| Category: | V Visit |
|---|---|
| Base rate: | $40.14 |
The three system theory for 03.04A is NOT accurate. 03.04A is a comprehensive service and all elements of service as described MUST be met in order to submit a claim.
Comprehensive visits include a complete physical examination which includes an examination of each organ system in the body, except in psychiatry, dermatology and the surgical specialities. "Complete physical examinations" 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.
For clarity, if the patient had a comprehensive May 16th, 2018, the next comprehensive by the same physician is not technically eligible until May 16th of 2019.
Alberta Health has relaxed the system rules to 345 days, be advised that this adjustment to the payment processing rules is intended to accommodate a small variance in patient/physician schedules; and not as permission to bill a comprehensive more frequently.
03.04A may not be claimed for registered hospital inpatients.
| Type | Code | # of calls | Explicit | Action | Amount |
|---|---|---|---|---|---|
| SKLL | ANES | Replace Base | $86.40 | ||
| SKLL | ANPA | Replace Base | $87.79 | ||
| SKLL | CARD | Replace Base | $96.82 | ||
| SKLL | CLIM | Replace Base | $178.59 | ||
| SKLL | CMSP | Replace Base | $178.59 | ||
| SKLL | CRSG | Replace Base | $107.21 | ||
| SKLL | CTSG | Replace Base | $107.21 | ||
| SKLL | DERM | Replace Base | $48.20 | ||
| SKLL | DIRD | Replace Base | $66.46 | ||
| SKLL | E/M | Replace Base | $123.24 | ||
| SKLL | EMSP | Replace Base | $53.92 | ||
| SKLL | FTER | Replace Base | $53.92 | ||
| SKLL | GAST | Replace Base | $88.69 | ||
| SKLL | GNSG | Replace Base | $63.76 | ||
| SKLL | GP | Replace Base | $108.61 | ||
| SKLL | HEM | Replace Base | $178.59 | ||
| SKLL | HEPA | Replace Base | $87.79 | ||
| SKLL | IDIS | Replace Base | $132.32 | ||
| SKLL | INMD | Replace Base | $178.59 | ||
| SKLL | MDBI | Replace Base | $87.79 | ||
| SKLL | MDGN | Replace Base | $122.71 | ||
| SKLL | MDMI | Replace Base | $87.79 | ||
| SKLL | MDON | Replace Base | $178.59 | ||
| SKLL | NCMD | Replace Base | $66.46 | ||
| SKLL | NEPH | Replace Base | $158.19 | ||
| SKLL | NEUR | Replace Base | $148.40 | ||
| SKLL | NPM | Replace Base | $122.71 | ||
| SKLL | NUPA | Replace Base | $87.79 | ||
| SKLL | NUSG | Replace Base | $53.54 | ||
| SKLL | OBGY | Replace Base | $63.90 | ||
| SKLL | OCMD | Replace Base | $178.59 | ||
| SKLL | OPHT | Replace Base | $98.16 | ||
| SKLL | ORTH | Replace Base | $61.53 | ||
| SKLL | OTOL | Replace Base | $53.12 | ||
| SKLL | OVAC | Replace Base | $98.16 | ||
| SKLL | PATH | Replace Base | $87.79 | ||
| SKLL | PDGE | Replace Base | $122.71 | ||
| SKLL | PDNR | Replace Base | $148.40 | ||
| SKLL | PDSG | Replace Base | $122.71 | ||
| SKLL | PED | Replace Base | $122.71 | ||
| SKLL | PEDC | Replace Base | $122.71 | ||
| SKLL | PEDN | Replace Base | $158.19 | ||
| SKLL | PHMD | Replace Base | $100.24 | ||
| SKLL | PLAS | Replace Base | $90.83 | ||
| SKLL | RHEU | Replace Base | $104.30 | ||
| SKLL | ROSP | Replace Base | $108.61 | ||
| SKLL | RSMD | Replace Base | $93.12 | ||
| SKLL | THOR | Replace Base | $41.83 | ||
| SKLL | UROL | Replace Base | $69.33 | ||
| SKLL | VSSG | Replace Base | $40.14 | ||
| CARE | CMXC30 | Yes | Increase Base By | $31.51 | |
| TELE | TELES | Yes | Increase Base To | 120% |
An "in office" service is defined as a service that is not provided in the following publically funded facility types: Active Treatment Centre, Ambulatory Care Centre, Auxiliary Hospital, Health Canada Nursing Station, Community Ambulatory Care Centre, Community Mental Health Clinic, Nursing Home, Regional Contracted Practitioner Office and Subacute Auxiliary Hospitals. The following Health Service Codes are designated as "in office": 03.03A, 03.03B, 03.03F, 03.04A, 03.05I, 03.07A, 03.08A, 03.08B, 03.08I, 03.08J, 08.19A, 08.19G, 08.19GA, and 08.45.
An "out of office" service is defined as a service that is provided in the following publically funded facility types: Active Treatment Centre, Ambulatory Care Centre, Auxiliary Hospital, Health Canada Nursing Station, Community Ambulatory Care Centre, Community Mental Health Clinic, Nursing Home, Regional Contracted Practitioner Office and Subacute Auxiliary Hospitals. The following Health Service Codes are designated as "out of office": 03.03AZ, 03.03BZ, 03.03FZ, 03.04AZ 03.05IZ, 03.07AZ, 03.08AZ, 03.08BZ, 03.08IZ, 03.08JZ, 08.19AZ, 08.19GZ, and 08.45Z
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.
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.
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.
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.
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.
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.
Three technical services and three interpretive services from the following examinations may be claimed in addition to HSCs 03.04A, 03.04AZ, 03.08A, 03.08AZ, 03.08H and 09.04:
