT THE HST Home Sleep Test Medicaid & CO$T OF Medicaid MY HMO HEALTH PAP NAP
7 INSURANCE PRIOR AUTHORIZATION INTERNATIONAL CLASSIFICATION OF DISEASES AKA ICD-10 Takes time: How G47.33 much? Give Obstructive Sleep Apnea G examples Narcolepsy w/o cataplexy (MSLT) G Patience Narcolepsy w/cataplexy (MSLT) G47.10 Precise Hypersomnia, unspecified* G47.90 Documentation Sleep Disorder, unspecified* Patience *Some payers will not accept G47.33 OSA for pre-authorization A Sense of Humor Adherence to the official coding guidelines in all healthcare settings is required under the Health Insurance Portability and Accountability Act Expect the Unexpected
8 Benefits of ICD-10-CM Measuring the quality, safety, and efficacy of care Designing payment systems and processing claims for reimbursement Conducting research, epidemiological studies, and clinical trials Setting health policy Operational and strategic planning and designing healthcare delivery systems Monitoring resource utilization Improving clinical, financial, and administrative performance Preventing and detecting healthcare fraud and abuse Tracking public health and risks Basic Introduction to ICD-10
9 SIMPLE MEASURES Get access to the Insurance Company Websites visit often Read their newletters Know their individual quirks there are many Plan ahead on clinic day
10 HAVE THE $$ ANSWERS PRE-AUTHORIZATION Schedule Pts out so you do not have to keep rescheduling them while you wait reason not to go Get it right the first time! Appeals are time consuming
11 IN 5 AMERICAN FAMILIES ARE STRUGGLING 400 WITH MEDICAL DEBT IN 51 IN 5 AMERICAN FAMILIES /3 2013/4 2014/5 2015/6 IN-LAB STUDIES CONSULTS HOME SLEEP TESTS
12 Healthcare Costs SIMPLE MEASURES (In Billions) Get access to the Insurance Company Websites visit often Read their newletters Know their individual quirks there are many Plan ahead on clinic day Centers for Medicare and Medicaid Services 2012 California Healthcare Foundation
13 INSURANCE RESPONSE Oops!!!!!!!!!!! Need a good reason for In-Lab Study Not willing to repeat PSGs/Titrations Need a good reason not to go straight to AutoPAP 4:35am Pt is supine with severe OSA 5am Tech gets Pt up Pt will not be diagnosed this time
14 DOCUMENT EVERYTHING These are some things I wish I had known when trying to get patient back for In-Lab Titration Pt had scars on head from recent brain surgery Pt tried to strangle girlfriend during a dream Pt is taking narcotic medication not listed in file Pt has Downes Syndrome Pt suffers from clausterphobia Everything is worth mentioning you never what will win an appeal
15
16 $ Co-Pay to prove to my wife I m perfectly healthy I bet they don t find anything Once upon a time... There was a charming patient who was ADAMENT he NEVER sleeps supine. The Wise Sleep Fairy makes no attempt to encourage supine sleep because people ALWAYS know exactly what is going on while they are sleeping. 4:35am the patient magically turns supine and becomes an Obstructive Monster. 5am the patient is awoken by a loud clicking noise coming from the Sleep Fairy s cave. It sucks to be that patient THE END...
17 Will the patient come back? Will insurance pay for a repeat PSG?
18 IT MAKES SENSE TO ALLOW A STUDY LIKE THIS RUN LONG
19 SLEEP STUDIES UP 36%
20 /3 2013/4 2014/5 2015/6 IN-LAB PSGs TITRATIONS HOME SLEEP TESTS
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