Fee Navigator

    Health Service Code 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

    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.
    Common terms:
    • removal of sutures
    Category:V Visit
    Base rate:$25.09

    Fee modifiers:

    TypeCode# of callsExplicitActionAmount
    SKLLANESReplace Base$25.63
    SKLLANPAReplace Base$40.84
    SKLLCARDReplace Base$54.13
    SKLLCLIMReplace Base$55.64
    SKLLCMSPReplace Base$55.64
    SKLLCRSGReplace Base$27.18
    SKLLCTSGReplace Base$27.18
    SKLLDERMReplace Base$37.65
    SKLLDIRDReplace Base$37.00
    SKLLE/MReplace Base$46.83
    SKLLEMSPReplace Base$30.63
    SKLLFTERReplace Base$30.63
    SKLLGASTReplace Base$65.95
    SKLLGNSGReplace Base$31.69
    SKLLGPReplace Base$38.03
    SKLLHEMReplace Base$55.64
    SKLLHEPAReplace Base$40.84
    SKLLIDISReplace Base$49.99
    SKLLINMDReplace Base$55.64
    SKLLMDBIReplace Base$40.84
    SKLLMDGNReplace Base$60.12
    SKLLMDMIReplace Base$40.84
    SKLLMDONReplace Base$55.64
    SKLLNCMDReplace Base$37.00
    SKLLNEPHReplace Base$78.90
    SKLLNEURReplace Base$45.51
    SKLLNPMReplace Base$60.12
    SKLLNUPAReplace Base$40.84
    SKLLNUSGReplace Base$34.80
    SKLLOBGYReplace Base$37.02
    SKLLOCMDReplace Base$55.64
    SKLLOPHTReplace Base$45.89
    SKLLORTHReplace Base$31.95
    SKLLOTOLReplace Base$34.70
    SKLLOVACReplace Base$45.89
    SKLLPATHReplace Base$40.84
    SKLLPDGEReplace Base$65.95
    SKLLPDNRReplace Base$60.12
    SKLLPDSGReplace Base$60.12
    SKLLPEDReplace Base$60.12
    SKLLPEDCReplace Base$60.12
    SKLLPEDNReplace Base$78.90
    SKLLPHMDReplace Base$60.14
    SKLLPLASReplace Base$62.19
    SKLLPSYCReplace Base$39.71
    SKLLRHEUReplace Base$47.26
    SKLLROSPReplace Base$38.03
    SKLLRSMDReplace Base$56.44
    SKLLTHORReplace Base$41.38
    SKLLUROLReplace Base$51.34
    SKLLVSSGReplace Base$25.09
    AGEG75GPIncrease Base To120%
    CARECMXV15YesIncrease Base By$15.70
    CARECMXV20YesIncrease Base By$15.70
    CARECMXV30YesIncrease Base By$31.43
    CARECMXV35YesIncrease Base By$31.43
    CMPXCMGP1 - 10YesFor Each Call Increase By$18.48
    TELETELESYesIncrease Base To120%

    Governing Rules:

    • 1.31

      "Active Practice" is defined as a physician that has fulfilled both of the following criteria in the previous 12 months:

      1. 5 or more procedures where the physician is acting as the primary surgeon AND
      2. the physician has submitted claims and provided at least 10 or more of either or any combination of the following HSCs: 03.03A, 03.07A, 03.07B or 03.08A.
    • 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.

    • 4.7 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.

    • 4.12.4

      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.

    • 4.13.6

      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 its equivalent.

    • 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 (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.

    • 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:

      1. Deleted
      2. HSC 03.02A, 03.03A, 03.03B, 03.04A as appropriate, or
      3. the applicable procedure.
    • 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.

    • 9.1.3

      Three technical services and three interpretive services from the following examinations may be claimed in addition to HSCs 03.02A, 03.03A, 03.07A and 03.07B:

      • 03.12A Intraocular pressure measurement
      • 09.01A Biomicroscopy (slit lamp examination)
      • 09.01B Gonioscopy
      • 09.01C Orthoptic analysis, interpretation
      • 09.01E Orthoptic analysis, technical (may include Hess screen)
      • 09.02B Anterior chamber depth measurement
      • 09.02E Amblyopia evaluation for patients nine years of age or younger
      • 09.05A Full threshold perimetric examination, technical
      • 09.05B Full threshold perimetric examination, interpretation
      • 09.06A Color vision test, interpretation and technical
      • 09.11A Bilateral specular microscopy for corneal graft patients only - technical
      • 09.11B Bilateral specular microscopy for corneal graft patients only - interpretation
      • 09.11C Potential acuity measurement (PAM)
      • 09.12A Intravenous fluorescein angiography (IVFA), interpretation
      • 09.12B Intravenous fluorescein angiography (IVFA), technical
      • 09.13E Optical coherence tomography (OCT), interpretation
      • 09.13F Optical coherence tomography (OCT), technical
      • 09.26A Diurnal tension curve
      • 09.26D Bilateral corneal pachymetry
      • 21.31A Diagnostic irrigation of nasolacrimal duct, office procedure, per eye
      • 24.89B Diagnostic conjunctival scraping
      • 25.81A Diagnostic corneal scraping
    • 9.1.4

      When done independently on a separate day or as a repeat, not more than three interpretations and three technical services from the list in GR 9.1.3 may be claimed.