Fee Navigator

    Governing Rule: 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.

    • AMA billing tips:

      • Consultations may only be claimed when ALL of the following criteria have been met:

        • Patient is examined by referring provider (full list G.R. 4.4.1)
        • Referring provider specifically requests (verbal or written)opinion and or advice of consultant
        • Consultant performs:
        1. full history and
        2. full physical (relative to their specialty)
        3. may order lab or diagnostics.
        4. discusses treatment and advice with the patient and in some cases the referring provider
        5. provides referring provider with written report about recommendations, treatment, opinion.

        Consultations may NOT be claimed for transfer of care or pre operative assessments.

        Consultations are billable up to and including the day of surgery.

    • 4.4.2

      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.
    • AMA billing tips:

      • Consultations may only be claimed when ALL of the following criteria have been met:

        • Patient is examined by referring provider (full list G.R. 4.4.1)
        • Referring provider specifically requests (verbal or written)opinion and or advice of consultant
        • Consultant performs:
        1. full history and
        2. full physical (relative to their specialty)
        3. may order lab or diagnostics.
        4. discusses treatment and advice with the patient and in some cases the referring provider
        5. provides referring provider with written report about recommendations, treatment, opinion.

        Consultations may NOT be claimed for transfer of care or pre operative assessments.

        Consultations are billable up to and including the day of surgery.

    • 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:

      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.

    • AMA billing tips:

      • Consultations may only be claimed when ALL of the following criteria have been met:

        • Patient is examined by referring provider (full list G.R. 4.4.1)
        • Referring provider specifically requests (verbal or written)opinion and or advice of consultant
        • Consultant performs:
        1. full history and
        2. full physical (relative to their specialty)
        3. may order lab or diagnostics.
        4. discusses treatment and advice with the patient and in some cases the referring provider
        5. provides referring provider with written report about recommendations, treatment, opinion.

        Consultations may NOT be claimed for transfer of care or pre operative assessments.

        Consultations are billable up to and including the day of surgery.

    • 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.

    • AMA billing tips:

      • Consultations may only be claimed when ALL of the following criteria have been met:

        • Patient is examined by referring provider (full list G.R. 4.4.1)
        • Referring provider specifically requests (verbal or written)opinion and or advice of consultant
        • Consultant performs:
        1. full history and
        2. full physical (relative to their specialty)
        3. may order lab or diagnostics.
        4. discusses treatment and advice with the patient and in some cases the referring provider
        5. provides referring provider with written report about recommendations, treatment, opinion.

        Consultations may NOT be claimed for transfer of care or pre operative assessments.

        Consultations are billable 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.

    • AMA billing tips:

      • Consultations may only be claimed when ALL of the following criteria have been met:

        • Patient is examined by referring provider (full list G.R. 4.4.1)
        • Referring provider specifically requests (verbal or written)opinion and or advice of consultant
        • Consultant performs:
        1. full history and
        2. full physical (relative to their specialty)
        3. may order lab or diagnostics.
        4. discusses treatment and advice with the patient and in some cases the referring provider
        5. provides referring provider with written report about recommendations, treatment, opinion.

        Consultations may NOT be claimed for transfer of care or pre operative assessments.

        Consultations are billable up to and including the day of surgery.

    • 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.

    • AMA billing tips:

      • Consultations may only be claimed when ALL of the following criteria have been met:

        • Patient is examined by referring provider (full list G.R. 4.4.1)
        • Referring provider specifically requests (verbal or written)opinion and or advice of consultant
        • Consultant performs:
        1. full history and
        2. full physical (relative to their specialty)
        3. may order lab or diagnostics.
        4. discusses treatment and advice with the patient and in some cases the referring provider
        5. provides referring provider with written report about recommendations, treatment, opinion.

        Consultations may NOT be claimed for transfer of care or pre operative assessments.

        Consultations are billable up to and including the day of surgery.

    • 4.4.7

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

    • AMA billing tips:

      • Consultations may only be claimed when ALL of the following criteria have been met:

        • Patient is examined by referring provider (full list G.R. 4.4.1)
        • Referring provider specifically requests (verbal or written)opinion and or advice of consultant
        • Consultant performs:
        1. full history and
        2. full physical (relative to their specialty)
        3. may order lab or diagnostics.
        4. discusses treatment and advice with the patient and in some cases the referring provider
        5. provides referring provider with written report about recommendations, treatment, opinion.

        Consultations may NOT be claimed for transfer of care or pre operative assessments.

        Consultations are billable up to and including the day of surgery.

    • 4.4.8 CLAIMS REQUIRING REFERRING PRACTITIONER NUMBER

      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.

      01.01A01.01B01.0301.04A01.05A01.09
      01.12A01.12B01.1401.16A01.16B01.16C
      01.2201.22A01.22B01.22C01.24A01.24B
      01.24BA01.24BB01.3201.3402.82A02.84A
      02.84B     
      03.01O*03.01LJ* 03.01LK* 03.01LL* 03.03D*03.03F*   
      03.03FA*03.04Q*03.05B*03.07A*03.07B*03.07C*
      03.08A*03.08B*03.08C*03.08F*03.08H*03.08K*
      03.08L*03.08M*    
      03.09A*03.09B*03.12A03.16A03.16B03.16C
      03.16D03.19C03.19D03.21A03.22A03.22B
      03.22C03.2603.29A03.37A03.37B03.38A
      03.38B03.38C03.38D03.38E03.38F03.38G
      03.38H03.38K03.38M03.38N03.38P03.38R
      03.38S03.38T03.38X03.41A03.41B03.41C
      03.41D03.44A03.45A03.45B03.52A03.52B
      03.52C03.52D03.55A03.55B03.56A03.56B
      07.09A07.09B08.19A*08.19B*08.19C*08.19AA*
      08.19BB*08.19CC*09.01A09.01B09.01C09.01E
      09.02B09.02E09.05A09.05B09.06A09.07C
      09.11A09.11B09.11C09.12A09.12B09.13C
      09.13D09.13E09.13F09.13G09.13H09.23A
      09.23B09.24B09.26A09.26D09.41A09.41B
      09.43A09.43B09.43C09.43D09.43E09.46A
      09.49A     
      10.0410.08A10.33B13.99CC 13.99GA*14.49A 
      14.8214.85B14.88A14.88B15.94A16.83A
      16.83B16.83C16.89A16.92B17.81B19.81
      22.8124.89A24.89B28.8 A28.81A29.0 A
      30.81A33.22B37.8137.82A37.82B38.89A
      38.89B39.21A39.62A39.83A  
      40.92A41.29A41.29B42.09B43.8143.82
      44.3 B45.81A45.8345.84B45.86A46.5 A
      46.81A46.8246.84A46.88A48.92A48.98A
      48.98B49.93A49.95A49.96A49.96B49.98B
      49.98C49.98D    
      50.81A50.81B50.81C50.81D50.81E50.82A
      50.82B50.83A50.84A50.84B50.84C50.87A
      50.87B50.87C50.88A50.89A50.89B50.89C
      50.89D50.89E50.91B50.95A50.95B50.98A
      52.1 A52.11A52.1252.1352.85A53.81A
      53.81B53.83A54.89A54.89B54.89D54.89E
      54.89F57.92A    
      60.82C60.89A62.12A62.12B62.81A63.86A
      63.96B64.95A64.97A66.19A66.3 C66.83
      66.89A66.89B66.89C67.8167.8667.87A
      67.89A68.9569.83A69.83B72.9172.92A
      74.82A75.83A76.89A78.7 A79.29E 
      80.8180.83B80.85A80.85B82.12A82.81A
      82.91A83.7 A87.53A87.53B87.54A87.55A
      89.59A89.59B89.59G89.98A92.7092.71
      92.7292.7492.7592.7692.78A92.78B
      92.78C92.8 A92.8 B95.81A97.11A97.11B
      97.8197.82A97.83A97.89A97.89B98.12A
      98.12B98.8 A98.81A98.81B98.89A98.89B
      98.89C98.89D98.89E98.89F98.89G98.89H
      F7
    • AMA billing tips:

      • Consultations may only be claimed when ALL of the following criteria have been met:

        • Patient is examined by referring provider (full list G.R. 4.4.1)
        • Referring provider specifically requests (verbal or written)opinion and or advice of consultant
        • Consultant performs:
        1. full history and
        2. full physical (relative to their specialty)
        3. may order lab or diagnostics.
        4. discusses treatment and advice with the patient and in some cases the referring provider
        5. provides referring provider with written report about recommendations, treatment, opinion.

        Consultations may NOT be claimed for transfer of care or pre operative assessments.

        Consultations are billable up to and including the day of surgery.