EXCERPT FROM GOVERNING RULES - Calgary · 2017. 5. 15. · dentist, optometrist, physical therapist or nurse practitioner. 4.3.2 Limited Consultation: Limited assessment of a patient

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Prepared by Health Economics

Alberta Medical Association

GENERAL PRACTICE BILLING (Rates – effective April 1, 2017)

NOTE: Please refer to Schedule of Medical Benefits for detailed descriptions and complete set of Governing Rules

EXCERPT FROM GOVERNING RULES:

1 DEFINITIONS 1.7 A physician’s “family” means children, grandchildren, siblings, parents, grandparents, spouse

or adult interdependent partner or any other person who is dependent on the practitioner for support in accordance with the Alberta Health Care Insurance Regulation.

1.7.1 A patient’s “family” means children, siblings, parents, legal guardian/agent (agent as defined in the Personal Directives Act (RSA 2007c37s3), spouse or adult interdependent partner.

1.8 "Home Care Worker" is defined as a registered: nurse, licensed practical nurse, psychiatric nurse, occupational therapist, physiotherapist, respiratory therapist, or any other health profession working in an Alberta home care program or Alberta palliative care program administered by a regional health authority.

1.9 "Community Mental Health Care Worker" is defined as a registered: nurse, licensed practical nurse, psychiatric nurse, social worker, psychologist, or any other health profession working in an Alberta community mental health care program administered by a regional health authority.

1.13 "Rotation Duty" means - scheduled hospital emergency department duty providing on-site emergency department physician coverage or physicians providing first call coverage for an emergency department with greater than 25,000 visits per year or; - scheduled on-site coverage in a facility designated by Alberta Health as an AACC or

UCC

1.14 Unless otherwise stated, the term "encounter" used in this Schedule means each separate and distinct time a physician provides services to a patient in a given day as defined in GR 1.19. To be recorded as separate encounters, multiple services provided to a patient may not be initiated by the physician, or may not be a continuation of a service which began earlier in the day. An example of continuation of services is the time spent with a patient to review x-ray or laboratory results ordered during an examination of the patient earlier in the day. If the patient initiates the second and subsequent encounter(s) or the physician is requested to attend the patient by hospital or nursing home staff, additional encounters may be claimed.

1.19 “Day” means a period of 24 hours starting at midnight.

1.22 “AACC” means Advanced Ambulatory Care Centre.

1.23 “UCC” means Urgent Care Centre.

1.27 When claiming for telecommunication and telephone call services, the location of the physician at the time of the service should be used on the claim.

1.30 “Calendar week” means a period of seven consecutive days beginning with Sunday and ending with Saturday.

GP Billing Rules & Codes

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2. APPLICATIONS 2.3.2 Cumulative time is calculated by adding the total time spent delivering patient care as

identified in the description of the HSC, over the course of the day (GR 1.19) and dividing the total time by the time units specified in the HSC to determine the appropriate number of calls. When the remainder of the time calculation equals less than half of one call, an additional call may not be claimed. Separate encounters may only be claimed when a special call for attendance has been made on the patient’s behalf.

2.3.4 Where time is described as a portion thereof, the physician may spend any amount of time providing the services described by the HSC in order to submit a claim for the service.

2.3.5 Where time is described as a major portion thereof, the physician must spend a minimum of half of the time described in the HSC providing the service in order to submit a claim for the service. Additional calls for the same HSC may not be claimed until the full time period as described in the HSC for each previous call has elapsed.

2.3.6 When billing time based services, including modifiers, the physician must document the time spent providing time based services for each day of service (as defined in GR 1.19). The record must be available upon request and should be kept in chronological order, for each day. The total time claimed for time based services in a single day cannot exceed the total time spent delivering patient care activities in relation to an insured service. Claims for services that are described as cumulative time, major portion thereof or portion thereof may continue to be submitted in accordance to GR’s 2.3.2, 2.3.4 and 2.3.5.

2.3.7 Concurrent billing for overlapping time for separate patient encounters/services may not be claimed.

2.7 CLAIMS FOR BENEFITS 2.7.3 For administrative purposes the start of the day is considered to be midnight. A hospital visit which takes place after 0700 hours may be claimed in addition to one of the following services provided between midnight and 0700 hours: a) emergency home visit and admission to a hospital and hospital visit on the same day b) home visit c) hospital admission or consultation claimed in lieu of hospital admission d) emergency visit/special callback to hospital emergency/outpatient department, AACC

or UCC, when specially called from home or office e) a special call for attendance to a patient at a closed office, with no staff in attendance 2.7.4 Unless the Minister considers that extenuating circumstances exist a claim for benefits is

payable subject to the timelines indicated in the Alberta Health Care Insurance Plan Act and regulations.


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3 EXCLUSIONS 3.1 The following includes examples of, but is not limited to, services which are not a benefit

under the Schedule and may not be claimed: a) advice by telephone or other telecommunication methods except as specified under

specific HSCs or for telehealth services b) ambulance services, except ambulance detention time HSC 13.99K, 13.99KA, 13.99KB c) anesthetic materials d) any service a physician provides to a member of his/her children, grandchildren,

siblings, parents, grandparents, spouse or adult interdependent partner or any other person who is dependent on the practitioner for support in accordance with the Alberta Health Care Insurance Regulation

e) drugs/agents f) intravenous sedation for dental procedures administered to a patient who is not an

inpatient or registered outpatient of a hospital g) medical appliances h) medical testimony in court, except psychiatric opinion at psychiatric review panel

under the Mental Health Act i) secretarial or reporting fees j) stand-by time k) travel time of a practitioner to see a patient l) services requested or required by a third party. Examples include but are not limited to: - examinations or certification related to adoption - medical examinations to indicate fitness to attend camp - autopsies - employment examinations and reports - examinations and reports requested under the auspices of the Child Welfare Act - immigration requirements - insurance/disability reports and forms - examinations and reports for judicial purposes (e.g., requested by police) - medical-legal reports requested by patients or by lawyers on behalf of patients with

the exception of HSC 03.01MT - motor vehicle license (except after age 74.5 years) - examinations and forms relating to participation in sports - examinations and forms relating to university or other school requirements - passport and visa applications m) pre-travel assessments, counseling or administration of vaccines or drugs for travel

purposes to reduce the patient’s risk of acquiring an illness, or for prevention of communicable diseases not endemic to Canada

n) administration of vaccines such as Hepatitis A and B is not covered unless specifically otherwise communicated by Alberta Health and Wellness


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4.1 COMPLETE EXAMINATION - DEFINITION: In the context of GR 4, complete physical examination shall include examination of each

organ system of the body, except in psychiatry, dermatology and the surgical specialties. "Complete physical examination" shall encompass all those organ systems which customarily and usually are the standard complete examination prevailing within the practice of the respective specialty. What is customary and usual may be judged by peer review.

4.2 VISITS - DEFINITIONS 4.2.1 Brief Visit: Assessment of a patient's condition when history is minimal and little or no

physical examination is included. 4.2.2 Limited Visit: A limited assessment, of a patient, which includes a history limited to and

related to the presenting problem, and an examination which is limited to relevant body systems, an appropriate record, and advice to the patient. It includes the ordering of appropriate diagnostic tests and procedures as well as discussion with the patient.

4.2.3 Comprehensive Visit: An in-depth evaluation of a patient. This service includes the recording of a complete history and performing a complete physical examination appropriate to the physician's specialty, an appropriate record and advice to the patient. It may include the ordering of appropriate diagnostic tests and procedures as well as discussion with the patient.

4.2.4 Palliative Care: Defined as care given to a patient with a terminal disease such as cancer, AIDS or advanced neurologic disease. Palliative care involves active ongoing multi-disciplinary team care. Physicians involved in palliative care may claim for services provided under 03.05I, 03.05T and 03.05U as applicable.

4.2.5 Chronic Pain: Defined as pain which persists past the normal time of healing, is associated with protracted illness or is a severe symptom of a recurring condition.

Interdisciplinary Chronic Pain Program: Defined as a comprehensive, coordinated, interdisciplinary program for persons complaining of chronic pain. The interdisciplinary team consists of a medical director; other team members will include psychologist(s) and/or psychiatrist(s), physiotherapist(s) and/or occupational therapist(s) and may include anesthetist(s) and other professional personnel. Treatment is delivered by a coordinated team within the same site by an interdisciplinary chronic pain program.

4.2.7 Comprehensive Visit in Emergency Department, AACC or UCC: An in-depth evaluation of a patient with a new or existing medical condition, including the recording of a complete history and a complete physical examination, and, where required, the ordering and reviewing of laboratory tests and x-rays and the initiation of appropriate therapy. May also be claimed for those patients whose illness or injury requires prolonged observation, continuous therapy and/or multiple reassessment(s) or for patients presenting with obstetrical problems or gynecological bleeding who require an internal examination. May be claimed by emergency medicine physicians, full-time emergency room physicians, general practitioners and pediatricians working a rotation duty shift in an emergency department with 24 hour on-site physician coverage or in an AACC or UCC with on-site coverage.


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4.3 CONSULTATIONS - DEFINITIONS 4.3.1 Comprehensive Consultation: An in-depth evaluation of a patient with a written report to the

referring physician, audiologist, Alberta registered midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner. This service includes the recording of a complete history, performing a complete physical examination appropriate to the physician's specialty, an appropriate record and advice to the patient. It may include the ordering of appropriate diagnostic tests and procedures as well as discussion with the patient and/or the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner.

4.3.2 Limited Consultation: Limited assessment of a patient and a written report to the referring physician, audiologist, Alberta registered midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner. A limited consultation includes a history limited to and related to the presenting problem, and an examination which is limited to relevant body systems, an appropriate record, and advice to the patient. It may include the ordering of appropriate diagnostic tests and procedures as well as discussion with the patient and/or the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner.

4.4 CONSULTATION - APPLICATION

4.4.1 In this Schedule "consultation" means that situation where a physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner after an appropriate examination of the patient, requests the opinion of a consultant physician, and the consultant does a history, an examination and a review of the diagnostic data and provides a written opinion with recommendations as to the treatment, to the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner. Consultations may not be claimed for the transfer of care alone.

4.4.2 The need for a consultation can arise as a result of the following: a) some unusual or serious clinical problem b) a physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist,

physical therapist or nurse practitioner requires further advice regarding diagnosis or management, or both, or

c) the patient, parent or guardian requests another opinion


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4.4.3 A referral may be accepted from any person; however, to receive reimbursement as a consultation, a request must be made by the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner to the consultant in the form of:

a) verbal or written communication (fax, email, letter) b) verbal or written communication between an agent representing the referring physician,

audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner and the consultant

c) verbal or written communication between the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner and an agent representing the consultant

d) verbal or written communication between agents representing the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner and the consultant

Agent means any of the following individuals who are acting under the direction of the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner and the consultant, as appropriate:

a) an employee of a physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner or

b) a hospital or long term facility staff member; or c) a supervised physician in training acting under the direction of a physician Payment for a consultation to an Alberta physician may also be made when an Out of

Province physician refers the patient and the criteria stated herein are met. 4.4.4 If a consultation is followed by a procedure performed by the consultant, a benefit may be

claimed for the consultation as well as a major procedure up to and including the day of surgery.

4.4.5 A benefit for continuing care may be claimed by a consultant following a consultation where the continuing care is provided at the request of the referring physician, audiologist, chiropractor, midwife, podiatrist, dentist, optometrist, physical therapist or nurse practitioner.

4.4.6 Repeat consultations may not be claimed unless a further request has been initiated by and received from the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner for another consultation. A repeat consultation may not be claimed if initiated by the consultant.

4.4.7 When a physician sends a member of his family to another physician, a consultation benefit may not be claimed.


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4.6 LIMITATION ON VISITS AND CONSULTATION DESCRIBED AS COMPREHENSIVE 4.6.1 Comprehensive visits and/or comprehensive/major consultations may only be claimed

once every 365 days per patient by the same physician. Comprehensive visit and consultation services are defined as HSCs 03.04A, 03.08A, 03.08B, 03.08C, 03.08F, 03.08H, 03.08K, 08.11A, 08.11C, 08.19A and 08.19AA.

HSC 03.09B is defined as comprehensive and may not be billed more frequently than once every 180 days by the same physician.

HSCs 03.04O and 03.04P are defined as comprehensive services and may not be billed more frequently than four times per year as indicated or within 180 days of a comprehensive service or consultation by the same physician.

4.6.2 Notwithstanding GR 4.6.1, 03.08A may only be claimed for patients under 12 months of age once every 90 days per patient by the same physician. There must be an interval of 90 days between the first and second consultation.

4.6.3 Notwithstanding GR 4.6.1, an initial prenatal examination 03.04B may not be claimed within 90 days of another comprehensive visit or consultation. Comprehensive visit and consultation services are defined under GR 4.6.1. There must be an interval of 90 days between the first and second services.

4.7 OTHER LIMITATIONS ON VISIT ITEMS In general, when an office visit and a hospital admission are provided to a patient on the

same day by the same physician, only the greater benefit may be claimed. There are two exceptions to this. Firstly, if a new condition arose and the patient was seen at two separate encounters, both services may be claimed. Information must accompany this claim. Secondly, two services may be claimed when they fall within the provisions of GR 2.7.3.

4.8 CONCURRENT CARE IN HOSPITAL 4.8.1 If the services of more than one physician are required because of the complexity of the

clinical needs of a patient, each physician may claim a benefit for concurrent care. Satisfactory supporting information must accompany the claim.

4.8.2 If a consultation is required, the attending physician and the consultant may each claim for services provided on the day of consultation.

4.8.3 If the provisions of GR 4.4.5 apply, a benefit may be claimed by the referring physician only after the full responsibility for the care of the patient has been returned to him/her, or the complexity of the clinical needs of the patient require the services of the referring physician in addition to those of the consultant.

4.8.4 When the care of the patient remains with the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, physical therapist or nurse practitioner and the nature of the illness makes further intermittent visits by the consultant advisable, they may not be claimed as repeat consultations.


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4.9 SUPPORTIVE CARE 4.9.1 When a patient is in hospital under a specialist's care, and the family physician or

paediatrician is not actively managing the case, the family physician or paediatrician may claim supportive care benefits (03.05M, 03.05MA). The following criteria apply: a) deleted

b) the patient, the patient's family or the most responsible physician specifically requests that the family physician or paediatrician visit for the purposes of liaison or reassurance

4.9.2 If medical complications develop or are present which require active management by the family physician, hospital visits should be claimed in accordance with GR 4.8.

4.10 TRANSFER OF CARE 4.10.1 If the care of a patient is transferred, each physician may claim for services provided on the

day of transfer. 4.10.2 If a physician transfers the care of a hospitalized patient to a second physician, the second

physician may claim daily care. The applicable benefit rate will be determined by the number of days of the patient’s hospitalization except as provided in GR 4.10.3.

4.10.3 When the care of a patient is transferred to a second physician, the second physician may charge daily hospital care, starting at the rate allowed for the first to seventh day, only if the transfer was due to the onset of a significant new illness.

4.10.4 If a patient is transferred to another hospital under the care of another physician, hospital visit services shall be claimed as though this were a first admission.

4.10.5 A physician who admits a patient to hospital and provides pre-operative care but does not perform the surgery, may claim benefits for the services up to and including the day of surgery.

4.14 POST PARTUM OFFICE VISITS Whether the baby is ill or well the first office visit of a newborn, within 14 days of the date

of birth, cannot exceed the "limited" evaluation rate if the physician has received payment for care of healthy newborn in hospital (03.05G) or inpatient care.

Subsequent to the initial post-partum visit, a physician may charge under whatever HSCs are appropriate for the care provided.

4.15 PRONOUNCEMENT OF DEATH When a physician is specially called and attends on a priority basis to pronounce a death, a

visit benefit may be claimed. There is no additional benefit for completion of a death certificate.


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5. EMERGENCY/URGENT/CRITICAL CARE 5.1 EMERGENCY DEPARTMENT/AACC /UCC VISITS/ASSESSMENTS BY ROTATION

DUTY PHYSICIANS OR BY PHYSICIANS PROVIDING FIRST CALL COVERAGE IN AN EMERGENCY DEPARTMENT THAT HAS GREATER THAN 25,000 VISITS TO THE EMERGENCY ROOM PER YEAR

5.1.1 HSCs 03.05CR, 03.05DR, 03.05ER, 03.05F, 03.05FA, 03.05FB may only be claimed by physicians on rotation duty or by physicians who are providing first call coverage in an emergency department that has greater than 25,000 visits to the emergency room per year. HSCs 03.05FR, 03.05GR, 03.05HR, 03.05FC, 03.05FD and 03.05FE may only be claimed by physicians on rotation duty in an AACC or UCC.

5.1.2 Only one of HSCs 03.05CR, 03.05DR, 03.05ER, 03.05FR, 03.05GR or 03.05HR may be claimed by either the same or a different physician, on the same date of service when the patient has remained in the emergency department, AACC or UCC.

5.1.4 When the patient has been discharged from an emergency department, AACC or UCC and returns on the same day, another visit by the same or different physician may be claimed.

5.1.5 HSCs 13.99H and 13.99HA may not be claimed in association with another visit HSC. Time units may be claimed on a cumulative basis.

5.1.6 If a physician on rotation duty in a hospital emergency department or a physician who is providing first call coverage in an emergency department that has greater than 25,000 visits to the emergency room per year and a second physician submit claims for visits to the same patient on the same day, the following rules apply: a) If the patient is not admitted, the physician on rotation duty or the physician who is

providing first call coverage in an emergency department that has greater than 25,000 visits to the emergency room per year may be paid and the second physician may only be paid when specially called to attend that specific patient or in the case of follow-up care as described under HSCs 03.05F, 03.05FA, 03.05 FB.

b) If the patient is admitted, both physicians may be paid and in this case, the second physician does not have to be specially called to claim for inpatient services.

5.1.7 If a physician working in an AACC or UCC, and a second physician submit claims for visits to the same patient on the same day, the physician working in an AACC or UCC may be paid and the second physician may only be paid when specially called from outside the facility to attend that specific patient.


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5.2 SPECIAL CALLBACKS TO AACC/UCC/HOSPITAL EMERGENCY/OUT-PATIENT DEPARTMENT BY NON-ROTATION DUTY PHYSICIANS

5.2.1 HSCs 03.03KA, 03.03LA, 03.03MC and 03.03MD may be claimed when a physician is specially called from home or office to a hospital emergency department, AACC or UCC to attend one patient. Maximums apply see GR 15.11.

5.2.2 If a physician is in a hospital, AACC or UCC for any purpose and is asked to see a another patient in the hospital emergency room or the same AACC or UCC, HSCs 03.03KA, 03.03LA, 03.03MC, 03.03MD do not apply. Benefits may be claimed for the applicable visit or procedure.

5.2.3 Services provided to additional patients seen during the same callback, or services over the limits specified in GR 15.11 may be claimed as:

a) deleted b) HSC 03.02A, 03.03A, 03.03B, 03.04A as appropriate, or c) the applicable procedure 6 PROCEDURES 6.1 If a physician performs a minor procedure and provides a service warranting a claim for an

office visit or a home visit on the same day, benefits for both may be claimed only if the services and diagnoses are unrelated.

6.2 If a service is provided in a hospital emergency department, AACC or UCC, only the minor procedure or the visit benefit, whichever is the greater, may be claimed, unless the problems are emergencies and the diagnoses are unrelated.

6.3 A procedure benefit includes removal of sutures. The physician who placed sutures may not claim for removing them. A second physician who is in the same practice group as the surgeon may not claim for removing the sutures either. However, a second physician may claim a visit for removal of sutures if he is not a member of the same practice group as the practitioner who put the sutures in.

6.4 Anaesthetic benefits for local infiltration are included in the benefit for the procedure. 6.5 NON-INVASIVE DIAGNOSTIC PROCEDURES IN HOSPITAL, AACC OR UCC Benefits for non-invasive diagnostic procedures performed for a hospital inpatient,

registered outpatient or AACC or UCC patient are not payable under the Schedule. Payment for these services is the responsibility of the hospital/Regional Health Authority. This applies to both the technical and professional components. (See SOMB for complete listing.)

6.6 DIAGNOSTIC SURGICAL PROCEDURES 6.6.1 If a patient is admitted to a hospital for the purpose of undergoing a procedure designated

"+", a benefit is payable for a visit provided the day before or the day after the procedure is performed, but if the procedure is performed and a visit occurs on the same day, a benefit is payable for either the procedure or the visit, but not both.


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6.6.2 If a procedure designated "+" is performed in a physician's office, both the procedural benefit and the appropriate office visit benefit for that day may be claimed, but if a consultation benefit pursuant to GR 6.6.4 has been claimed, a visit benefit will not be payable for the day on which the procedure is performed.

6.6.3 If a procedure designated "+" is performed in a place other than a physician's office, either a procedural benefit or a visit benefit, but not both, may be claimed for that day.

6.6.4 If a procedure designated "+" and a consultation are provided on the same day, both the procedural benefit and the appropriate consultation benefit are payable.

6.7 MINOR PROCEDURES 6.7.1 If a minor procedure (M or M+) is provided with a hospital visit on the same day, only the

greater benefit item may be claimed. 6.7.2 When more than one procedure with a "V" category is provided at the same encounter only

the greater benefit may be claimed. 6.8 MAJOR PROCEDURES 6.8.1 HSCs with a designated category code of 1 and 15 include related post-operative services

and those with a designated category code of 3, 4, 6 and 14 include both related pre-operative and post-operative services.

a) a consultation benefit may be claimed up to and including the day of surgery b) pre-operative hospital care may be claimed by the physician who performs the surgery

if information is submitted to show that conservative treatment was attempted before surgery was performed

c) benefits may be claimed as applicable for complications occurring during or following post-operative time periods

e) HSC 03.04R may be claimed in the pre-operative time frame when all conditions in the notes have been met.

The following chart gives the pre-operative and post-operative periods. Category Pre-operative Post-operative 1 0 – Days 14 - Days 3 7 – Days 7 - Days 4 7 – Days 14 - Days 6 14 – Days 14 - Days 14 30 – Days 14 - Days 15 0 - Days 7 – Days


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6.8.4 Where a procedure is performed under general anaesthesia, the following applies: a) If the procedure is the only procedure performed at that time, a benefit of $134.85 may

be claimed. b) If another procedure is also performed at the same encounter and the listed benefit

payable in respect of it under the Schedule is greater than $134.85 the physician is entitled to receive that listed benefit plus a percentage of the listed benefit for the lesser procedure(s) calculated in accordance with this Schedule. The $134.85 minimum benefit does not apply to the lesser procedures.

c) If multiple procedures are performed at the same encounter and the listed benefit payable in respect of each of them under the Schedule is less than $134.85, the physician is entitled to receive a benefit of $134.85 in respect of the greater procedure plus a benefit in respect of each of the lesser procedures that is a percentage of the listed benefit and calculated in accordance with this schedule. The $134.85 minimum benefit does not apply to the lesser procedures.

d) If multiple procedures are performed at the same encounter and only one of them appears under rule GR 6.8.4 (e), the physician is entitled to receive a benefit of $134.85 in respect of that procedure plus a benefit in respect of each of the other procedures that is a percentage of the listed benefit and calculated in accordance with this schedule.

e) GR 6.8.4 applies to the following HSCs: (Please refer to SOMB for listing) 8.1 OBSTETRICS - GENERAL 8.1.1 Obstetrical care is divided into its components. An initial prenatal visit 03.04B includes a

full history, examination, completion of the prenatal record and advice to the patient. Usual prenatal care includes a prenatal visit, follow-up visits which would generally occur at four-week intervals to 32 weeks, followed by visits every second week to 36 weeks, then weekly visits until delivery. Additional visit or procedure items may be claimed as required for complicated pregnancies.

8.1.2 Prenatal visits (HSC 03.03B), emergency, outpatient and inpatient hospital visits may be claimed up to the time of delivery, including the day of delivery; except in the situation where delivery occurs within 24 hours of admission, in which case neither a hospital admission (03.04C) nor a hospital visit (03.03D) may be claimed.

8.1.4 The delivery benefit includes payment to the attending physician for procedures such as surgical induction, episiotomy, repair of episiotomy or non-extensive lacerations (first or second degree as defined below), and ordinary immediate care of the newborn.

First degree is defined as a superficial laceration of the vaginal mucosa or perineal body which does not require suturing.

Second degree is defined as a laceration involving the vaginal mucosa and/or perineal skin and deeper subcutaneous tissue and requiring suturing.

Third degree is defined as an extension of the laceration which involves any part of the capsule or anal sphincter muscle or deep vaginal sidewall laceration.

Fourth degree is defined as extensive including involvement of the rectal mucosa.


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8.1.5 When a delivery occurs within 24 hours of admission, the delivery benefit includes the hospital admission (HSC 03.04C) or hospital visit (03.03D). Post-partum hospital visits, by the same or different physician, for the period of one week after the delivery and ordinary immediate care of the newborn are also included. When there is a life threatening situation which requires neonatal resuscitation, HSC 13.99F may be claimed as well.

11.2.1 PULMONARY FUNCTION PROCEDURES Physicians performing procedures identified as Level I do not require approval from the

CPSA to perform these services. These services are reflected in HSCs 03.37A, 03.37B, 03.38D, 03.38E and 03.38R. Physicians performing procedures identified by the CPSA as requiring Level II, III or IV require approval and may only be claimed by physicians with the appropriate level of CPSA approval.

In addition to Level I procedures, physicians with Level II approval may claim: 03.38A 03.38B 03.38C 03.38F 03.38G In addition to Level I and Level II procedures, physicians with Level III approval may claim: 03.38H 03.38K 03.38M 03.38N 03.38P 03.38Q 03.38S 03.38T 03.38X 11.2.2 The CPSA accredits facilities for the performance of Pulmonary Function Tests (PFT). With

the exception of interpretive services, physicians may only perform Level II or higher PFT services in accredited facilities, and must ensure that claims submitted for these services include the applicable facility number. Claims for services provided in non-accredited facilities or hospitals as per GR 6.5 will not be paid.

12 ANESTHESIA 12.2.3 When providing procedural sedation in the emergency department, a consultation benefit

may not be claimed in addition to the procedural sedation. 13 SURGICAL ASSISTANCE BENEFITS 13.1 Claims for surgical assistance shall reflect the amount of time the assistant was required to

assist the surgeon. Time claimed shall not exceed the anaesthetic time. 13.2 Surgical assistance benefits may not be claimed if an intern or resident is the first assistant. 13.3 Benefits may not be claimed for procedures that do not routinely require the services of a

surgical assistant or a 2nd surgeon for a 2nd surgical team, unless supporting information detailing unusual circumstances satisfactory to the Minister is provided. Such procedures include but are not limited to the following list. (Refer to SOMB for list.)

13.4 Unless otherwise specified in this Schedule, surgical assistance benefits may not be claimed for performing ultrasound monitoring and guidance or other imaging during a procedure that is being performed by another physician.


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15 OFF HOURS PREMIUM BENEFITS 15.1 In the case of physicians working exclusively in a hospital setting on either a full-time basis

or as a part of their normal practice for a specified period of time (e.g., weekly hospital rotations among a practice group), off hours premium benefits may be claimed in accordance with the GRs for those claims, as long as the claiming physician is the attending physician or is primarily responsible for the patient’s care, or is claiming concurrent care in accordance with GR 4.8. In the case of physicians working in an AACC or UCC, off hours premium benefits may be claimed in accordance with the GRs for those claims as long as the claiming physician is the attending physician.

15.3 UNSCHEDULED SERVICES/SPECIAL CALLBACKS – AACC, UCC, HOSPITAL

INPATIENT, OUTPATIENT AND EMERGENCY DEPARTMENTS Benefits for UNSCHEDULED services (modifier SURC) and special callback HSCs 03.03LA,

03.03MC, 03.03MD, 03.05P, 03.05QA, 03.05QB and 03.05R are intended to cover a degree of disruption that a physician would have to experience to provide such services during: - the evening on weekdays (1700 – 2200 hours) - the day and evening on weekends and statutory holidays (0700 – 2200 hours) - any night of the week (2200 – 0700 hours)

15.4 In situations where the physician initiates the service, the unscheduled service or special callback benefits may not be claimed. Claims may, however, be made for the after hours time unit premium benefit (modifier SURT) under 03.01AA. See GR 15.13.

15.5 Only one unscheduled service or special callback benefit may be claimed for each encounter with a patient. In the event of a special callback, the following visit services may be claimed in addition: HSC 03.02A, 03.03A, 03.03B, 03.04A, 03.03DF, or 03.03EA.

15.6 The unscheduled service and special callback benefit must be claimed according to the time at which the encounter commences and not from the time of the call for attendance.

15.7 CLAIMS FOR UNSCHEDULED SERVICES/SPECIAL CALLBACK BENEFITS 15.7.1 Claims for the unscheduled service benefit (modifier SURC) must meet all of the following

conditions: a) a special call for attendance is made on the patient’s behalf b) the physician responds to such a call on an unscheduled basis outside of his/her

normal working hours c) the patient is attended on a priority basis d) there is direct attendance by the physician 15.7.2 Claims for special callbacks must meet all of the following conditions a) a special call for attendance is made on the patient’s behalf b) the physician responds to such a call from outside the hospital, auxiliary hospital,

nursing home, AACC or UCC on an unscheduled basis c) the patient is attended on a priority basis d) there is direct attendance by the physician


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15.8 Special callback benefits may not be claimed for subsequent patients seen during the same callback or in association with another service during the same encounter. However:

a) HSC 03.03AR may be claimed for second and subsequent hospital inpatients b) for second and subsequent emergency/outpatients, or AACC or UCC patients seen

during the same callback, see GR 5.2.3 c) HSCs 03.03DF and 03.03EA may be claimed in addition to a callback in accordance

with GR 15.5 15.9 The unscheduled service benefit (modifier SURC) may be claimed for the services

outlined in GRs 15.9.1 through 15.9.3. 15.9.1 selected “V” category code services: a) consultations, including telehealth (except those provided using store and forward

videotechnology) b) intensive care unit visit (HSC 03.05A) c) psychiatric mental status determination requiring complete mental health status

examination and investigation (HSC 08.11A) d) For complex patient, requiring complete mental status examination and investigation

(HSC 08.11C) e) certification under the Mental Health Act (HSC 08.12A) f) trauma assessment, multiple trauma, severely injured patient (HSC 13.99GA) g) hyperbaric oxygen therapy detention time (HSC 13.99I) h) medical emergency detention (HSC 13.99J) i) management of complex labor, per 15 minutes (HSC 13.99JA) j) donor maintenance prior to cadaveric harvesting of organs (HSC 13.99L) k) examination and crisis counseling for sexual/physical abuse (HSCs 13.99V) l) attendance at delivery (HSC 87.98E) 15.9.2 radiology, pathology and other diagnostic and therapeutic services if the physician is

directly involved in the provision of services of an invasive nature 15.9.3 procedures including surgical assists, obstetrical deliveries, anesthesia, major surgery and

minor surgery 15.9.4 The unscheduled service benefit (modifier SURC) may also be claimed for services

outlined in GR’s 15.9.1 through 15.9.3 when provided to second and subsequent patients seen during the same special call for attendance at the same facility.

15.10 The unscheduled service benefit (modifier SURC) may not be claimed for: 15.10.1 stand-by time 15.10.2 services provided by physicians who are on-site and working a scheduled rotation duty

shift in a hospital emergency department, AACC or UCC or providing first call coverage in an emergency department with greater than 25,000 visits per year

15.10.3 additional procedures, i.e., those performed in association with another procedure 15.10.4 non-invasive diagnostic procedures 15.10.5 “V” category code services except for those listed under GR 15.9.1; and


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15.10.6 Services included in the following list unless supporting information detailing unusual circumstances satisfactory to the Minister is provided.

03.21A 03.22A 03.22B 03.25 03.29A 07.29B

07.51A 07.51C 07.54A 07.56A 13.42A 13.53A

13.57A 13.59A 13.59B 13.59H 13.59J 17.81A

21.69A 22.13B 22.13C 22.71 22.81 23.99D

24.91 26.91A 29.91 30.19A 30.81A 32.1

32.81 33.21A 33.22B 33.51A 37.82A 37.82B

38.89A 39.21A 39.62A 39.83A 40.92A 41.29A

50.97A 51.92A 52.1A 52.11A 52.11B 52.12

52.13 60.82C 61.29B 61.39B 69.83A 69.83B

73.2A 75.83A 76.1A 79.22 79.23A 79.29E

81.91A 82.81A 82.91A 83.2B 83.7A 87.99B

95.81A 95.94A 95.94B 97.11A 98.12A 98.12B

98.12C 98.12J 98.12K 98.12L 98.12M 98.12N

98.12Q 98.12R 98.12T 98.8A 98.81A 98.81B

98.99AA

15.11 MAXIMUMS FOR SPECIAL CALLBACKS 15.11.1 A maximum of five (5) special callbacks, either HSC 03.03KA, 03.05N or any combination

thereof may be claimed, per physician, in any given weekday day. The weekday day is defined as Monday – Friday (0700-1700 hours).

15.11.2 A maximum of five (5) HSC 03.03LA, 03.05P or any combination thereof may be claimed, per physician, in any given weekday, Monday – Friday (1700-2200 hours).

15.11.3 A maximum of fifteen (15) HSC 03.03LA, 03.05R or any combination thereof may be claimed, per physician, on any day of the weekend or statutory holiday (0700-2200 hours).

15.11.4 A maximum of two (2) HSC 03.03MC, 03.05QA or any combination thereof may be claimed, per physician, any day (2200-2400 hours).

15.11.5 A maximum of seven (7) HSC 03.03MD, 03.05QB or any combination thereof may be claimed, per physician, any day (2400-0700 hours).

15.11.7 A maximum of five (5) special callbacks to a closed office, HSC 03.03ME, may be claimed, per physician, in any given weekday, Monday - Friday (0000 - 2400 hours).

15.11.8 A maximum of ten (10) special callbacks to a closed office, HSC 03.03MF may be claimed, per physician, on any day of the weekend or statutory holiday, (0000 - 2400 hours).

15.13 AFTER HOURS TIME PREMIUM – HOSPITAL INPATIENT, OUTPATIENT AND

EMERGENCY DEPARTMENTS, AACCs, UCCs, AUXILIARY HOSPITALS AND NURSING HOMES

15.13.1 Benefits for the AFTER HOURS TIME PREMIUM (modifier SURT) are intended to provide physicians with compensation for services provided after hours during: - the evening on weekdays (1700-2200 hours) - the day and evening on weekends and statutory holidays (0700-2200 hours) - any night of the week (2200-0700 hours)


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15.13.2 The after hours time premium modifier applies to both scheduled and unscheduled services. In the case of unscheduled services the unscheduled services modifier will also apply according to GRs 15.3 through 15.10.6.

15.13.4 The after hours time premium modifier is to be claimed on a per 15 minute basis beginning at the time of contact with the patient and may only be claimed for direct patient care time related to the provision of an insured service. The after-hours time premium units may not be claimed for stand by time e.g., time spent waiting for results of diagnostic tests.

15.13.5 Time for the after hours time premium may be determined on a cumulative basis, and claimed according to the time period(s) in which the majority of the service occurred. HSC 03.01AA should be used to claim the after-hours time modifier for all services.

15.13.6 In the event that one 15 minute period covers two time periods, the modifier claimed will be based on the time period where the majority of the 15 minute period occurred.

15.13.7 In the event that the time spent with the patient covers more than one time period, additional modifiers may be claimed, each according to the time spent with the patient in that particular time period.

15.13.9 The after hours time premium modifier may not be claimed for: - stand-by time - non-invasive diagnostic procedures

15.13.10 The maximum number of after hours time premium modifiers per hour, per physician is 4.

18. BODY MASS INDEX (BMI) MODIFIER 18.1 The Body Mass Index (BMI) modifier may be claimed for selected procedures,

obstetrical services, anaesthesia, second qualified surgeon and surgical assistant services provided in any location when the following criteria are met:

a) An adult patient has a body mass index of 40 or more. b) A patient under 18 years of age who is above the 97th percentile for BMI on an

approved pediatric growth curve c) The following HSCs are only eligible for the BMI modifier when the service is

provided under general, spinal, epidural anaesthetic or regional nerve block performed in an operating room, day surgery or surgical suite: 98.11A, 98.11B, 98.11C, 98.11D, 98.11E, 98.11F, 98.22A, 98.22B.


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Category Codes (Inclusive care periods) M (Minor) Office: Payable with visit on same date of service only if

visit and procedure unrelated diagnosis (see GR 6) Hospital: Not payable with visit on same date of service as a

hospital visit (see GR 6 & 6.7) M+ (Designated minor) Office: Visit or consultation payable on same date of

service irrespective of diagnosis of procedure and visit/consultation

Hospital: Consultation payable on same date of service irrespective of diagnosis of procedure and consultation.

Visit (ER or hospital visit) not payable on same date of service.

V (Visit) No inclusive care period T (Test) No inclusive care period Refer to GR 6.8.1 for inclusive care periods for categories 1-15.


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MODIFIERS

After hours time premium modifiers (Explicit) This modifier type is used to indicate after hours time services provided to patients in active treatment hospitals, AACCs, UCCs, nursing homes and auxiliary hospitals. This modifier is payable in 15 minute blocks to a maximum of 4 per hour, per physician. It is to be billed beginning at the time of contact with the patient and may only be claimed for direct patient care time related to the provision of an insured service. The after hours time premium units may not be claimed for standby time, e.g., time spent waiting for results of diagnostic tests. In the event that one 15 minute period covers two time periods; the modifier claimed will be based on the time period where the majority of the 15 minute period was spent. In the event that the time spent with the patient covers more than one time period, additional SURT modifiers may be claimed, each according to the time spent with the patient in that particular time period.

Refer to GR 15. 13. Modifiers are added to HSC 03.01AA.

TEV W/D 1700 – 2200 ............................................................................................................. $ 22.34 TWK W/E 0700 – 2200 .............................................................................................................. $ 22.34 TDES Designated holiday 0700 -2200 ...................................................................................... $ 22.34 TST Stat holidays 0700 – 2200 ................................................................................................ $ 44.66 TNTP 2200 – 2400 daily .............................................................................................................. $ 44.66 TNTA 2400 – 0700 daily .............................................................................................................. $ 44.66

Multiple units are claimed by adding a two digit number to the modifier e.g., TEV02 represents two 15 minute units.

Body Mass Index Modifiers BMI - (Explicit) – This modifier is used to support the additional payment of 25% for selected procedures, obstetrical services, anesthesia, second qualified surgeon and surgical assistant services for adult patients who meet requirements indicated in the Governing Rules and patients under 18 years of age who are above the 97th percentile for BMI on an approved pediatric growth curve.

Web site addresses for BMI charts for children age 2 years to age 18 years can be found at:

http://www.cdc.gov/nchs/data/nhanes/growthcharts/set2clinical/cj41c073.pdf for boys or http://www.cdc.gov/nchs/data/nhanes/growthcharts/set2clinical/cj41c074.pdf for girls.

BMIABD – Body Mass Index, ANAESTHETIC BY DEFINITION - (Explicit) - The physician functions as the Anaesthetist and is claiming a Health Service Code (HSC) which is an anesthetic by definition and does not have modifier ANE. This modifier only applies to HSCs 16.91A, 16.91C, 16.91F, 36.99AA.

BMIANE – Body Mass Index, ANAESTHETIST - (Explicit) - The physician functions as the Anaesthetist and is claiming the listed anaesthetic benefit. (To be used instead of ANE).

BMIANT – Body Mass Index, ANAESTHETIST TRC - (Explicit) - The physician functions as the Anaesthetist and is claiming a benefit based on the duration of the anaesthetic. (To be used instead of ANEST).

http://www.cdc.gov/nchs/data/nhanes/growthcharts/set2clinical/cj41c073.pdf

http://www.cdc.gov/nchs/data/nhanes/growthcharts/set2clinical/cj41c074.pdf


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BMI2AN – Body Mass Index, ANAESTHETIST TRC 2 - (Explicit) - The physician functions as the anaesthetist and is claiming anaesthetic time premium units based on the duration of the anaesthetic. (To be used instead of 2ANES). BMIPRO - Body Mass Index, SURGEON/SECOND QUALIFIED SURGEON/SURGICAL ASSISTANT - (Explicit) - The physician functions as the Surgeon, Second Qualified Surgeon, or as a Surgical Assistant and is claiming the listed applicable benefit. Complex Patient Care Modifiers COINPT COMPLEX INPATIENT CARE - (Explicit) - This modifier is used to indicate management of a complex hospital inpatient, or a long term care (LTC) patient for palliative care or intercurrent illness when the conditions to claim HSCs 03.03D or 03.03AR are met. ($40.21)

1. May only be claimed once per patient, per physician, per day.

2. May only be claimed for the management of complex hospital inpatients with multi-system disease:

- whose co-morbidities contribute to complicating or increasing the care required by the claiming physicians involved in the care of the patient; and

- whose care requires that the physician spend 20 minutes or more per day on management of the patient's ongoing care.

3. May not be claimed for transfer of care where the receiving physician requires time to familiarize him/herself with the patient unless the conditions outlined in (2) above are met.

CMGP COMPLEX PATIENT VISIT – (Explicit) – This modifier is used to indicate a complex patient requiring that the physician spend 15 minutes or more on management of the patient’s care. ($18.27) EACH ADDITIONAL UNIT REPRESENTS 10 MINUTES ($18.27). ADDITIONAL

UNITS MAY NOT BE CLAIMED UNLESS A FULL 10 MINUTES HAS ELAPSED. (Example: CMGP03 indicates a general practice physician has spent a minimum of 35 minutes with the patient ($54.81). The first unit represents 15 minutes and each subsequent unit represents 10 minutes.) A maximum of 10 calls may be claimed. May only be claimed by:

- general practitioners for HSCs 03.01J, 03.03A, 03.03B, 03.03C, 03.03N, 03.03P, 03.03Q,

03.07A, 03.07B. See modifier CMPX for further information.

CMXC30 COMPLEX PATIENT CONSULTATION – (Explicit) – This modifier is used to indicate a complex patient consultation or visit requiring that the physician spend 30 minutes or more on management of the patient’s care. ($31.27) May only be claimed for HSCs 03.04A, 03.04B, 03.04C, 03.04D, 03.04E, 03.04F, 03.04FA,

03.04G, 03.04GA, 03.04H, 03.04HA, 03.04M, 03.08A, 03.08B, 03.08C, 03.08F, 03.08H, 03.08K and 03.09A.


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Complex care modifiers cont’d

CMXV20 COMPLEX PATIENT CONSULTATION/VISIT – (Explicit) – This modifier is used to indicate a complex patient consultation or visit requiring that the physician spend 20 minutes or more on management of the patient’s care. ($15.62) Refer to modifier CMXV35 for visits taking 35 minutes or more. May be claimed by GP’s for HSCs 03.05CR, 03.05DR, 03.05ER, 03.05F, 03.05FA,

03.05FB, 03.05FF, 03.05FG, 03.05FH when location and time conditions (above) are met. CMXV30 COMPLEX PATIENT CONSULTATION/VISIT - (Explicit) - This modifier is used to indicate a complex patient consultation or visit requiring that the physician spend 30 minutes or more on management of the patient's care. ($31.27) Refer to modifier CMXV15 for visits less than 30 minutes. - General Practice may claim for 03.05H only.

CMXV35 COMPLEX PATIENT CONSULTATION/VISIT - (Explicit) - This modifier is used to indicate a complex patient consultation or visit requiring that the physician spend 35 minutes or more on management of the patient's care. ($31.27) Refer to modifier CMXV20 for visits taking less than 35 minutes. This modifier may be claimed by any physician for HSCs 03.05CR, 03.05DR, 03.05ER,

03.05F, 03.05FA, 03.05FB, 03.05FF, 03.05FG, 03.05FH when location and time conditions (above) are met.

Surcharges modifiers (Modifier code for unscheduled services for hospital services – procedures, consultations, anesthetics, obstetrical services, surgical assists, detention time). Refer to GR 15. Modifiers to be added to the applicable procedure/service: EV W/D 1700 - 2200 ................................................................................................................ $ 48.70 WK W/E, Stat 0700 - 2200 ........................................................................................................ $ 48.70 NTPM 2200 - 2400 daily ................................................................................................................ $116.83 NTAM 2400 - 0700 daily ................................................................................................................ $116.83 SUBD SUBD SUBDIVISION - (Explicit) - This modifier type is used with visit health service codes to indicate during which time period the service recipient/service provider encounter took place. These modifiers are applicable during the evening on weekdays, during the day and evening on weekends and statutory holidays, and during the night on any day. A fee is added to the base rate as indicated by the modifier. For home visits and hospice visits, the SUBD modifier should be claimed based on the time at which the encounter commences and the physician responds on an unscheduled basis within a 24 hour period from the time of the call.


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HEALTH SERVICE CODES NOTE: Please refer to Schedule of Medical Benefits for complete details. Visits/Consultations: NOTE: 1. CMGP may be applicable to 03.01J, 03.03A, 03.07A & 03.07B). 2. CMXC30 may be applicable to 03.04A, 03.04M & 03.08A. 3. HSC 03.03A may not be claimed for hospital inpatients or LTC facilities. 4. CMXV30 may be applicable to 03.05H. See pages 20-21 for modifier definitions. 03.02A Brief assessment of a patient’s condition requiring a minimal history with little or no

physical examination ................................................................................................................. $ 28.20 03.03A Limited assessment of a patient’s condition requiring a history related to the presenting

problems, an examination of the relevant body systems, appropriate records, and advice to the patient ................................................................................................................................. $37.35

NOTE: 1. Benefit includes the ordering of appropriate diagnostic tests and procedures as well as discussion with the patient.

2. May not be claimed in addition to HSC 03.05JB at the same encounter. NOTE: May be claimed in addition to HSC 03.04J 03.01J Assessment of unrelated condition in association with a Workers’ Compensation service .............................................................................................................................. $ 23.50 NOTE: May only be claimed when services are provided for an unrelated illness or injury in

conjunction with a WCB related service, including visits. 03.04A Comprehensive assessment of a patient’s condition requiring a complete history, a

complete physical examination appropriate to the physician’s specialty, an appropriate record and advice to the patient .............................................................................................. $103.41

NOTE: 1. This may be used for an annual medical examination within the limitations of GR 4.6.1. 2. Complete physical examination shall include examination of each organ system of the

body, except in psychiatry, dermatology and the surgical specialties. “Complete physical examination” shall encompass all those organ systems which customarily and usually are the standard complete examination prevailing within the practice of the respective specialty. What is customary and usual may be judged by peer review.

3. Benefit includes the ordering of appropriate diagnostic tests and procedures as well as discussion with the patient.

4. Not payable more frequently than once every 365 days. (GR 4.6.1) 5. May be claimed in addition to HSC 03.04J. 03.04I Comprehensive visit, including completion of form, required for admission to a

regional health authority addiction residential treatment centre ..................................... $122.21 03.04M Pre-operative history and physical examination in relation to an insured service ........ $103.41 NOTE: 1. May only be claimed when an examination and a standard form for pre-operative

assessment have been completed. 2. A copy of the form must be retained in the patient’s chart. 3. May not be claimed in addition to a surgical assist (SA, SAQS, SSOS) for the same

patient by the same physician. 4. HSC 03.04M may not be claimed for a pre operative physical examination when the

request is for a cataract procedure (HSC 27.72A) that will not require the use of a general anesthetic.


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Visits/Consultations cont’d 03.05H Medical examination, including completion of form, required pursuant to the Traffic

Safety Act to obtain or renew an operator’s license, where the patient is 74.5 years of age or older (CMXV30 applicable) ....................................................................................... $ 84.61

03.07A Minor consultation ................................................................................................................. $ 65.80 NOTE: May not be claimed in addition to a surgical assist (SA, SAQS, SSOS) for the

same patient by the same physician. 03.07B Repeat consultation ................................................................................................................ $ 39.65 03.08A Comprehensive [Not payable more frequently than once every 180 days] (GR 4.6.1)

......................................................................................................................................... $122.84 NOTE: 1. May not be claimed in addition to a surgical assist (SA, SAQS, SSOS) for the

same patient by the same physician. 2. A comprehensive consultation may not be claimed for a transfer of care. 03.05LA Group session, multiple patients, per patient where a physician is involved in

providing care and teaching to patients in attendance .................................................... $ 15.67 NOTE: May not be claimed in addition to a visit at the same encounter. 03.04K Comprehensive geriatric assessment, first full 90 minutes ............................................. $310.22 Subsequent 15 minutes, or major portion thereof. Maximum 7 calls ............................. $ 51.71 NOTE: 1. If the assessment is less than 90 minutes, then HSC 03.04A or 03.08A should

be claimed. 2. May only be claimed in an AHS regional facility or AHS/Contracted partner

run geriatric program(s) or community clinic where a PCN multi-disciplinary team is contributing to the assessment.

3. May only be claimed for patients 75 years or older. 4. May only be claimed by general practitioners, internal medicine specialists

or geriatric medicine specialists. 5. May only be claimed once per patient per year. 6. Assessment must include the following components:

a) Medical includes but is not limited to a complete physical examination, a problem list, co-morbidity conditions and disease severity, a medication review and nutritional status.

b) Functional includes but is not limited to a review of basic activities of daily living, instrumental activities of daily living, activity/exercise status, gait, balance and assessment of senior falls.

c) Cognitive/psychological includes but is not limited to review of mental status, administration of the Mini Mental State Examination (MMSE) and mood/depression through Geriatric Depression Scale (GDS).

d) Social includes but is not limited to a review of informal support needs and assets, care resource eligibility and a financial assessment.

e) Environmental includes but is not limited to a review of current living situation, home safety and transportation.

7. Evidence that all components in note 7 were completed must be documented in the patient’s records. This includes physician notes and copies of the MMSE and GDS.


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Visits/Consultations cont’d 03.04J Development, documentation and administration of a comprehensive annual care plan

for a patient with complex needs (Category T) ........................................................... $188.01 NOTE: 1. A maximum of 15 comprehensive annual care plans per physician per calendar

week may be claimed. 2. May only be claimed by the most responsible primary care general practitioner. 3. May only be claimed once per patient per year and includes ongoing

communication as required as well as re-evaluation and revision of the plan within a year.

4. May be claimed in addition to HSCs 03.03A, 03.03N or 03.04A. 5. Time spent on the preparation of the complex care plan may not be included in the

time requirement for a complex modifier. 6. “Complex needs” means a patient with multiple complex health needs including

chronic disease(s) and other complications. The patient must have at least two or more diagnoses from group A or one diagnosis from group A and one or more from group B in order to be eligible.

Group A Group B - Hypertensive Disease - Mental Health Issues - Diabetes Mellitus - Obesity (Adult = BMI 40 or - Chronic Obstructive Pulmonary Disease greater. Child = 97 Percentile) - Asthma - Addictions - Heart Failure - Tobacco - Ischaemic Heart Disease - Chronic Renal Failure

7. “Care Plan” means a single document that meets the following criteria: a) Must be communicated through direct contact with the patient and/or the

patient’s agent. b) Must include clearly defined goals which are mutually agreed upon between the

patient and/or the patient’s agent and the physician. c) Must include a detailed review of the patient’s chart, current therapies, problem

list and past medical history. d) Must include any relevant information that may affect the patient’s health or

treatment options, such as demographics (education, income, language) or lifestyle behaviors (addictions, exercise, sleep habits, etc.)

e) Must incorporate the patient’s values and personal health goals in the care plan, with respect to his or her complex needs.

f) Must outline expected outcomes as a result of this plan, including end-of-life issues when clinically appropriate.

g) Must identify other health care professionals that would be involved in the care of the patient and their expected roles.

h) Must include confirmation that the care plan has been communicated verbally and in writing to the patient and/or the patient’s agent.

i) Must be signed by the physician and the patient and/or the patient’s agent. j) Must be retained in the patient’s medical record.


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Determination of Capacity 03.04N Comprehensive evaluation including completion of forms to determine capacity as

defined by the Personal Directives Act (PDA) (RSA 2007 s9(2)(a) ............................ $191.15 NOTE: 1. Benefit includes witnessing the agents’ or service providers’ assessment. 2. May be claimed to determine lack of capacity or to determine that capacity

has been regained. Post surgical cancer

03.04Q Post surgical cancer surveillance examination ....................................................................... $103.41

NOTE: 1. Intended for patients requiring scheduled comprehensive evaluations relevant to the specific type of cancer.

2. Comprehensive evaluations must adhere to protocols as defined by the facility, program or surgeon from which the patient was discharged.

3. The discharge letter that states the protocols must be forwarded to Alberta Health for claim processing for each claim submitted. The letter must indicate:

a. Date of surgery b. Schedule of required comprehensive visits and other diagnostic testing c. Duration of required follow-ups (i.e. two years from date of surgery) INR Management

03.01N Management of anticoagulant therapy to include ordering necessary blood tests, interpreting results, adjusting the anticoagulant dosage as required ........................ $ 17.23

NOTE: 1. May only be claimed twice per calendar month, per patient regardless of whether the same or different physician provides the service.

2. May only be claimed in months where advice has been given regarding dosage.

3. May be claimed in addition to visits or other services provided on the same day by the same physician.

4. May not be claimed for hospital inpatients or hospital outpatients. 5. Documentation of the communication must be recorded.


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Electronic Communication Codes 03.01O Physician to Physician secure E-Consultation, consultant .......................................... $76.27

NOTE: 1. May only be claimed when both the referring and consulting physician exchange communication using secure electronic communication that is in compliance with the CPSA guidelines on secure electronic communication and when the physician/clinic has submitted a Privacy Impact Assessment for this service acceptable to the Office of the Privacy Commissioner of Alberta.

2. This service is only eligible for payment if the consultant physician has provided an opinion/advice and/or recommendations for patient treatment and/or management within thirty (30) days from the date of the e-consultation request.

3. May only be claimed when initiated by the referring physician.

4. The consultant may not claim a major consultation, physician to physician phone call, or procedure for the same patient for the same condition within 24 hours of receiving the request for an e-consultation unless the patient was transferred from an outside facility and advice was given on management of that patient prior to transfer.

5. May only be claimed when the consultant has provided an opinion and recommendations for patient treatment as well as management after reviewing pertinent family/patient history, history of the presenting complaint as well as laboratory and other data where indicated. It is expected that the purpose of the communication will be to seek the advice of a physician more experienced in treating the particular problem in question, and that the referring physician intends to continue to care for the patient.

6. May not be claimed for situations where the purpose of the communication is to:

a. arrange for an expedited consultation or procedure within 24 hours except when the conditions in note 4 are met

b. arrange for laboratory or diagnostic investigations

c. discuss or inform the referring physician of results of diagnostic investigations.

7. Documentation of the request and advice given must be recorded by the consultant in their patient records.

8. This service may not be claimed for transfer of care alone.

NOTE: If claiming 03.01O, a referral PRACID is required.


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Electronic communication codes cont’d 03.01R Physician to Physician secure E-Consultation, referring physician ........................... $ 32.43 NOTE: 1. Time spent completing the referral may not be claimed using complexity

modifiers. 2. May only be claimed when both the referring and consulting physician

exchange communication using secure electronic communication that is in compliance with the CPSA guidelines on secure electronic communication and when the physician/clinic has submitted a Privacy Impact Assessment for this service acceptable to the Office of the Privacy Commissioner of Alberta.

3. May not be claimed for situations where the purpose of the communication is to:

a) arrange for laboratory or diagnostic investigations b) discuss or inform of results of diagnostic investigations, or

c) arrange for an expedited consultation with the patient 4. Documentation of the request and advice given must be recorded in the

patient record. 5. This service may not be claimed for transfer of care alone. 03.01S Physician to patient secure electronic communication ................................................ $15.88 NOTE: 1. May only be claimed for medically necessary advice or follow up where the

nature of the condition can safely be managed via secure email. 2. May only be claimed when the service is provided using a secure email

system that is in compliance with the CPSA guidelines on secure electronic communication and when the physician/clinic has submitted a Privacy Impact Assessment for this service acceptable to the Office of the Privacy Commissioner of Alberta.

3. May only be claimed for those patients where an established physician-patient relationship exists and the physician has seen the patient in the previous 12 months.

4. Physicians and patients must have previously discussed and agreed to the limitations of health management using electronic means.

5. Secure electronic communication must inform patients when the physician is unavailable.

6. May only be claimed once per week per patient per physician. 7. A maximum of seven 03.01S per calendar week per physician may be

claimed. 8. A visit service may not be claimed if provided within 24 hours following the

electronic communication. 9. HSC 03.01S is not payable in the same calendar week as 03.05JR or 03.01T by

the same physician for the same patient. 10. May not be claimed when the service is provided by a physician proxy. 11. Documentation of the service must be recorded in the patients' record. 12. May not be claimed for inpatients.


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Telephone/Videoconference Advice

Home Care Advice (Mental health workers) Advice in relation to the care and treatment of a patient receiving community mental

health care services under the Alberta community mental health care program. NOTE: Refer to notes following 03.01BB for further information. Patient care advice provided to community mental health care workers, child protection workers, group home staff, or educational personnel 03.01B Weekdays 0700 to 1700 hours .......................................................................................... $ 17.23 03.01BA Weekdays 1700 to 2200 hours, weekends and statutory holidays 0700 to 2200 hours .......................................................................................................................... $ 23.85 03.01BB Any day 2200 to 0700 hours ............................................................................................. $ 27.83 NOTE: 1. HSCs 03.01B, 03.01BA, 03.01BB are to be claimed using the Personal Health

Number of the patient. 2. May only be claimed when the request for advice is initiated by the

community mental health care worker, child protection worker, group home staff, or educational personnel.

3. May be claimed: - for advice provided in person or via telephone or other

telecommunication methods - in addition to visits or other services provided on the same day by the

same physician 4. A maximum of two (any combination of HSC 03.01B, 03.01BA, 03.01BB)

claims may be claimed per patient, per physician, per day. 5. Documentation of the request and advice must be recorded by both the

physician and the community health care worker in their respective patient records.


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Telephone/videoconference advice – allied health care workers Patient care advice to paramedic – pre hospital patch, assisted living/designated assisted living and lodge staff, active treatment facility worker for hospital in-patient, long term care worker for patients in a long term care facility, nurse practitioner, hospice worker, home care worker or public health nurse, provided via telephone or other telecommunication methods, in relation to the care and treatment of a patient. NOTE: Refer to notes following HSC 03.01NI. 03.01NG Weekdays 0700 to 1700 hours .......................................................................................... $ 17.23 03.01NH Weekdays 1700 to 2200 hours, weekends and statutory holidays, 0700 to 2200 hours ............................................................................................................. $ 20.37 03.01NI Any day 2200 to 0700 hours ............................................................................................. $ 23.50 NOTE: 1. Active treatment facility worker may include registered: nurse, licensed

practical nurse, occupational therapist, physiotherapist, speech language pathologist, social worker, pharmacist, psychologist, recreational therapist or respiratory therapist.

2. Long term care worker/hospice worker may include registered: nurse, licensed practical nurse, occupational therapist, physiotherapist, speech language pathologist, social worker, pharmacist, psychologist or recreational therapist.

3. Advice to nurse practitioners may only be claimed if the nurse practitioner is in independent practice or working at a nursing station where no physician is present. Advice to public health nurse may only be claimed if the public health nurse is employed by AHS and working in an AHS health unit.

4. In the case of long term care or active treatment facility worker, claims may only be submitted when the physician is outside the facility where the patient is located.

5. May be claimed for advice given to hospice worker, home care worker or public health nurse in person as well as advice by telephone or other telecommunication methods.

6. HSCs 03.01NG, 03.01NH and 03.01NI are to be claimed using the Personal Health Number of the patient.

7. May only be claimed when the call is initiated by the long term care worker, assisted living/designated assisted living or lodge staff member, active treatment facility worker, home care worker, nurse practitioner, hospice worker, public health nurse or paramedic.

8. In the case of a long term care or hospice patient the call may be initiated by the physician if it is in response to receipt of diagnostic or other information that would affect the patient's treatment plan.

9. May be claimed in addition to visits or other services provided on the same day, by the same physician.

10. A maximum of two (any combination of HSC 03.01NG, 03.01NH, 03.01NI) claims may be made per patient, per physician, per day.

11. Documentation of the communication must be recorded in their respective records.


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Telephone/videoconference advice re: Obstetrical Outpatient Patient care advice to active treatment facility worker or nurse practitioner in relation to the obstetrical outpatient NOTE: Refer to notes following HC 03.01LO. 03.01LM Weekdays 0700 – 1700 hours .......................................................................................... $ 17.71 03.01LN Weekdays 1700 – 2200 hours, weekends and statutory holidays 0700 – 2200 hours ................................................................................................................................. $ 26.16 03.01LO Any day 2200 – 0700 hours .............................................................................................. $ 30.87

NOTE: 1. Active treatment facility worker may include registered nurse, licenced practical nurse, midwife.

2. To be claimed using the Personal Health Number of the patient. 3. May only be claimed by general practice or obstetrics and gynecology. 4. Advice to nurse practitioners may only be claimed if the nurse practitioner is

in independent practice or working at a nursing station where no physician is present.

5. May only be claimed when the physician is outside the facility from where the patient is located.

6. May only be claimed when the call is initiated by the active treatment facility worker or nurse practitioner.

7. May only be claimed for advice given to the active treatment facility worker or nurse practitioner by telephone or other telecommunication means.

8. A maximum of two (any combination of HSC 03.01LM, 03.01LN or 03.01LO) may be claimed per patient, per physician, per day.



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Telephone/videoconference advice Physician to patient telephone call 03.05JR Physician telephone call directly to patient, to discuss patient management/diagnostic

test results .......................................................................................................................... $15.88 NOTE: 1. A maximum of 7 telephone calls per physician, per calendar week may be

claimed. 2. May not be claimed for management of patient’s anticoagulant therapy

(billable under HSC 03.01N). 3. May only be claimed when communication is provided by the physician. 4. Documentation of the communication to be recorded in the patient record. 5. May be claimed in addition to visits or other services provided on the same

day by the same physician. 6. Neither HSCs 03.01S or 03.01T are payable if HSC 03.05JR is claimed in the

same calendar week by the same physician for the same patient. Physician to patient videoconference 03.01T Physician to patient secure videoconference ................................................................. $15.88 NOTE: 1. May only be claimed for medically necessary advice or follow up where the

nature of the condition can safely be managed via secure videoconference. 2. May only be claimed for those patients where an established physician-

patient relationship exists and the physician has seen the patient in the previous 12 months.

3. May only be claimed when the service is provided using a secure videoconference system that is in compliance with the CPSA guidelines on secure electronic communication and when the physician/clinic has submitted a Privacy Impact Assessment for this service acceptable to the Office of the Privacy Commissioner of Alberta.

4. May only be claimed once per week per patient per physician. 5. A maximum of seven 03.01T per calendar week per physician may be

claimed. 6. A visit service may not be claimed if provided within 24 hours following

the electronic communication. 7. HSC 03.01T is not payable in the same calendar week as 03.05JR or 03.01S

by the same physician for the same patient. 8. May not be claimed when the service is provided by a physician proxy. 9. Documentation of the service must be recorded in the patients' record. 10. May not be claimed for inpatients.


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Physician to physician or podiatric surgeon telephone/videoconference advice (referring physician) Physician to physician or podiatric surgeon telephone or telehealth videoconference or secure videoconference consultation, referring physician NOTE: Refer to notes following HSC 03.01LI. 03.01LG Weekdays 0700 to 1700 hours .......................................................................................... $ 32.90 03.01LH Weekdays 1700 to 2200 hours, weekends and statutory holidays 0700 to 2200 hours .......................................................................................................................... $ 38.32 03.01LI Any day 2200 to 0700 hours ............................................................................................. $ 45.21 NOTE: 1. HSCs 03.01LG, 03.01LH, 03.01LI, may be claimed in addition to visits or

other services provided on the same day by the same physician when the criteria listed below are met.

2. May only be claimed when the consultant has provided an opinion and recommendations for patient treatment as well as management after reviewing pertinent family/patient history and history of the presenting complaint as well as discussion of the patient's condition and management after reviewing laboratory and other data where indicated. It is expected that the purpose of the call will be to seek the advice of a physician or podiatric surgeon more experienced in treating the particular problem in question, and that the referring physician intends to continue to care for the patient.

3. May not be claimed for situations where the purpose of the call is to: - arrange for transfer of care that occurs within 24 hours unless the patient

was transferred to an outside facility and advice was given on management of that patient prior to transfer

- arrange for an expedited consultation or procedure within 24 hours - arrange for laboratory or diagnostic investigations - discuss or inform the referring physician or podiatric surgeon of results of

diagnostic investigations 4. A maximum of two (any combination of HSC 03.01LG, 03.01LH, 03.01LI)

claims may be claimed per patient, per physician, per day. 5. Documentation must be recorded by both the referring physician and the

consultant in their respective records. 6. Telehealth videoconferences may only be claimed when all participants are

participating in the videoconference from regional telehealth facilities. 7. Claims for secure videoconference may only be claimed when the service is

provided using a secure videoconference system that is in compliance with the CPSA guidelines on secure electronic communication and when the physician/clinic has submitted a Privacy Impact Assessment for this service accepted by the Office of the Privacy Commissioner of Alberta.


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Physician or podiatric surgeon to physician telephone/videoconference advice (consultant physician) Physician or podiatric surgeon to physician telephone or telehealth videoconference or secure videoconference consultation, consultant NOTE: Refer to notes following 03.01LL 03.01LJ Weekdays 0700 to 1700 hours .......................................................................................... $ 77.35 03.01LK Weekdays 1700 to 2200 hours, weekends and statutory holidays 0700 to 2200 hours ......................................................................................................................... $114.50 03.01LL Any day 2200 to 0700 hours ............................................................................................ $135.13 NOTE: 1. HSCs 03.01LJ, 03.01LK, 03.01LL may only be claimed when initiated by the

referring physician or podiatric surgeon. 2. The consultant may not claim a major consultation or procedure for the

same patient for the same condition within 24 hours, unless the patient was transferred from an outside facility and advice was given on management of that patient prior to transfer.

3. May only be claimed when the consultant has provided an opinion and recommendations for patient treatment as well as management after reviewing pertinent family/patient history and history of the presenting complaint as well as discussion of the patient's condition and management after reviewing laboratory and other data where indicated. It is expected that the purpose of the call will be to seek the advice of a physician more experienced in treating the particular problem in question, and that the referring physician or podiatric surgeon intends to continue to care for the patient.

4. May not be claimed for situations where the purpose of the call is to: - arrange for an expedited consultation or procedure within 24 hours except

when the conditions in note 2 are met - arrange for laboratory or diagnostic investigations - discuss or inform the referring physician or podiatric surgeon of results of

diagnostic investigations 5. A maximum of two (any combination of HSC 03.01LJ, 03.01LK, 03.01LL)

claims may be claimed per patient, per physician, per day. 6. Documentation must be recorded by both the referring physician or the

podiatric surgeon and the consultant in their respective records. 7. Telehealth videoconferences may only be claimed when all participants are

participating in the videoconference from regional telehealth facilities. 8. Claims for secure videoconference may only be claimed when the service is

provided using a secure videoconference system that is in compliance with the CPSA guidelines on secure electronic communication and when the physician/clinic has submitted a Privacy Impact Assessment for this service accepted by the Office of the Privacy Commissioner of Alberta.

NOTE: In order to receive payment, referring PRACID is required.


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03.01NM Patient care advice to a pharmacist provided via telephone or other telecommunication methods in relation to the care and treatment of a patient .................$17.23

NOTE: 1. It is expected that the purpose of the communication will be to seek the advice/opinion or to inform a physician when changes such as but not limited to prescription adaptations, pharmacist initiated prescriptions, care plans or medication reviews have occurred.

2. May only be claimed when the pharmacist has initiated the communication and the physician has provided an opinion or recommendation for patient treatment.

3. May not be claimed where the primary purpose of the communication is to clarify, decipher or interpret the physician’s handwriting and/or written instructions.

4. May not be claimed for the authorization of repeat prescriptions for which long-term repeats would more properly have been authorized at the time of writing the initial prescription.

5. May not be claimed for instances where a physician directs a patient to request the pharmacist to contact the physician.

6. May not be claimed for patients in an active treatment, auxiliary, or nursing home facility.

7. May not be claimed when a physician proxy, e.g. nurse or clerk, provides advice to the pharmacist.

8. A maximum of one (1) communication per patient per day may be claimed, regardless of the number of issues or concerns discussed with the pharmacist.

9. Where more than one patient is discussed in a single communication, a claim may be submitted with respect to each patient discussed.


11. To be claimed using the Personal Health Number of the patient.



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Palliative care NOTE: Palliative care – defined as involving multidisciplinary team care. Refer to GR 4.2.4. 03.05I Direct care, reassessment, education and/or general counseling of a patient requiring

palliative care, per 15 minutes or portion thereof ......................................................... $ 51.39 03.05T Formal, scheduled, professional interview relating to the care and treatment of a

palliative care patient with other physicians, family, and/or direct therapeutic supervision of allied health professionals or community agencies, on behalf of a specific patient, full 15 minutes or portion thereof for the first call when only one call is claimed .......................................................................................................................... $ 41.99

NOTE: This service is to be claimed in the name of a patient by the physician most responsible for the patient.

03.05U Second and subsequent physician attendance at formal, scheduled, professional interview relating to the care and treatment of a palliative care patient with other physicians, family and/or direct therapeutic supervision of allied health professionals or community agencies, on behalf of a specific patient, full 15 minutes or major portion thereof for the first call when only one call is claimed (Cat. V) .................................. $ 28.20

NOTE: This service is to be claimed in the name of the patient.

Chronic Pain: NOTE: In those situations where the physician is not part of a comprehensive,

coordinated, interdisciplinary chronic pain program, the patient must have been initially assessed at an interdisciplinary chronic pain program, the name of which must be identified in the patient’s chart when the patient is referred back to the home community for ongoing treatment. Refer to GR 4.2.5.

03.05O Direct management, reassessment, education and/or general counseling of a patient with chronic pain, per 15 minutes or portion thereof .................................................. $ 44.90

03.05V Formal, scheduled, professional interview relating to the care and treatment of a patient with chronic pain with other physicians, and/or direct therapeutic supervision of allied health professionals or community agencies, on behalf of a specific patient, per 15 minutes .......................................................................................................................... $ 41.99

NOTE: This service is to be claimed by the physician most responsible for the patient where the physician spends a minimum of 30 minutes with medical and/or para-medical personnel regarding the management of chronic pain.

03.05W Second and subsequent physician attendance at a formal, scheduled, professional interview relating to the care and treatment of a patient with chronic pain with other physicians, family, and/or direct therapeutic supervision of allied health professionals or community agencies, on behalf of a specific patient, per 15 minutes

.......................................................................................................................... $ 27.39 NOTE: This service is to be claimed in the name of the patient. 03.05X Formal, scheduled, professional interview with relative(s) relating to the care and

treatment of a patient with chronic pain on behalf of a specific patient, full 15 minutes or major portion thereof when only one call is claimed .............................................. $ 51.39

NOTE: This service is to be claimed in the name of the patient.


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Mandatory testing and Disclosure Act 03.01MT Completion of Physician Report form under the Mandatory Testing and Disclosure Act .......................................................................................................................... $ 82.42 NOTE: May only be claimed for preparing Physician’s report as outlined in the

Mandatory Testing and Disclosure Act when requested by a patient for purposes of seeking a court order to require a source individual to submit to testing for blood-borne infections.

Call back to closed office:

NOTE: May not be billed in addition to a procedure for the same encounter. 03.03ME Special call to closed office, weekdays (0000-2400) .................................................... $ 56.40 NOTE: 1. When a physician must travel to his/her office which is closed, with no staff

in attendance. 2. A maximum of five (5) per weekday, per physician may be claimed. 3. Subsequent patients seen may be claimed under code 03.02A, 03.03A, 03.04A

or the appropriate procedural code. (Modifier required for after hours) OFEV (1700 - 2200 M-F) ($56.40 + $78.34) ..................................................................... $134.74 OFNTAM 2400 - 0700 daily ($56.40 + $207.51) ............................................................. $263.91 OFNTPM 2200 - 2400 Daily ($56.40 + $207.51) ............................................................. $263.91 03.03MF Special call to closed office, weekends and statutory holidays (0000-2400) ............. $ 56.40 NOTE: 1. When a physician must travel to his/her office which is closed, with no staff

in attendance. 2. A maximum of ten (10) per weekend day or statutory holiday, per physician

may be claimed. 3. Subsequent patients seen may be claimed under code 03.02A, 03.03A, 03.04A

or the appropriate procedural code. (Modifier required for after hours) OFEVWK 0700 - 2200 W/E, Stat ($56.40 + $78.34) ....................................................... $134.74 OFNTAM 2400 - 0700 daily ($56.40 + $207.51) ............................................................. $263.91 OFNTPM 2200 - 2400 Daily ($56.40 + $207.51) ............................................................. $263.91


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Psychiatric Services: 08.12A Certification under the Mental Health Act .................................................................... $ 57.03 08.19D Professional interview with relative(s) in connection with the management of a patient

with a psychiatric disorder, but without the patient being present during the interview, per 15 minutes or major portion thereof ........................................................................ $ 51.39

NOTE: 1. This service is to be claimed using the Personal Health Number of the patient. 2. The relationship of the patient to the person interviewed, must be indicated. 3. The maximum benefit to be claimed by a physician other than a psychiatrist or a

pediatrician is 2 hours per patient, per benefit year. 08.19F Formal, scheduled, professional conference related to the care and treatment of a

psychiatric patient with other physician(s) and/or direct therapeutic supervision of, allied health professionals, educational, correctional and other community agencies on behalf of a specific patient, provided by the physician most responsible for the patient's care, per 15 minutes or major portion thereof .............................................................. $ 41.99

NOTE: Refer to notes following HSC 08.19H. 08.19H Second and subsequent physician attendance at a formal, scheduled, professional

conference related to the care and treatment of a psychiatric patient, on behalf of a specific patient, per 15 minutes or major portion thereof ........................................... $ 28.20

NOTE: 1. HSC 08.19F and 08.19H may only be claimed by general practice physicians, generalists in Mental Health, pediatricians, psychiatrists and specialists in Mental Health.

2. HSC 08.19F and 08.19H are to be claimed using the Personal Health Number of the patient, naming the personnel, agencies or organizations involved.

3. HSC 08.19H may be claimed when the physician most responsible for the patient's care has submitted a claim under HSC 08.19F.

08.19J Formal, scheduled, professional conference related to the care and treatment of multiple psychiatric patients with other physician(s), allied health professionals, educational, correctional and other community agencies on behalf of a specific patient, provided by the physician most responsible for the patient's car ............................. $ 28.27

NOTE: Refer to notes following HSC 08.19K. 08.19K Second and subsequent physician attendance at a formal, scheduled, professional

conference related to the care and treatment of multiple psychiatric patients, when discussion occurs on behalf of a specific patient .......................................................... $ 22.72

NOTE: 1. HSC 08.19J and 08.19K may only be claimed by general practice physicians, generalists in Mental Health, pediatricians, psychiatrists, community medicine specialists and specialists in Mental Health.

2. HSC 08.19J and 08.19K are to be claimed using the Personal Health Number of the patient, naming the personnel, agencies or organizations involved.

3. Each physician involved in a patient conference may claim for patient services using HSC 08.19J or 08.19K, per patient, to a maximum of 6 patients in a 30-minute period.

4. HSC 08.19K may be claimed when the physician most responsible for the patient's care has submitted a claim under HSC 08.19J.

5. HSC 08.19K may be claimed to a maximum of 2 calls per patient, per week, per physician.


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Psychiatric Services cont’d 03.05JQ Family conference with relative(s) via telephone in connection with the management of

a patient with a psychiatric disorder ............................................................................... $51.23 NOTE: 1. This service is to be claimed using the Personal Health Number of the

patient. 2. May be claimed in situations where: a) the patient’s family is to be notified of a mental health crisis. b) location or mobility factors of family members at the time of the call

preclude in person meetings. c) timely communication with family members is essential to patient care

and/or management. d) communication about a patient’s condition is required to gather

collateral information that is relative to the patient management and care activities.

3. May not be claimed for: a) relaying results for lab or diagnostics. b) gathering information that is in relation to the development of a

Community Treatment Order (CTO). c) arranging for follow-up care.

4. Documentation of the communication and relationship of family member to the patient must be recorded in the patient record.


08.19G Direct contact with an individual patient for psychiatric treatment (including medical psychotherapy and medication prescription), psychiatric reassessment, patient education and/or general psychiatric counseling, per 15 minutes or major portion thereof .......................................................................................................................... $ 47.00

NOTE: 1. May be claimed: - if the intent of the session is the therapy of one individual patient,

whether or not more than one person is involved in the session - when a physician assessment has established (during the same or a

previous visit) that the patient is suffering from a psychiatric disorder 2. For treatment of non-psychiatric disorders, the appropriate office visit health

service code should be claimed. 08.45 Assessment or therapy of a family, requiring comprehensive psychiatric or family

systems evaluation, first full 45 minutes or major portion thereof for the first call when only one call is claimed .................................................................................................... $150.41

After the first full 45 minutes has elapsed, each subsequent 15 minutes, or major portion thereof ................................................................................................................... $ 46.07

NOTE: May only be claimed: - when the purpose of the visit is to provide psychiatric assessment or therapy to

deal with systemic issues in the family unit - by general practice physicians, generalists in mental health, pediatricians,

(including subspecialties) and psychiatrists


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Nursing Home and Auxiliary Hospital Visits: NOTE: CMXC30 may be applicable to 03.04D (page 21) 03.04D LTC admission (nursing home, auxiliary hospital or LTC bed in general hospital) ......................................................................................................................... $109.67 03.03E Periodic chronic care visit to a LTC patient. .................................................................. $ 28.20 NOTE: 1. May be claimed once/calendar week if no other visit precedes in the same

calendar week for the same patient by the same physician. 2. HSC 03.03EA and special callbacks (HSCs 03.03AR, 03.03KA, 03.03LA,

3.03MC, 03.03MD) may be claimed subsequent to a 03.03E in the same calendar week for the same patient by the same physician.

3. HSC 03.03D may be claimed for palliative care or intercurrent illness. 03.03EA Visit to long term care patient in association with a special callback (HSCs 03.03KA,

03.03LA, 03.03MC, 03.03MD) ........................................................................................... $ 53.37 NOTE: See note following 03.03MD (below) 03.03AR Urgent or priority attendance on hospital inpatient or long term care inpatient, at

request of facility staff when physician is already on site ........................................... $ 47.00 NOTE: 1. May only be claimed by the patient’s physician of record, or by physicians

working as part of an on-call rotation. 2. May not be claimed by physician extenders. 3. May only be claimed for direct attendance with the patient. 03.03KA Special call to LTC 0700 - 1700 W/D .............................................................................. $ 75.21 03.03LA Special call to LTC 1700 - 2200 W/D, 0700 - 2200 W/E and Stats ............................. $112.81 03.03MC Special call to LTC 2200 - 2400 daily .............................................................................. $150.41 03.03MD Special call to LTC 2400 - 0700 daily .............................................................................. $150.41 NOTE: For auxiliary hospital and nursing home visits, refer to the following notes: - Benefits for HSCs 03.03KA, 03.03LA, 03.03MC, 03.03MD may only be

claimed when the physician is requested to attend a patient, by the patient, the patient's relatives or a healthcare provider of the facility involved in managing the patient’s care.

- HSC 03.03EA may be claimed in addition to a special callback to an auxiliary hospital or nursing home.

- HSC 03.03D may be claimed for palliative care or acute inter-current illness. - HSC 03.DF may only be claimed where HSC 03.03D has been claimed for

palliative care or acute inter-current illness in an auxiliary hospital or nursing home. Special callback benefits (03.03KA, 03.03 LA, 03.03MC, 03.03MD) may be claimed in addition.

- Benefits for HSCs 03.03KA, 03.03LA, 03.03MC 03.03MD are payable based on the time at which the encounter commences.

- The physician responds to such a call from outside the auxiliary hospital or nursing home, on an unscheduled basis.

- The patient is attended on a priority basis. - Special callback benefits (HSCs 03.05N, 03.05P, 03.05QA, 03.05QB, 03.05R)

may not be claimed in addition.


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Team conference: 03.05JD Formal, scheduled, multiple health discipline team conference for purposes to include

care planning, care plan review, annual integrated care conference, patient management, related to a patient in a continuing care facility where the facility or program, as outlined in the Continuing Care Health Service Standards, is responsible for patient care, full 5 minutes or major portion thereof for the first call when only one call is claimed to a maximum of 12 units per hour .............................................................. $ 14.10

Medication reviews: NOTE: Refer to the notes following HSC 03.05JF. Billing note: May be claimed in addition to other services on the same day of service

similar to other team conferences. 03.05JE Formal, scheduled review of patient medication (multiple patients) for patients in

continuing care facilities where the facility or program, as outlined in the Continuing Care Health Service Standards is responsible for medication management, by the physician most responsible for the patient’s care. ........................................................ $ 20.27

03.05JF Second physician attendance where required at a formal, scheduled review of patient medication (multiple patients) for patients in continuing care facilities where the facility or program, as outlined in the Continuing Care Health Service Standards, is responsible for medication management on behalf of a specific patient

.......................................................................................................................... $ 16.59 NOTE: 1. HSCs 03.05JE and 03.05JF may only be claimed by physicians present during

and directly involved in the medication review. 2. HSCs 03.05JE and 03.05JF are to be claimed using the Personal Health

Number of the patient, naming the personnel, agencies or organizations involved.

3. Each physician involved in a patient conference may claim for patient services using HSCs 03.05JE or 03.05JF per patient, to a maximum of 6 patients in a 30-minute period.

4. HSC 03.05JF may be claimed when the physician most responsible for the patient's care has submitted a claim under HSC 03.05JE.


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Home Visits NOTE: CMGP may be applicable to 03.03N, 03.03P, 03.03Q (page 20) 03.03N 1st patient 0700 to 1700 W/D ........................................................................................... $ 84.61 (Modifier required for after hours when special call for attendance was received) OFEV - 1700 - 2200 W/D ($84.61 + $43.29) ................................................................... $127.90 OFEVWK - 0700 - 2200 W/E and Stats ($84.61 + $50.75) ............................................ $135.36 OFNTPM - 2200 - 2400 daily ($84.61+ $116.35) ............................................................ $200.96 OFNTAM - 2400 - 0700 daily ($84.61 + $116.35) .......................................................... $200.96 NOTE: May be claimed in addition to HSC 03.04J (page 24). 03.03P Second/subsequent patients……………………………………………….. .................. $ 31.34 03.03Q Repeat home visit same day (SUBD modifier applicable) ........................................... $ 60.58 03.04E Emergency home visit and admission to the hospital and hospital visit on the same day.

Subdivision/modifier required to enhance fee ............................................................ $184.88 (Modifier required for after hours) BNEV -1700 - 2200 W/D ($184.88 + $22.01) .................................................................. $206.89 BNEVWK - 0700 –2200W/E and stats ($184.88 + $22.01) ........................................... $206.89 BNNTPM - 2200 - 2400 any day ($184.88 + $54.90) ..................................................... $239.78 BNNTAM - 2400 - 0700 bundled ($184.88 + $54.90) .................................................... $239.78 NOTE: CMXC30 may be applicable to 03.04E (page 21) 03.03NA Home visit to patients residing in Assisted Living, Designated Assisted Living (DAL),

group homes, seniors lodges or personal care home, first patient ............................ $ 84.61 NOTE: 1. A maximum of one visit per day, per facility may be claimed. For the

subsequent patient seen in the same facility on the same date of service, see HSC 03.03NB.

2. If a special call for attendance is made for a second visit on the same date of service, a second 03.03NA may be submitted with supporting information.

3. Modifiers OFEV, OFEVWK, OFNTAM or OFNTPM may only be claimed if a special call for attendance is received and the physician attends within 24 hours of receiving the call.

4. If the facility provides a room for the physician to see the patient, an appropriate visit (03.02A, 03.03A or 03.04A) should be billed instead.

03.03NB Home visit to patients residing in Assisted Living, Designated Assisted Living (DAL), group homes, seniors lodges or personal care home, second/subsequent patients

.......................................................................................................................... $ 84.61 NOTE: 1. A maximum of one visit per day, per facility, per patient may be claimed. 2. If a special call for attendance is made for a second visit on the same date of

service, a second 03.03NB may be submitted with supporting information. 3. Modifiers OFEV, OFEVWK, OFNTAM or OFNTPM may only be claimed if a

special call for attendance is received and the physician attends within 24 hours of receiving the call.

4. If the facility provides a room for the physician to see the patient, an appropriate visit (03.02A, 03.03A or 03.04A) should be billed instead.


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In-patients/Hospital Visits/Admissions: NOTE: CMXC30 may be applicable to 03.04C (page 21) 03.04C Hospital admission (M-F 0700 – 1700) ........................................................................... $128.48 (Modifier required for after hours) HAEV 1700 - 2200 M-F ($128.48 + $42.68) ............................................................ $171.16 HAEVWK 0700 - 2200 W/E and Stats ($128.48 + $42.68) .......................................... $171.16 HANTAM 2400 - 0700 daily ($128.48 + $146.21) ........................................................ $274.69 HANTPM 2200 - 2400 daily ($128.48 + $146.21) ........................................................ $274.69 03.03D Daily hospital visit per day (days 1 –7) (one /day/patient/physician) .................... $ 43.87 Daily hospital visit per day (day 8 and subsequent) (one /day/patient/physician) .......................................................................................................................... $ 31.67 NOTE: 1. Specialist rates are for referred hospital visits only. 2. A maximum of six level one days may be claimed when the same physician

claims a comprehensive visit or consultation on the date of hospital admission.

3. Only one HSC 03.03D may be claimed per patient, per physician, per day. Special callbacks (HSCs 03.05N, 03.05P, 03.05QA, 03.05QB, 03.05R) may be claimed when the criteria listed under HSC 03.05R are met.

4. Modifier COINPT may be claimed for the management of complex acute care hospital inpatients with multi-system disease. Refer to the COINPT modifier definition for clarification regarding the use of this modifier.

NOTE: See COINPT modifier (page 20) for information on additional payment for complex patients.

NOTE: PRACID required.

03.03AR Urgent or priority attendance on hospital inpatient or long term care inpatient, at request of facility staff when physician is already on site ........................................... $ 47.00

NOTE: 1. May only be claimed by the patient’s physician of record, or by physicians working as part of an on-call rotation.

2. May not be claimed by physician extenders. 3. May only be claimed for direct attendance with the patient. NOTE: See COINPT modifier (page 20) for information on additional payment for

complex patients. 03.05M Supportive care visit ................................................................................................ $ 28.20 NOTE: May be claimed to a maximum of four visits per patient hospitalization.


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After Hours Time premium 03.01AA After hours time premium .................................................................................................. $0.00 NOTE: 1. Use with modifiers TDES, TEV, TNTA, TNTP, TST, TWK to claim for the

after hours time unit premium in accordance with GR15 and the SURT modifier definition.

2. Benefit will vary depending on the modifier used. See page 19. 03.03DF Visit to hospital in-patient in association with a callback (HSC 03.05N, 03.05P, 03.05QA,

03.05QB, 03.05R) ............................................................................................................... $ 43.87 NOTE: 1. May be claimed when HSC 03.03D has been claimed at a different encounter

by the same or different physician. 2. May be claimed in addition to a special callback (HSC 03.03KA, 03.03LA,

03.03MC, 03.03MD) only where HSC 03.03D has been claimed for palliative or acute inter-current illness in an auxiliary hospital or nursing home.

3. Claims for second and subsequent patients seen on a priority basis after initial callback (HSC 03.05N, 03.05P, 03.05QA, 03.05QB, 03.05R) must be made using HSC 03.03AR, if HSC 03.03D has already been claimed at a different encounter by the same or different physician.

Special call backs (from outside the hospital) - In-patient: 03.05P W/D 1700 – 2200 .............................................................................................................. $112.81 03.05R W/E, Stat. 0700 – 2200 ..................................................................................................... $112.81 03.05QA Night 2200 – 2400 .............................................................................................................. $150.41 03.05QB Night 2400 – 0700 .............................................................................................................. $150.41 03.05N Called from home or office 0700 – 1700.......................................................................... $ 75.21 NOTE: 1. May only be claimed when a special call for attendance is made on the

patient's behalf. 2. Benefits are payable based on the time at which the encounter commences. 3. The physician responds to such a call from outside the hospital, on an

unscheduled basis. 4. The patient is attended on a priority basis. 5. There is direct attendance by the physician. 6. Second or subsequent patients seen during the same callback are not eligible

for benefits under HSCs 03.05N, 03.05P, 03.05QA, 03.05QB or 03.05R but may be claimed using HSC 03.03AR.

7. May not be claimed in association with any HSC except HSC 03.01AA or 03.03DF. Refer to GR 15.8.

8. Special callback benefits (03.05N, 03.05P, 03.05QA, 03.05QB or 03.05R) should be claimed in addition to HSC 03.03DF.


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Emergency Room Visits: (from outside the hospital) (Refer to GR 5.2 and 15.3) NOTE: 1. May not be billed in addition to a procedure for the same encounter. 2. May be billed in addition to after hours time premium 03.01AA with

applicable modifier. 3. May be billed in addition to 03.03A, 03.03B or 03.04A. 03.03KA Special call to ER from home or office 0700 – 1700 W/D ............................................ $ 75.21 03.03LA Special call to ER 1700 - 2200 W/D, 0700 - 2200 W/E and Stats ................................ $112.81 03.03MC Special call to ER from home or office 2200 – 2400 daily ............................................ $150.41 03.03MD Special call to ER from home or office 2400 – 0700 daily ............................................ $150.41 Subsequent patients seen after callback: (Refer to GR 5.2).

Follow-up Care of Patient remaining in ER (Non-Rotation duty) NOTE: CMXV20 or CMXV35 modifier applicable to 03.05FF, 03.05FG or 03.05FH NOTE: Refer to the notes following 03.05FH 03.05FF Follow-up care of a patient remaining in a non-rotation duty emergency department

awaiting further evaluation, treatment and/or waiting for a bed, transfer to another facility, or requiring extended care by another physician, 0700 to 1700 hours, weekdays ................................................................................................................................. $ 28.20

03.05FG Follow-up care of a patient remaining in a non-rotation duty emergency department, awaiting further evaluation, treatment, and/or waiting for a bed, transfer to another facility, or requiring extended care by a physician, weekday, 1700 to 2200 hours, weekend and statutory holiday, 0700 to 2200 hour ....................................................... $ 31.34

03.05FH Follow-up care of a patient remaining in a non-rotation duty emergency department, awaiting further evaluation, treatment, and/or waiting for a bed, transfer to another facility, or requiring extended care by a physician, any day, 2200 to 0700 hrs.

................................................................................................................................. $ 34.47 NOTE: 1. May only be claimed by the same physician who provided the initial

assessment when a second call for attendance has been made by staff or another physician.

2. May be claimed by a different physician who is taking over care of the patient.

Rotation Duty In ER NOTE: CMXV20 or CMXV35 modifier applicable to 03.05CR, 03.05DR & 03.05ER Refer to note following 03.05ER 03.05CR Rotation duty, emergency department, 0700 – 1700 hours ......................................... $ 29.18 03.05DR Rotation duty, emergency department, 1700 – 2200 weekdays, 0700 – 2200 hours, Sat/Sun/Holidays ............................................................................ $ 29.18 03.05ER Rotation duty, emergency department, 2200 – 0700 hours ......................................... $ 29.18 NOTE: HSCs 03.05CR, 03.05DR and 03.05ER may only be claimed by physicians who are

on-site and working a scheduled rotation duty shift in an emergency department, or are providing first call coverage in an emergency department with greater than 25,000 visits per year.


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Comprehensive visits in ER (Rotation duty) NOTE: CMXC30 modifier applicable to 03.04F, 03.04G & 03.04H (page 21) Rotation duty only or by physicians who are providing first call services in an ED with

greater than 25,000 visits/year. Refer to GR 4.2.7. NOTE: Refer to notes following 03.04H. 03.04F Comprehensive visit in an emergency department, weekday, 0700 – 1700 hrs. .......................................................................................................................... $ 96.92 03.04G Comprehensive visit in emergency department, weekday, 1700 – 2200 hours, weekends

and statutory holidays, 0700 – 2200 hours ..................................................................... $ 96.92 03.04H Comprehensive visit in emergency department, 2200 – 0700 hours .......................... $ 96.92 NOTE: 1. HSCs 03.04F, 03.04G, 03.04H may only be claimed by emergency medicine

physicians, full time emergency room physicians, general practitioners or pediatricians working a rotation duty shift in an emergency department with 24 hour on-site coverage or by physicians who are providing first call coverage in an emergency department that has greater than 25,000 visits to the emergency room per year.

2. HSCs 03.04F, 03.04G, 03.04H may be claimed for those patients whose illness/injury requires prolonged observation, continuous therapy and multiple reassessments as described in GR 4.2.7 or for female patients requiring an internal examination because of obstetrical problems or gynecological bleeding.

Follow-up Care of Patient remaining in ER (Rotation duty) Follow-up care of a patient remaining in an emergency department awaiting further evaluation, treatment and/or waiting for a bed, transfer to another facility, or requiring extended care by a physician NOTE: Refer to notes following HSC03.05FB 03.05F Weekday, 0700 to 1700 hours (Category V) .................................................................. $ 29.36 03.05FA Weekday, 1700 to 2200 hours, weekend and statutory holiday, 0700 to 2200 hours (Category V) ....................................................................................................................... $ 29.36 03.05FB Any day, 2200 to 0700 hours ........................................................................................... $ 29.36 NOTE: 1. HSCs 03.05F, 03.05FA and 03.05FB may not be claimed on the same shift by the

physician who provided the initial assessment. 2. HSCs 03.05F, 03.05FA and 03.05FB may only be claimed once per patient per

emergency room shift. 3. HSCs 03.05F, 03.05FA and 03.05FB may only be claimed by physicians on rotation

duty in an emergency department, or providing first call coverage in an emergency department with greater than 25,000 visits per year.

4. Should the patient remain in the emergency room awaiting an in-patient bed after admission to hospital, HSCs 03.05F, 03.05FA and 03.05FB may not be claimed by the emergency room physician.


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Team / Family Conferences 03.05JA Formal, scheduled, multiple health discipline team conference, full 15 minutes or major

portion thereof for the first call when only one call is claimed ...................................... $ 41.99 With para-medical personnel regarding the provision of health care where social and

other issues are involved. NOTE: 1. May be claimed when the conference involves the physician and one or more

allied health professionals. 2. May be claimed by more than one physician where circumstances warrant

(text will be required). 3. May be claimed to a maximum of 12 calls or 3 hours per year (April 1 to

March 31), per patient, per physician. 03.05JB Formal, scheduled family conference relating to a specific patient, per 15 minutes or

major portion thereof ........................................................................................................ $ 51.39 NOTE: 1. May not be claimed at the same encounter as HSC 03.03A. 2. May be claimed to a maximum of 12 calls or three hours per year (April 1 to

March 31), per patient, per physician. 03.05JC Family conference relating to acute care facility in-patient, or registered emergency or

out-patient, or auxiliary hospital, or nursing home patient, AACC or UCC patient per 15 minutes or major portion thereof ............................................................................... $ 41.99

NOTE: 1. Intended specifically for patients whose condition warrants periodic family conferences.

2. May be claimed to a maximum of 12 calls or 3 hours per year (April 1 to March 31), per patient, per physician.

03.05JP Family conference via telephone relating to acute care facility in-patient or registered emergency or out-patient, or auxiliary hospital, nursing home patient, hospice patient, AACC or UCC patient ....................................................................................................................$40.70

NOTE: 1. Intended specifically for patients whose condition warrants periodic family conferences or for patients who are unable to properly communicate with their physician (e.g., situations where there is a language barrier, unconscious patient, etc.)

2. This service is to be claimed using the Personal Health Number of the patient.

3. May be claimed in situations where:

a) location or mobility factors of family members at the time of the call preclude in person meetings.

b) timely communication with family members is essential to patient care or organ/tissue transfer collection., and

c) communication about a patient’s condition or to gather collateral information that is relative to patient management and care activities.

4. May not be claimed for:

a) relaying results for lab or diagnostics.

b) arranging follow up care.

5. Documentation of the communication to be maintained in the patient record.



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03.05JH Family conference via telephone, in regards to a community patient ........................ $ 15.12 NOTE: 1. This service is to be claimed using the Personal Health Number of the patient. 2. May be claimed in situations where: a) location or mobility factors of family members at the time of the call preclude in

person meetings. b) communication about a patient's condition or to gather collateral information that

is relative to patient management and care activities. 3. May not be claimed for: a) relaying results for lab or diagnostics. b) arranging follow up care. 4. Documentation of the communication to be maintained in the patient record. 5. May be claimed in the pre and post-operative periods.

Emergency Services: Detention Time 13.99J Medical emergency detention time, per 15 minutes ........................................................ $ 59.54 NOTE: 1. Time may be claimed on a cumulative basis per day (defined as 0001 to 2400), and

may include time spent with the patient, review of patient history including diagnostics, review of patient prescriptions and other activities the physician does in relation to the patient's care on the same date of service.

2. Time spent providing services compensated elsewhere in the Schedule, e.g., family conferences and procedures, may not be included in time claimed for HSC 13.99J.

3. Supporting information must be submitted. 4. May be claimed by a physician during the time he/she is medically required to

personally and continuously attend and treat an illness or injury of an emergency nature.

5. May not be claimed for such services as: - counseling or psychotherapy except for crisis intervention situations - for the results of laboratory or radiological examination giving advice to family members or the patient - waiting for a family physician or consultant - attendance at labour or fetal monitoring (see HSC 13.99JA) 6. Detention time may not be claimed if the service was provided in the office in

conjunction with routine visits except when it is documented that an emergency existed.

7. Illness of an "emergency nature" may apply to mental or emotional disorders as well as to physical illness.

8. If a visit benefit is claimed, the detention time benefit may not be claimed until thirty minutes after the start of the visit.

9. Only HSC 13.99J or procedures provided during the same encounter (with the exception of HSC 13.99E) may be claimed, but not both. Concurrent claims for overlapping time for the same or different patients may not be claimed.

10. A maximum of 16 calls per physician per day may be claimed in any location other than a physician's office.

11. A maximum of 8 calls per physician per day may be claimed in the physician's office. NOTE: Text must be provided to indicate what was done.


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Ambulance Detention Time NOTE: Refer to notes following 13.99KB 13.99K Ambulance detention time, full 15 minutes or major portion thereof, weekday, 0700 – 1700 hours .............................................................................................................. $ 86.49 13.99KA Ambulance detention time, full 15 minutes or major portion thereof, weekday, 1700 – 2200 hours, weekends, statutory holidays, 0700 – 2200 hours ....................... $118.50 13.99KB Ambulance detention time, full 15 minutes or major portion thereof, any day, 2200 – 0700 hours .............................................................................................................. $142.57 NOTE: 1. Supporting information must be submitted for HSCs 13.99K, 13.99KA and

13.99KB. 2. May be claimed by a physician during the time he/she is medically

required to personally and continuously attend a patient being transported by surface or air ambulance.

3. Only time in attendance with the patient may be claimed. 4. Concurrent billing for overlapping time for separate patient

encounters/services may not be claimed. 5. A maximum of 20 calls applies. NOTE: Return trip is not payable. Resuscitation 13.99E Resuscitation, per 15 minutes or major portion ......................................................... $386.03 NOTE: 1. Resuscitation is defined as the emergency treatment of an unstable patient

whose condition may result in imminent mortality without such intervention.

2. May be claimed when this service follows a consultation or hospital visit earlier in the same day as defined under GR 1.19.

3. When the condition of the patient is such that further care is provided, either before or after the patient is resuscitated, at a level consistent with the description of HSC 13.99H, 13.99HA, 13.99J, 13.99K, 13.99KA or 13.99KB, time spent providing that care may be claimed using these HSCs. Concurrent claims for overlapping time for the same or different patients may not be claimed.

4. If two claims for HSC 13.99E at different encounters are submitted by the same or different physician, text is required.

5. Two physicians may not claim HSC 13.99E for concurrent care. The second and subsequent physician involved in the resuscitation may claim HSC 13.99EC.


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Resuscitation cont’d 13.99EC Resuscitation, per 15 minutes or major portion thereof for the second and subsequent

physician actively participating and providing assistance to the primary physician at a resuscitation ....................................................................................................................... $87.66

NOTE: 1. Resuscitation is defined as the emergency treatment of an unstable patient whose condition may result in imminent mortality without such intervention.

2. May only be claimed for the time spent when the physician is directly involved in assisting the primary physician in a resuscitation.

3. May not be claimed in addition to other procedures or visits at the same encounter by the same physician.

4. May not be claimed for Medical Emergency Team (MET) coverage. Emergency Services 13.99H Critical care of severely ill or injured patient in a hospital emergency department,

requiring major treatment intervention(s), per 15 minutes ......................................... $ 58.61 NOTE: 1. May only be claimed when a patient presents with a serious condition

requiring at least a two hour stay in the active treatment portion of the emergency department or care results in hospitalization. The two hour period criterion does not apply in cases where the patient dies after having been seen.

2. Time spent may be claimed on a cumulative basis per day (defined as 0001 to 2400), and may include time spent with the patient, review of patient history including diagnostics, review of patient prescriptions and other activities the physician does in relation to the patient’s care on the same date of service.

3. Time spent providing services compensated elsewhere in the Schedule, e.g., family conferences and procedures, may not be included in time claimed for HSC 13.99H.

4. Major treatment intervention is defined as a medical intervention which prevents or treats a condition that may result in significant morbidity.

13.99V Examination and crisis counseling, for sexual/physical abuse, full 15 minutes or major portion thereof for the first call when only one call is claimed................................... $ 55.88

NOTE: 1. A maximum of 16 calls may be claimed. 2. Time taken for forensic evidence is not to be included in total time. 10.04B Intubation performed in emergency room, AACC or UCC (Category M) .............. $106.61 NOTE: 1. May only be claimed when performed in an emergency room, AACC or

UCC. 2. May not be claimed in addition to HSC 10.04 or 13.99E when performed by

the same physician. 3. May be claimed in addition to visits or other services provided on the same day

by the same physician.


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Obstetrical Services: Visits: NOTE: 1. CMGP may be applicable to 03.03B or 03.03C 2. CMXC30 may be applicable to 03.04B See pages 20-21 for modifier definitions. 03.03B Prenatal visit ....................................................................................................................... $ 36.94 03.03C Routine post-natal office examination ............................................................................ $ 36.94 NOTE: May be claimed once per patient per physician per pregnancy. 03.04B Initial pre-natal visit requiring complete history and physical examination ......................................................................................................................... $103.41 NOTE: 1. May not be charged within 90 days of another comprehensive visit or

consultation. 2. May only be claimed once per pregnancy.

3. Includes a full history, examination, initiation of the prenatal record and advice to the patient.

Pre delivery services: 87.54B Interpretation and supervision of continuous fetal monitoring (includes application of

internal electrode) (Category M+) ................................................................................... $ 63.41 NOTE: 1. May be claimed:

- for continuous monitoring by either internal or external electrical means - at 100% in addition to delivery benefits regardless of who performs the delivery

2. May only be claimed in situations of suspected fetal or maternal compromise requiring greater than usual physician supervision.

3. May only be claimed once per hospitalization unless the patient is transferred to another physician or facility for a higher level of care.

87.54A Interpretation of non-stress test (Category T) ............................................................... $ 15.39

NOTE: May not be claimed if labour has commenced. 85.5A Medical induction (Category M) .................................................................................... $120.21

NOTE: 1. May only be claimed when a physician has assessed the patient prior to the induction and monitors the patient's progress subsequent to the induction.

2. A maximum of two per 24 hour period to a maximum of four per pregnancy may be claimed unless the patient is transferred to another facility for a higher level of care.

3. If the patient is transferred to another facility for a higher level of care, the receiving physician may also claim a maximum of two per 24 hour period to a maximum of four per pregnancy.

4. May be claimed at 100% in addition to delivery benefits regardless of who performs the delivery.


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Management of Labor 13.99JA Management of complex labor, per 15 minutes ............................................................ $ 52.33

NOTE: 1. Time may be determined on a cumulative basis. 2. May be claimed for complex or non-progressive labour where the physician

is actively managing a higher risk labour (defined as prolonged labour exceeding 12 hours during the first stage of labour or 1 hour during the second stage of labour, non-progressive labour, non-reassuring fetal/maternal status, multiple gestation, pregnancy induced hypertension, HELLP, insulin dependent diabetes, antepartum hemorrhage, prelabour ruptured membranes, non-reassuring fetal heart tracing, multiple pregnancy and preterm labour, seizure disorder, unstable patient).

3. May only be claimed when the physician is on-site and immediately available or when called to monitor or reassess the patient with complex or non-progressing labour.

4. Only HSC 13.99JA or the services relating to labor provided may be claimed, but not both. Concurrent billing for overlapping time for separate patient encounters/services may not be claimed.

5. May be claimed in addition to HSCs 86.9B, 86.9D or 87.98A 6. May not be claimed in addition to HSC 87.98B or 87.98C. 7. A maximum of eight 15 minute units may be claimed per patient per

pregnancy. Deliveries: 87.98A Vaginal delivery (Category 15) ....................................................................................... $446.37 87.98B Management of labour and attempted delivery (Category 15) ................................. $448.10 NOTE: 1. The benefit includes all usual hospital care associated with the confinement

and provided by the referring physician. 2. May be claimed by the referring physician, when the referring physician

intended to conduct the delivery, provided the following conditions are met: - the referring physician attended the patient during labour and provided

assessment of the progress of the labour, both initial and ongoing - there is a documented complication warranting the referral, such as fetal

distress or dysfunctional labour (failure to progress), and - the referring physician remains in attendance and assists the consultant; or - where the physician must transfer the patient to another facility because of

either fetal or maternal indications and delivery occurs within 24 hours of transfer

3. The same physician may not claim both the delivery and management of labour and attempted delivery.

87.98C Vaginal delivery following trial of labour after previous cesarean section (Category 15) ..................................................................................................................... $680.33 86.9C Elective Cesarean section, any approach (Category 15) ............................................. $486.39


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Codes associated with deliveries: 84.21D Assisted delivery, forceps, vacuum with or without rotation, mid or lower cavity

(Category M) .................................................................................................................................. $136.99

NOTE: May be claimed at 100% in addition to delivery benefits regardless of who performs the delivery.

85.69B Management of shoulder dystocia (Category M) ........................................................ $133.54 NOTE: 1. May only be claimed when one of the recognized maneuvers for correction

of the situation is employed. 2. May be claimed at 100% in addition to delivery benefits regardless of who

performs the delivery. 85.69C Manually assisted delivery (breech presentation, manually or forceps assisted) (Category M) ..................................................................................................................... $187.78

NOTE: May be claimed at 100% in addition to delivery benefits regardless of who performs the delivery.

87.6 Manual removal of retained placenta and membranes (Category M) (UGA modifier applicable $134.85) ................................................................................ $107.74

NOTE: 1. May be claimed at 100% in addition to delivery benefits regardless of who performs the delivery.

2. May be claimed in addition to a consultation. 87.72A Repair of extensive laceration of cervix (Category M) (UGA modifier applicable $134.85) ................................................................................. $ 96.17


2. May be claimed in addition to a consultation. 87.82 Repair of obstetric laceration of sphincter ani (Category M)

(UGA modifier applicable $134.85) ................................................................................ $107.74 NOTE: 1. May be claimed at 100% in addition to delivery benefits regardless of who

performs the delivery. 2. May be claimed in addition to a consultation.

87.89A Repair of obstetrical laceration involving rectal mucosa (Category M) (UGA modifier applicable $134.85) ................................................................................. $ 96.17


2. May be claimed in addition to a consultation. 87.89B Repair of extensive vaginal laceration (Category M) (UGA modifier applicable $134.85) ................................................................................. $ 96.17 NOTE: 1. May be claimed at 100% in addition to delivery benefits regardless of whom

performs the delivery. 2. A second call may only be claimed if a non-contiguous site requires

suturing. 3. A maximum of two calls applies. 4. May be claimed in addition to a consultation.


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Codes associated with deliveries: 87.92 Evacuation of other hematoma of vulva or vagina (Category M) (UGA modifier applicable $134.85) ................................................................................ $107.74


2. May be claimed in addition to a consultation. 87.98D Multiple birth, vaginal delivery (for each additional newborn) (Category M) ..................................................................................................................... $150.84 NOTE: May be claimed at 100% in addition to delivery benefits regardless of who

performs the delivery. 87.99A Non-surgical management of post partum hemorrhage (Category M) .................... $ 96.17


2. May be claimed in addition to a consultation. 87.99AA Surgical management of severe post partum hemorrhage including but not limited to the

use of an intrauterine balloon device or suturing encircling the uterus

(Category M) ................................................................................................................................ $153.92

Care of newborn:

03.05G Care of healthy newborn in hospital (first day)(Category M) .................................... $ 65.80 03.05GA Care of healthy newborn in hospital (subsequent days) ........................................................$ 52.64

NOTE: May only be claimed when no other visit service has been provided on that day, regardless of physician.

13.99F Neonatal resuscitation (Category M) .............................................................................. $ 41.99 NOTE: May be claimed in addition to delivery benefit regardless of who performs the

delivery. 87.98E Attendance at delivery ...................................................................................................... $ 88.99

NOTE: 1. May only be claimed when a physician is specifically requested by the physician intending to perform a delivery and no other service may be claimed for that attendance.

2. Care of healthy newborn in hospital (03.05G) may be claimed in addition. 3. This service is billable when physician attendance on behalf of the baby is

required. 03.7A Examination of stillborn ................................................................................................... $ 65.80 NOTE: May be claimed in addition to other services provided on the same day by the

same physician.


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Diagnostic and General Procedures: 76.0 Circumcision (Category 40 ....................................................................................................... $254.67 NOTE: Routine newborn circumcisions are not an insured service. 33.01A Control of epistaxis by anterior nasal packing with or without cautery (Category M) (add $13.04 for tray if office) .................................................................. $125.00 NOTE: 1. Benefit includes visit. 2. May not be claimed in addition to HSC 21.71. 33.03A Control of epistaxis by cautery (Category M) (add $13.04 for tray if office) ............... $ 55.42 NOTE: 1. Benefit includes visit. 2. Repeat performed within 14 days payable at ............................................ $ 33.17 61.03 Excision of perianal skin tags (Category M) (add $38.59 for tray if office) .................. $ 44.99 61.37A Inc./Exc. of thrombosed hemorrhoid (Category M) (add $38.59 for tray if office) (UGA modifier applicable $134.85) ................................................................................. $ 56.40 98.03A I & D of an abscess, hematoma, subcutaneous or submucous (Category M) (add $13.04 for tray if office) (UGA modifier applicable $134.85) ..... $ 25.41 NOTE: May be claimed in addition to a visit or a consultation. 98.03C Aspiration of hematoma (Category M) (add $13.04 for tray if office) ........................ $18.80 98.03D Abscess requiring procedural sedation and extensive drainage and packing (Category 4) ....................................................................................................................... $100.49 NOTE: May only be claimed when performed in an emergency room, AACC or UCC. 16.81A Spinal Tap for diagnosis or imaging studies (Category M+) ..................................... $127.45 NOTE: 1. May not be claimed in addition to HSC 50.98B or 50.99C. 2. May be claimed in addition to a visit or a consultation. 98.12H Excision of soft tissue tumor(s) (subcutaneous) full 30 minutes of operating time or

major portion thereof for the first call when only one call is claimed (Category 4) (add $38.59 for tray if office) ............................................................................................. $94.01 After the first full 30 minutes has elapsed, each subsequent 15 minutes or major portion

thereof, is payable at the rate of ........................................................................................ $47.01 Maximum .......................................................................................................................... $564.12 NOTE: For sebaceous cyst removal see HSC 98.12C. 98.12C Removal of sebaceous cyst (Category M) (add $38.59 for tray if office) (UGA modifier applicable $134.85) ................................................................................. $ 42.41 NOTE: 1. May be claimed in addition to a visit or a consultation. 2. A maximum of three calls may be claimed 75.64 Vasectomy (complete) (partial) (Category 14) (add $38.59 for tray if office) ........... $175.48 NOTE: May not be claimed if vasectomy is subsequent to a previous reversal. If a repeat

procedure is required due to a previously failed attempt, supporting documentation must be provided.

09.41A Impedance audiometry/tympanometry (technical) (Category T) ............................... $ 8.72 NOTE: Includes acoustic reflexes and hard copy of results. 03.37A Vital capacity (Category T) .............................................................................................. $ 10.58 03.38D Vitalometry, alone (Category T) ...................................................................................... $ 21.93 37.91A Release of simple tongue tie, clipping (Category M) (add $13.04 for tray if office) .................................................................................................................................. $56.40


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Biopsies: 95.81A Biopsy of muscle (add $38.59 for tray if office) (Category M+) (UGA modifier applicable $134.85) ................................................................................. $ 76.50 97.11B Breast biopsy and/or local excision of lesion(s) (Category M+) (add $38.59 for tray if

office) ................................................................................................................................ $168.68 98.12A Excisional biopsy, skin, (add $38.59 for tray if office) (Category M+) (UGA modifier applicable $134.85) ................................................................................. $ 41.76 Calls 2-3 payable at 75% ................................................................................................... $ 31.32 Maximum ......................................................................................................................... $104.40 98.12B Excisional biopsy, skin of face (add $38.59 for tray if office) (Category M+) (UGA modifier applicable $134.85) ................................................................................. $ 53.55 Calls 2-3 payable at 75% ................................................................................................... $ 40.16 Maximum ........................................................................................................................ $133.88 98.81B Punch biopsy (Category M+) ........................................................................................... $ 23.98 Second call payable at 75% ............................................................................................... $ 17.99 97.81 Percutaneous (needle) biopsy breast (add $13.04 for tray if office) (Category M+) (UGA modifier applicable $134.85) ...................................................... $ 44.75 Burn treatment (office): 07.57A Initial treatment – minor burn (add $38.59 for tray if office) (Category M) (UGA modifier applicable $134.85) ................................................................................. $ 37.60 07.57B Subsequent treatment – minor burns – dressing and/or debridement (add $13.04 for tray if office) (Category V) .................................................................... $ 56.40 Foreign Body removal: 12.31 Removal of non penetrating FB from eye w/o incision (Category M) (add $38.59 for tray

if office) (UGA modifier applicable $134.85) ..................................................................... $ 37.60 25.1A Removal FB from cornea (Category M) (add $38.59 for tray if office) (UGA modifier applicable $134.85) ................................................................................. $ 40.45 12.01 Removal of intraluminal foreign body from nose without incision (Category M)

(add $13.04 for tray if office) (UGA modifier applicable $134.85) .............................. $ 49.56 12.21 Removal of intraluminal foreign body from ear without incision (Category M)

(add $13.04 for tray if office) (UGA modifier applicable $134.85))............................. $ 51.88 95.09A Removal of deep foreign body, with or without imaging, full 15 minutes of operating

time or major portion thereof for the first call when only one call is claimed (add $38.59 for tray if office) ........................................................................................... $120.09 After the first full 15 minutes has elapsed; each subsequent 15 minutes, or major

portion thereof, is payable at the rate of ......................................................................... $35.91 to a maximum of ............................................................................................................... $443.28 98.04A Incision with removal of foreign body of skin and subcutaneous tissue under

anaesthesia (Category M) (add $38.59 for tray if office) (UGA modifier applicable $134.85) ................................................................................. $ 43.73 98.04B Incision with removal of foreign body of skin and subcutaneous tissue without

anaesthesia (Category M) (add $13.04 for tray if office) ............................................... $23.19


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Gynecological services: 10.16A Pessary fitting (Category M) (add $13.04 for tray if office) ....................................................$ 56.24 NOTE: May be claimed in addition to a visit or consultation. 10.16B Pessary removal, adjustment and/or reinsertion (Category M) (add $13.04 for tray if office)

...............................................................................................................................................$13.47

NOTE: 1. May not be claimed in addition to HSC 10.16A. 2. May be claimed in addition to a visit or consultation. 13.99BA Periodic Papanicolaou Smear for patients between the ages of 21 and 69 ................ $28.21 NOTE: 1. Two Papanicolaou smears may be claimed per patient, per physician, per

year (April 1 of one year to March 31 of the following year). Additional claims may be submitted with supporting information.

2. May be claimed in addition to a visit or consultation. 3. When clinically indicated, Papanicolaou smears may be claimed for those

patients not meeting the age requirements. In those instances, text must be submitted explaining the specific circumstance.

4. May not be claimed at the same encounter as HSC 13.99BD or 13.99BE. 13.99BD Anal Papanicolaou Smear ................................................................................................ $16.92 NOTE: 1. Two Anal Papanicolaou smears may be claimed per patient, per physician,

per year (April 1 of one year to March 31 of the following year). Additional claims may be submitted with supporting information.

2. May be claimed in addition to a visit or consultation. 3. May not be claimed at the same encounter as HSC 13.99BA or 13.99BE. 13.99BE Pelvic examination using a speculum requiring swab(s) and/or sample(s) collection ........................................................................................................................... $ 28.21 NOTE: 1. May be claimed with a visit or consultation. 2. May not be claimed at the same encounter as HSC 13.99BA or 13.99BD. 81.8 IUD insertion (add $13.04 for tray if office) (Category M) (UGA modifier applicable $134.85) ................................................................................. $ 67.73 NOTE: May be claimed in addition to a visit or consultation. 11.71A Removal of intrauterine contraceptive device (IUD) (Category M) (add $13.04 for tray if

office) (UGA modifier applicable $134.85) ...............................................................................$17.23

NOTE: May be claimed in addition to a visit or consultation.

80.83B Endometrial biopsy (add $13.04 for tray if office) (Category M+) (UGA modifier applicable $134.85) ................................................................................. $ 43.10

Hernias: 13.99DD Non-surgical reduction of abdominal or inguinal hernia (Category M) .................. $ 63.08 NOTE: 1. May be claimed in addition to a visit or consultation at the same encounter. 2. May only be claimed in an emergency room, AACC or UCC.

Dislocations: 91.75B Closed reduction of patellar dislocation (Category M) ............................................... $ 70.93 NOTE: 1. May be claimed in addition to a visit or consultation at the same encounter. 2. May only be claimed in an emergency room, AACC or UCC.


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Endoscopies: 01.24A Sigmoid, rigid w/wo biopsy and/or polypectomy (Category M+) (add $38.59 for tray if office) (UGA modifier applicable $134.85) .............................. $ 52.31 NOTE: Benefit includes biopsies and/or polypectomies. 01.24B Sigmoid, flex, diagnostic only (Category M+) (add $38.59 for tray if office) (UGA modifier applicable $134.85) .............................. $ 74.92 NOTE: 1. HSCs 13.99AE, 57.13A, 57.21A, 57.21B, 58.99C and 58.99D may be claimed in

addition. 2. Benefit includes biopsies. 3. Benefit includes the removal of diminutive polyps that are 5mm or less in

size. Injections/aspirations: 13.59A Intramuscular/subcutaneous injection (Category M).................................................. $ 10.03 Second call payable at 75% ................................................................................................. $ 7.52 NOTE: 1. May be claimed in addition to a visit or a consultation. 2. May not be claimed for injection of allergy serum. 13.59C Initiation of intravenous (Category M) (add $38.59 tray if office) ............................... $24.25 NOTE: 1. Sole procedure only and may not be claimed in addition to a radiology

service. 2. May be claimed in addition to a visit or a consultation providing the

purpose of the visit is not for the initiation of the intravenous. 3. May be claimed only when performed by a physician where suitable

qualified nursing personnel are unavailable. 13.59O Injections of Botulinum A Toxin for the prophylaxis of chronic migraine headaches for

eligible patients 18-65 years of age (Category M) (add $13.04 tray if office)

(UGA modifier applicable $134.85) .......................................................................................... $101.91

NOTE: 1. Eligible patients will have suffered headache activity for greater than 15 days per month with each episode lasting for four or more hours for three consecutive months prior to the initial treatment.

2. Follow up treatment may be claimed in 12 week intervals.

3. Only one call may be claimed regardless of the number of injections performed.

4. May be claimed in addition to a visit or a consultation. 95.96A Aspiration/injection other bursea, tendon sheath, ganglion of wrist or ankle (Category M) (add $13.04 for tray if office) (UGA modifier applicable $134.85) .......................................................................................................................... $ 13.16 Second call payable at 75% ................................................................................................. $ 9.87 NOTE: A second call may only be claimed when the second bursa, tendon sheath,

ganglion is either aspirated and/or injected. 93.91A Joint aspiration, injection, hip (Category M) (add $13.04 for tray if office). (UGA modifier applicable $134.85) ................................................................................. $ 37.10 Second call payable at 75% ................................................................................................ $27.83 NOTE: Refer to notes following 93.91B


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Injections/aspirations: 93.91B Joint aspiration, injection, other joint (Category M) (add $13.04 for tray if office) (UGA modifier applicable $134.85) ................................................................................. $ 19.68 Second call payable at 75% ............................................................................................... $ 14.76 NOTE: 1. HSC 93.91A and 93.91B may be claimed in addition to a visit or a consultation. 2. A second call may only be claimed for HSCs 93.91A and 93.91B when a second joint

is either aspirated and/or injected. 95.93 Injection/aspiration of therapeutic substance into bursa (subacromial) (Category M) (add $13.04 for tray if office) (UGA modifier applicable) ............................................. $17.98 Second call payable at 75% ................................................................................................ $13.49 NOTE: A second call may only be claimed when the second bursa is either aspirated and/or

injected. Allergy: 13.42A Desensitization treatments with allergy serums (may be provided by nurse) (Category M) ....................................................................................................................... $17.16 NOTE: 1. When performed by physician or under physician supervision. 2. A maximum of one office visit per month may be claimed for reassessment of the

patient in lieu of a claim for desensitizing injection. 3. Benefit includes cost of all material other than allergy serum. 4. Only one benefit may be claimed per treatment regardless of number of injections

given. 98.89D Skin test, patch, per test (Category T) ............................................................................... $ 1.65 Maximum per benefit year ................................................................................................ $74.25 98.89E Skin test, airborne allergens, intradermal or prick, per test (Category T) ................... $ 2.21 Maximum ......................................................................................................................... $132.60 98.89F Skin test, food allergens, intradermal or prick, per test (Category T) .......................... $ 2.21 Maximum ......................................................................................................................... $265.20 NOTE: 1. A second set of tests may be claimed only by a specialist for a patient who is referred. 2. Benefits do not include the cost of materials. Lacerations: 98.22A Laceration up to 2.5 cm on face or 5 cm on body (Category M) (add $38.59 for tray if office) (UGA modifier applicable $134.85) .............................. $ 56.40 98.22B Laceration, face, over 2.5 cms (1 unit) and/or body, over 5 cms (1unit) (Category 1) (add $38.59 for tray if office) ..................................................................... $ 58.98 Each additional 2.5 cm face or 5cm body ....................................................................... $ 29.51 NOTE: The following applies to HSCs 98.22A and 98.22B. 1. Benefit includes primary closure of wound by any method excluding adhesive tape

skin closure or simple bandaging, normal wound care follow-up and suture removal. 2. Where the laceration is treated with the use of adhesive tape skin closure or simple

bandaging, a visit should be claimed. 3. Where multiple lacerations are repaired, use the combined length. 4. May only be claimed when the laceration is a result of a trauma either minor or major. 5. May not be claimed in addition to an elective procedure.


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Nail bed: 98.96A Nail wedge excision (Category M) (add $38.59 for tray if office) (UGA modifier applicable $134.85) ................................................................................. $ 59.54 Second call payable at 75% ................................................................................................ $44.65 98.96B Radical nail excision (Category 6) (add $38.59 for tray if office) (UGA modifier applicable $134.85) ................................................................................. $ 78.34 Second call payable at 75% ............................................................................................... $ 58.75 98.96C Wedge excision with plastic repair, one side of nail (Category M) (add $38.59 for tray if office) (UGA modifier applicable $134.85) .............................. $ 65.80 Second call payable at 75% ............................................................................................... $ 49.35 98.96D Wedge excision with plastic repair, two sides of nail (Category M) (add $38.59 for tray if office) (UGA modifier applicable $134.85) .............................. $ 72.07 Second call payable at 75% ................................................................................................ $54.05 Warts/keratoses/benign nevi: NOTE: 1. Items 98.12J, 98.12K and 98.12L may only be claimed for the following:

genital warts; plantar warts; precancerous skin lesions, e.g., actinic keratoses; seborrhoeic keratoses which are irritated and treatment is medically required; warts in immuno-deficient patients or immuno- suppressed patients; or molluscum contagiosum.

2. The treatment of common warts or keratoses is an uninsured service. 98.12J Removal or excision 1st lesion (Category M) (add $38.59 for tray if office) ............. $ 18.80 (UGA modifier applicable $134.85) 2nd & 3rd lesion, each ................................................................................................. $ 7.53 4th lesion ................................................................................................. $ 7.42 To maximum of ............................................................................................... $ 41.28 NOTE: May be claimed in addition to a visit or a consultation. 98.12K Removal by fulguration, (1st lesion) (Category M) (UGA modifier applicable $134.85)(add $13.04 for tray if office) ............................... $ 23.84 2nd – 5th lesion each ................................................................................................. $ 6.31 6th lesion ................................................................................................. $ 3.21 To a maximum of ................................................................................................ $ 52.29 98.12L Non surgical treatment (cryotherapy, chemotherapy), warts or keratoses (Category M) ...................................................................................................................... $ 16.57 NOTE: May be claimed in addition to a visit or consultation. 98.12M Removal of pigmented naevus, benign excluding face (Category M) (add $38.59 for tray if office) (UGA modifier applicable $134.85) .............................. $ 34.47 98.12N Removal of pigmented naevus of face, benign (Category M) (add $38.59 for tray if office) (UGA modifier applicable $134.85) .............................. $ 53.27 98.12R Removal of 1st planter wart (Category M) (add $38.59 for tray if office) (UGA modifier applicable $134.85) ................................................................................. $ 38.66 2nd planter wart .................................................................................................................. $ 15.46 3rd planter wart .................................................................................................................. $ 2.07 To a maximum of ............................................................................................................... $ 56.19 NOTE: 1. May be claimed in addition to a consultation. 2. For non surgical treatments see HSC 98.12L.


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Varicose vein injections Injection of sclerosing agent or solution into vein 51.92A Varicose vein, single injection (Category M) (add $13.04 for tray if office) .............. $ 13.16 NOTE: 1. Sclerotherapy for asymptomatic varicose veins is not an insured service.

2. At any one visit, a maximum of three HSC 51.92B may be claimed in addition to a 51.92A.

3. A maximum of six HSC 51.92A and eighteen 51.92B may be claimed per benefit year.

4. May be claimed in addition to a visit or a consultation. 51.92B Varicose vein, additional injection (Category M) .......................................................... $ 6.89 To a maximum of ................................................................................................................ $20.67 NOTE: Refer to notes following 51.92A.

Cast application: 07.53D Cast applied to lower extremity (Category M) (add $38.59 for tray if office) ........... $ 38.66 07.53B Cast applied of upper extremity, excluding finger (Category M) (add $38.59 for tray if

office) ................................................................................................................................. $ 46.80 07.53H Fiberglass cast application upper limb, excluding finger (Category M) ................... $ 61.28 07.53J Fiberglass cast application lower limb (Category M) ................................................... $ 75.94

NOTE: 1. Benefits for HSC 07.53H and 07.53J include the cost of supplies and the application of cast (07.53B or 07.53D).

2. When HSC 07.53H or 07.53J are performed in a nursing home, general or auxiliary hospital, AACC, UCC or a facility which has a contract with Alberta Health Services to provide the insured service for which a fiberglass cast is applied, only the rate equivalent to HSC 07.53B or 07.53D will be paid.

3. When HSC 07.53H or 07.53J are claimed in association with fracture reduction HSC, they will be reduced by a rate equivalent to HSC 07.53B or 07.53D.

4. HSC 07.53H or 07.53J may not be claimed in association with 07.53B or 07.53D.

NOTE: There are no tray service fees to be charged in a hospital, auxiliary hospital or nursing home.

Surgical Assist: When billing for a surgical assist, please read General Rule 13. Claims for surgical assist shall indicate the number of time units the assistant was required. The number of units of time submitted for surgical assist shall not exceed that for anesthetic. Surgical assist benefits may not be claimed if an intern or resident is the first assistant. Benefits may not be claimed for procedures that do not routinely require the services of an SA unless supporting documentation is provided. When billing for a surgical assist, you must bill the procedure that the surgeon is billing for, and then add the Role Modifier (SA). SA First hour or portion thereof ........................................................................................... $147.31 SAU Subsequent 15 minute units ............................................................................................. $ 36.86

Revised: May 9, 2017

R:\Locum Information\2017\April\Final\GP Rules Common Codes - April 2017 Final.doc

Documents

EXCERPT FROM GOVERNING RULES - Calgary · 2017. 5. 15. · dentist, optometrist, physical therapist or nurse practitioner. 4.3.2 Limited Consultation: Limited assessment of a patient