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.

Brief Visit: Assessment of a patient's condition when history is minimal and little or no physical examination is included.

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.

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. Advice to the patient must include discussion of a care plan related to the patient's condition(s). Patient care advice, including the discussed care plan, must be documented in the patient's record. The care plan does not have to be formally signed by the patient.

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, 03.05IZ, 03.05T and 03.05U as applicable.

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.

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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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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.

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.

Time Based Consultations: Notwithstanding GRs 4.3.1 and 4.3.2, claims for consultation services as defined under HSCs 03.08F, 03.08I, 03.08IV, 03.08IZ, 03.08J, 03.08JV, 03.08JZ, 03.08L, 03.08M, 08.19A, 08.19AZ, 08.19AA, 08.19B, 08.19BB, 08.19C, 08.19CC, and 08.19CX may be claimed on a time basis.

Psychiatric Consultation referred by other professions: A benefit for a psychiatric consultation (HSCs 08.19AA, 08.19BB, 08.19CC) may be claimed when a patient is referred to a psychiatrist by a registered: occupational therapist, psychologist, community based psychiatric nurse, social worker or speech language pathologist and the provisions that apply to consultations under GRs 4.3, 4.4 and 4.6 are met.

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.

The need for a consultation can arise as a result of the following:

1. some unusual or serious clinical problem,
2. a physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner requires further advice regarding diagnosis or management or both, or
3. the patient, parent or guardian requests another opinion.

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:

1. verbal or written communication (fax, email, letter);
2. 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;
3. 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;
4. 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:

1. an employee of a physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner; or
2. a hospital or long term care facility staff member; or
3. 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.

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.

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.

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.

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

When a claim is submitted for the following HSCs, the referring practitioner field must be completed with a valid referring practitioner number.

HSCs in the following list marked with an asterisk(*) cannot be self-referred. Self-referred means the physician is providing the diagnostic service and treating the patient.

HSCs in Section E (Lab and Pathology) and X (Diagnostic Radiology) require a valid referring practitioner number with the following exceptions: HSC X27D does not require a referral and HSC X27F may be self-referred. HSC 03.03D requires a valid referring physician, chiropractor, midwife, podiatrist, dentist, optometrist, physical therapist or nurse practitioner number when it is a visit to a referred patient.

A physician on rotation duty in the emergency department or in an AACC or UCC may claim a comprehensive consultation when the conditions in GR 4.3 have been met.

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A limited consultation may be claimed when dealing with one particular problem and shall include interpretation of laboratory tests, and a written report to the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner who must care for the patient in the future. A claim for a limited consultation may be made when there is a written request or other documented communication from the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist, nurse

practitioner or their agent for an opinion or treatment by the emergency physician.

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, 03.04AZ, 03.08A, 03.08AZ, 03.08B, 03.08BZ, 03.08C, 03.08CV, 03.08F, 03.08H, 03.08K, 08.11A, 08.11C, 08.19A, 08.19AZ, 08.19AA, and 08.19CX.

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.

Notwithstanding GR 4.6.1, 03.08A, 03.08AZ, and 03.08CV 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.

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.

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.

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.

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

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.

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.

When a patient is in hospital under a specialist's care, and the family physician or pediatrician is not actively managing the case, the family physician or pediatrician may claim supportive care benefits (03.05M, 03.05MA). The following criteria apply:

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2. the patient, the patient's family or the most responsible physician specifically requests that the family physician or pediatrician visit for the purposes of liaison or reassurance.

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.

If the care of a patient is transferred, each physician may claim for services provided on the day of transfer.

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.

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.

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.

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.

A physician may submit claims for group psychotherapy, psychiatric management and/or indirect services for the same patient on the same day.

Psychotherapy or psychiatric management claims for time units may be submitted for separate encounters for the same patient on the same day.

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The benefit for care of a healthy newborn in hospital does not apply when the infant is ill. In these circumstances, the daily hospital visit HSCs apply.

If newborn and premature care is provided by a pediatrician,

1. HSC 03.05G may be claimed for care of a healthy newborn infant referred by anyone practicing obstetrics and in this instance no consultation benefit may be claimed;
2. if an infant appears initially well but becomes ill after a number of days and consultation is required as well as continuing daily care, benefits may be claimed for consultation under HSC 03.08A or 03.08AZ and the appropriate number of hospital days involved;
3. if consultation is requested during the newborn period and continuing care is not required, a consultation benefit may be claimed, but not HSC 03.05G and
4. subject to GR 4.12.1 routine care of a premature infant may be claimed as HSC 03.07A or 03.07AZ for the initial visit and continuing daily care benefits may be claimed as HSC 03.03D.

Routine care is considered to include minor conditions.

Routine follow-up visits provided for a premature infant after 90 days and 180 days of age may each be claimed under HSC 03.03A or 03.03AZ.

The benefit for care of a healthy newborn in hospital does not apply when the infant is ill. In these circumstances, the daily hospital visit HSCs apply.

If a physician performs the delivery and resuscitates the infant, HSC 13.99F may be claimed in addition to a delivery benefit.

The benefit for care of a healthy newborn in hospital may be claimed by the same physician who claimed the benefit for the delivery.

If newborn and premature care is provided by a physician other than a pediatrician,

1. the benefit for care of a healthy newborn may be claimed under HSC 03.05G whether or not the case is received as a referral;
2. if a consultation is required, a claim under HSC 03.05G may be claimed by the attending physician and a consultation benefit by the consultant;
3. if a newborn requires transfer to a consultant, a benefit to the attending physician may be claimed on a fee for service basis, and
4. subject to GR 4.13.5 routine care of a healthy premature newborn may be claimed as applicable visit HSCs.

Routine care is considered to include minor conditions.

Routine follow-up visits provided for a premature infant after 90 days and 180 days of age may each be claimed under HSC 03.03A, 03.03AZ or its equivalent.

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 (HSC 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.

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.