The Fee Sheet confuses me

OpenEMR Development
1

drbowen wrote on Thursday, August 27, 2009:

Per Rod’s request I have started a new thread after the release of 3.1.0.
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I personally do not find the fee sheet to be intuitive. I’m still trying to figure out how to get it working. I have been working with this software a while and I just find it hard to use.

it seems like there ought to be a CPT code with up to four matching ICD-9 codes and a charge/fee in a group or possible in a row of data. Justification of a CPT code especially E&M codes should have documentation for up to four ICD-9 codes per row. The insurance companies if I understand correctly only read one ICD-9 per CPT code but depending on the documentation the practitioner needs to list up to 4 ICD-9 codes per E&M code.

Sam Bowen, MD
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I agree that the "fee sheet" is confusing. I am looking into utilizing CAMOS as a replacement for the "fee sheet."

-Mike
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I’m happy to entertain specific questions from those who do not understand the Fee Sheet, and specific suggestions from those who do. But please start a new thread for that; this one is turning into a hodgepodge of unrelated topics. And to just complain that it’s “too complicated” is not constructive.

Rod
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I have just received this from Peter Wayne:

Hello Sam,
Thank you for your response.
I don’t think this fee sheet would work for our practice.  I don’t know how much the basic structure of OpenEMR can be modified, but there are multiple issues I can see right off the top of my head:
1) No place to enter a prior authorization code for the service (e.g., for referrals).
2) No place to enter the referring doctor for the service (for consultations).
3) No place to specify the rendering physician in a multi-physician group.
4) Limit of only one ICD9 code per CPT4.
5) No place to specify place of service.

I suppose some of these issues are addressed by creating an "encounter" for the patient before a bill is created, but there are multiple cases in which an encounter does not seem appropriate, e.g., if the patient is seen in a nursing home, hospital, ASU, there is no office-based encounter.

I’m not trying to be critical – I appreciate  the effort that’s gone into OpenEMR. I’m just trying to assess its suitability for our practice.
Thanks again for your reply. I will try to see one of the practices and also talk to one of the support people you mentioned. Perhaps they have dealt with these issues before.

One other option I’m thinking of is using OpenEMR for medical records and simply sharing the patient table with my home-grown billing system.  Then I could continue to tailor billing as needed for our type of practice.  As you are well aware, though, OpenEMR has a long way to go to become CCHIT certified – it doesn’t even support patient suffixes, to say nothing of aliases, and all the other 471 (I think!) criteria that CCHIT specifies.

- Peter Wayne
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Isn’t saying “too complicated” the same thing as saying “non-intuitive” or “confusing” or “I don’t think this fee sheet would work for our practice.”  The majority of OpenEMR is “easy to use”, why not the “fee sheet”?

I am sorry that this is not very constructive.  I simply remember my prior "constructive criticism" as not being very accepted.

Sam Bowen, MD

2

tmccormi wrote on Thursday, August 27, 2009:

Peter and Sam both covered my basic concerns, mostly we have need to do some encounter-less charges as well and the Charge screen allows that easily.  But it also lacks some of the features that would be used for ‘recurring’ medical charges in a nursing home.

Mostly the fee sheet set up seems, somehow, complicated and the Code search tools in the Fee Sheet for are not straight up like they are in other places where you can search codes.  The search always reverts back to ICD9 after each try.   It would be a lot better to just have separate search buttons  for each code type, I think.

I understand that the IPPF code has a ‘tally’ sheet set up, is that just a well configured Super Bill/Fee Sheet or a custom feature?

–Tony

3

drpwayne wrote on Thursday, August 27, 2009:

I see that my comment to Sam has been copied. Sam did not include the demo of my current “fee sheet”, which is what I use now in my practice:
http://screencast.com/t/shdkb484q
The screencast shows how we create a bill in our current system. It’s very fast, has help available when needed but doesn’t force lookups for experienced users who know all the common ICD9 and CPT4 codes.

4

drpwayne wrote on Thursday, August 27, 2009:

oops, wrong url for screencast:

5

sunsetsystems wrote on Thursday, August 27, 2009:

Sam, are you aware that the drop-downs in the Fee Sheet are configurable?  Go to Administration -> Lists -> Fee Sheet.  "Group" corrresponds to the list box title.  "Option" is an individual list item.  "Generates" is the set of codes that will be placed into the Fee Sheet when you select that item, and may be multiple codes (such as a CPT and corresponding ICD9 codes).

You can also build the drop-downs by assigning categories to individual service items, but that is not as flexible as the above.  See Administration -> Lists -> Service Category and Administration -> Services.

The Fee Sheet is not the place to put prior authorization codes or referring doctors.  Use the "Misc Billing Options HCFA" form and the demographics form, respectively.

Rendering doctor *is* specified in the FS, and as of release 3.1.0 you can even specify a different provider for each service.

You *can* have multiple ICD9 codes per CPT.  Just add them, in order, using the Justify dropdown.

Please of service is specified in the New Encounter form, which is what you see when you first create the encounter.

It is fundamental to OpenEMR that you must create an encounter before you can enter billing information.  This is not peculiar to the FS.

"Tally Sheet" is just another name for the Fee Sheet.

Bottom line: It appears there are many misconceptions about the FS, and more in-depth documentation is needed.  Lack of understanding, the complexity of insurance billing, and richness or features will all contribute to an appearance of complexity.  Please invest the time to understand the FS before pronouncing it useless.

And yes, there is always room for improvement.

Now, any specific questions?

Rod
www.sunsetsystems.com

6

tmccormi wrote on Thursday, August 27, 2009:

Rod,
  I don’t  thnik anyone  said it was useless, just confusing … writing good documentation for each section of the product is a must.  This section is poorly documented, not poorly designed.  You understand it better than anyone (maybe because you wrote it?)   Could you write up something more formal on how you configure it and use it so  that we can incorporate into the users guide?

–Tony

–Tony

7

sunsetsystems wrote on Thursday, August 27, 2009:

Tony, I can but free time is scarce at the moment.  In the meantime I hope answering questions in this thread will help some folks.

Rod
www.sunsetsystems.com

8

bo2999 wrote on Thursday, August 27, 2009:

It is the most important part of openEMR for billing.

I would not consider openEMR if it did not have Fee sheet form.

It allows you to add modifiers, customize superbill. assigning appropriate provider, etc…

However, it would be nice if there is an option to choose which insurance (primary, secondary, tertiary insurance plan) to bill right in the fee sheet, instead of going to '“billing” section.  Because when it is time to do claim batching, I don’t always remember to change to the appropriate insurance plan for a specific patient.  I ended up having to resubmit the claims.  It is a pain!

Bo

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sunsetsystems wrote on Thursday, August 27, 2009:

Hi Bo,

When you get your eob/payment from primary insurance, you go to the EOB Invoice page to enter that info.  In that page is also an option to "reopen for secondary billing", and a selection to indicate that you are "done with" primary.  If you do that, then the correct secondary insurance should then appear by default on the Billing page for that encounter.

I’ve not checked that very recently, but that’s how it should work.

Rod
www.sunsetsystems.com

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bo2999 wrote on Thursday, August 27, 2009:

That’s works with certain patients who has crossover insurance.  But there are some patients we need to bill secondary insurance directly, because certain services will not be covered under primary insurance.  I would be nice if  “fee sheet form” allows to choose health plan to bill,  leaving primary as a default, of course.

Thanks,
Bp

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sunsetsystems wrote on Thursday, August 27, 2009:

The notion of billing primary and secondary concurrently is unfamiliar to me.  If it’s needed, I’d say the place to fix that is on the Billing page and related billing modules.  The Fee Sheet is about coding the visit.

Rod
www.sunsetsystems.com

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bo2999 wrote on Thursday, August 27, 2009:

I did not mean that we bill both primary and secondary insurance at the same time.   I just want to have the option to choose one to bill when I am coding.  For example, The drop box just like the one in the billing section is sufficient.  

Currently, I have to go to billing section to change it. 

Thanks,
Bo 

13

tmccormi wrote on Thursday, August 27, 2009:

Heres a bit of the confusion.
   Administration -> Lists -> Fee Sheet 

This selection (Fee Sheet) is not part of any of the 3.0.1 installations I have.  When was it added?  of how can I add it to my existing installs if somehow the base install did not put it there by default?
–Tony

14

sunsetsystems wrote on Friday, August 28, 2009:

Tony, that was part of the 2.9.0 release.  There is a fee_sheet_options table and you can find most of the relevant code by searching for that name.

Rod
www.sunsetsystems.com

15

drpwayne wrote on Friday, August 28, 2009:

I hesitate to reply because I really don’t want to offend anyone or disparage the work that’s been done on OpenEMR, but I have to disagree with some of the way the workflow is set up.
According to Rod:

'The Fee Sheet is not the place to put prior authorization codes or referring doctors. Use the “Misc Billing Options HCFA” form and the demographics form, respectively. ’

Well, I assume the Misc Billing Options HCFA will pull the prior authorization code and put it in the X12 submission. But the referring doctor in the patient demographics? What’s the point of that? Half the time when patients are admitted to the hospital, the referring doctor changes. Even if the patient is admitted by the same group of family practitioners or internists, when a consult is called, the referring doctor is the doctor who calls the consult, not the group. It would be necessary to go into patient demographics and change the referring doctor for each bill.
Even worse, for Medicare, for in-office lab tests such as stool guaiacs, dipstick urines, or glucose testing, Medicare requires the ordering doctor be entered as the referring doctor for the service. So if Sam refers a patient to me and in the process I do a stool guaiac, I have to create 2 bills, one in which Sam is the referrer (for the consult) and another in which I am the referrer (for the stool guaiac).  In the current OpenEMR system, I have to change the referrer in patient demographics from Sam to me and then back to Sam when it’s all over.  And if the  patient is subsequently admitted and I’m called by Brady on consult, then I have to go into demographics and change the referring doctor to Brady.

Now, let’s say I see the patient in the hospital – the OpenEMR Medical Center.  I need to have 2, maybe 3 separate “location” entries for OpenEMR Medical Center – one for inpatient services, one for ambulatory surgery, one for ER services. That’s a recipe for confusion and mistakes on the part of the biller.

"It is fundamental to OpenEMR that you must create an encounter before you can enter billing information. This is not peculiar to the FS. "

Again, it seems redundant to me. If the patient is seen in, say, a nursing home, then it’s a lot faster if no “encounter” is created but if everything, or as much as possible, is in one place. Incidentally, if the Open Medical Center has a nursing home, that’s a fourth place of service.

"Bottom line: It appears there are many misconceptions about the FS, and more in-depth documentation is needed. Lack of understanding, the complexity of insurance billing, and richness or features will all contribute to an appearance of complexity."

I gave an example using a screencast service of how I create a bill currently. It would clarify things and take only a few minutes if someone who uses OpenEMR could create a screencast showing how to create a comparable bill and send it out to an electronic intermediary.

16

sunsetsystems wrote on Friday, August 28, 2009:

Nothing wrong with suggesting changes and reasons for them.  Thank you for doing that.

Are you saying there can be separate referring doctors for different services in the same visit?  If so, then it only makes sense for the referring doc to go into the Fee Sheet, since that’s where the services are entered.  If not, then the New Encounter form is probably the best place.

Billing requires a place of service.  Don’t see how you are going to get around multiple facilities for that.

In case this helps: Encounter = visit = claim.  It’s not a place of service (though that is an attribute of the visit).  The encounter *is* that “one place” where everything goes for a claim.

Rod
www.sunsetsystems.com

17

drpwayne wrote on Friday, August 28, 2009:

Rod,
Yes, there are different referring doctors for the same visit if we perform a CLIA-waived laboratory service. We <i>do</i> create separate claims when that happens.
If a patient is referred, though, and then seen in follow-up, the next visit (encounter) is not a referral and should not have the referrer there in the bill. I don’t see how the fee sheet will distinguish between claims that require a referrer and those that don’t, if the referrer is part of the patient demographics.  Will every subsequent claim pull the referrer into the 2310 loop of the 837 claim?

As for place of service: a given institution may have more than one place of service. I can provide services in the inpatient hospital, the outpatient cinic, the ER, the ASU, all as part of the same facility.  All I was saying is that if you make the HCFA place of service part of the facility, then you have to have the same facility listed multiple times, and that’s confusing.
E.G.
St. Josephs Medical Center Inpatient
St. Josephs Medical Center ASU
St Josephs Medical Center ER
St Josephs Medical Center Outpatient Hospital

It’s much easier, in my mind, if you just have one “St Josephs Medical Center” and then in the fee sheet/bill enter whether the service is an ASU, IH, or ER or OH service.

18

bo2999 wrote on Friday, August 28, 2009:

I think you can change place of service in the encounter section prior to coding.

Am I wrong here?

Bo

19

drpwayne wrote on Friday, August 28, 2009:

I suppose the place of service isn’t a big issue – I would just need to declare several different POS for each facility, as mentioned in my last post.
I can’t find where in the patient demographics, though, the referring physician is entered.

20

sunsetsystems wrote on Friday, August 28, 2009:

Sounds like we definitely want to move the referring doc to the New Encounter form (yes the place of service is already set there and you can change it any time before billing is run, not necessarily before coding).

Currently it’s the “Provider” field in the “Choices” section of demographics.

Rod
www.sunsetsystems.com