What does the current Physician’s Manual include?
The Physician’s Manual contains information about medically-insured services available to Nova Scotians.
The preamble outlines provincial policies and rules. The MSI Billing Instructions Manual is a companion document that guides physicians on how to submit claims for payment for insured services provided.
New fees, adjustments to fees, reporting reminders, and policy changes are communicated through the MSI Physicians’ Bulletin.
The current Physician’s Manual contains information about medically-insured services available to Nova Scotians.
The preamble at the beginning of the Physician’s Manual outlines provincial health services policies as well as a number of associated rules. The rules are intended to explain who, when, where, and how a particular health service may or may not be insured by the province.
The main document is divided into specialties and contains health service codes, modifiers and fee values. The descriptions of health services are based on clinical diagnoses codes from the 9th revision of the International Classification of Diseases, Clinical Modification (ICD-9-CM) and the clinical service descriptions from the Canadian Classification of Procedures (CCP) as well as some locally-developed descriptions. Each clinical service is identified by a health service code and there are usually a number of modifiers for each code that help to specify things like location or specialty.
The MSI Billing Instructions Manual is a separate document intended to be a guide for physicians on how to properly submit claims to MSI for health services they have provided. It outlines all the requirements for the submission of service encounter claims.
The MSI Physicians’ Bulletin is intended to update providers on reporting reminders, holidays, Workers’ Compensation Board due dates, etc.
What are the problems?
Outdated clinical diagnoses and service codes cause ambiguity, which leaves physicians vulnerable during routine audits.
While it is prudent for physicians’ billing practices to be audited, documentation guiding their reporting has to modernize so it reflects the services they provide to patients.
Once the documentation has been updated, physicians will be able to bill with confidence thus alleviating surprises during the audit process.
There are a number of issues with the current Physician’s Manual and supporting documents. The primary problems that underlie many of the other issues are due to the wording used to describe clinical service descriptions and clinical diagnoses. The ICD-9-CM descriptions for clinical diagnoses are out of date and the Canadian Classification of Procedures (CCP) has not been supported for over a decade and therefore is not current. Since these are out of date, Nova Scotia (and other provinces using the descriptions) has had to develop its own clinical service definitions to create new health service codes whenever new health services become insured in the province.
The many layers of rules and modifiers necessary to claim each health service have made the process confusing, cumbersome, and highly prone to errors. This complexity has also made it difficult to create new health service codes in a timely manner so the entire breadth of insured services fails to capture many procedures, diagnoses and treatments that physicians are currently providing.
Other logistical issues are:
- a lack of linkages between the Physician’s Manual, Billing Instructions Manual and Physicians’ Bulletin
- inconsistent translation of new information from the bulletins to the manual
- inconsistent information contained within all manuals and supporting documents (i.e. currently, rules are found in both Physician’s Manual and the Billing Manual should be contained in one or the other).
What did physicians say they wanted to see in a good physician’s manual?
Physicians identified the need for:
- Information reflecting the services physicians provide to patients with clear alignment of rules and modifiers to make reporting easier.
- Streamlined documentation that is easy to use, easy to update and can be clearly interpreted.
- Clinical data provided back to physicians in a format useful for them and their practices.
- A new and improved manual to support fair and effective audits.
Last year RKL Consulting conducted a number of interviews with physicians as a part of Phase I, the MSI Physician’s Manual Scoping and Mapping project. Each physician was asked to consider what a useful, well-constructed physician’s manual might look like.
The responses were divided into four main themes:
- Specific clinical information: Physicians want to see improved clinical content that accurately reflects the services they are providing. They want to see a clear alignment of the necessary rules and modifiers so it is straightforward and makes reporting easier.
- Supporting documentation: Physicians would like to see a manual with a redesigned documentation structure that makes the documentation easy to use, streamlined, and flexible enough to allow for timely and uncomplicated updates. All documentation should be clear for ease of interpretation across all users.
- Information value, access and data quality: The clinical diagnoses and clinical health service information should accurately reflect each patient and each service provided to that patient. The descriptions used for clinical diagnoses and clinical health service descriptions must be current, well supported, have an educational component, and have regular data quality checks in place. The clinical data collected would be provided back to physicians in a format useful for them and their practices.
- Audit integrity impact: The purpose of an audit is to support good clinical practice, provide helpful feedback to physicians and other users, and to ensure timely payment for each service encounter claim reassessments. The current conditions of the Physician’s Manual, Billing Instructions Manual and Physicians’ Bulletin impact the integrity of the audit process. A new and improved Physician’s Manual would support fair and effective audits.
Why not use another province’s physician’s manual?
The findings from a detailed review of insured clinical services used across Canada showed there were various problems with poor documentation in most of the physician manuals.
The lack of supported, standard clinical descriptions and the documentation issues in all physician manuals made them as unsustainable as Nova Scotia’s Physician’s Manual.
One of the options within the scope of Phase I, the Physician’s Manual Scoping and Mapping project, was to consider the adoption of current best practices from other provinces with ongoing monitoring of changes.
The findings from this detailed review of insured clinical service used across Canada showed there were various problems, reflecting poor documentation in most of the physician manuals. Some of the documentation issues were:
- Illogical order of content
- No section overviews
- Confusing sentence structure
- Tariffs mixed in with preamble content
- No examples showing different claims scenarios or properly completed claims
More importantly, the review also showed there is no current standard for reporting insured clinical services in use by any of the provinces. In other words, the other provinces have also had to use or create their own descriptions for health service descriptions over the years, and none have been updated or are currently supported.
The lack of supported, standard clinical descriptions and other shared concerns across all physician manuals make them as unsustainable as Nova Scotia’s Physician’s Manual.
What is the Nova Scotia Physician's Manual Modernization Project?
The Nova Scotia Physician Services Project is a joint initiative between Doctors Nova Scotia and the Nova Scotia Department of Health and Wellness to improve and modernize the terminology used to describe the services physicians provide to Nova Scotians. The result will be easier billing and reporting for physicians and the expanded use of information for health services planning at the practice level and provincial level.
How is the project going to be done?
RKL Consulting has been hired to lead the project. In partnership with Doctors Nova Scotia and the Department of Health of Wellness, the consulting firm will work with physicians to analyze and identify irrelevant health service codes and to describe their work not currently captured in documentation. In the long term, the goal will be creation of new documentation that reflects the services physicians provide and new processes to support, maintain and update its use.
Due to the volume of work, the Physician’s Manual Update project has been divided into six phases.
Phase I, the Physician’s Manual Scoping and Mapping project, was completed in December 2012.
Currently, the project’s working group and steering committee, along with RKL Consulting, have reconvened for Phase II.
Physicians will be engaged to review the diagnoses and service descriptions they use now and to identify the additional descriptions required to reflect the work they do. New documentation will be available for use by physicians. Process changes will be defined and a plan developed for the next phase.
What is going to happen to the existing FSAC, MASG processes?
The existing Fee Schedule Advisory Committee (FSAC) and Master Agreement Steering Group (MASG) processes will continue until the Master Agreement expires March 31, 2015. The work of the project will be designed to run in parallel with the work of these two groups and does not involve the process of contract negotiations for a new Master Agreement.
What will happen to the data that has been collected over the past 20 years?
The data that has been collected over the past 20 years will be recorded and stored. Any new data generated will be cross-referenced with the old data so it can continue to be used as required.
Will MSI audits occur while the project is ongoing?
Yes, MSI audits will continue as usual.
Doctors Nova Scotia