Fee Navigator

    Health Service Code 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

    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.
    Category:V Visit
    Base rate:$40.14

    AMA billing tips:

    • 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.

    Fee modifiers:

    TypeCode# of callsExplicitActionAmount
    SKLLANESReplace Base$60.00
    SKLLANPAReplace Base$81.68
    SKLLCARDReplace Base$96.75
    SKLLCLIMReplace Base$174.86
    SKLLCMSPReplace Base$174.86
    SKLLCRSGReplace Base$106.45
    SKLLCTSGReplace Base$106.45
    SKLLDERMReplace Base$46.84
    SKLLDIRDReplace Base$66.28
    SKLLE/MReplace Base$120.19
    SKLLEMSPReplace Base$53.92
    SKLLFTERReplace Base$53.92
    SKLLGASTReplace Base$88.69
    SKLLGNSGReplace Base$63.39
    SKLLGPReplace Base$104.60
    SKLLHEMReplace Base$174.86
    SKLLHEPAReplace Base$81.68
    SKLLIDISReplace Base$129.98
    SKLLINMDReplace Base$174.86
    SKLLMDBIReplace Base$81.68
    SKLLMDGNReplace Base$120.24
    SKLLMDMIReplace Base$81.68
    SKLLMDONReplace Base$174.86
    SKLLNCMDReplace Base$66.28
    SKLLNEPHReplace Base$157.81
    SKLLNEURReplace Base$148.40
    SKLLNPMReplace Base$120.24
    SKLLNUPAReplace Base$81.68
    SKLLNUSGReplace Base$53.54
    SKLLOBGYReplace Base$61.70
    SKLLOCMDReplace Base$174.86
    SKLLOPHTReplace Base$97.59
    SKLLORTHReplace Base$61.53
    SKLLOTOLReplace Base$50.68
    SKLLOVACReplace Base$97.59
    SKLLPATHReplace Base$81.68
    SKLLPDGEReplace Base$120.24
    SKLLPDNRReplace Base$148.40
    SKLLPDSGReplace Base$120.24
    SKLLPEDReplace Base$120.24
    SKLLPEDCReplace Base$120.24
    SKLLPEDNReplace Base$157.81
    SKLLPHMDReplace Base$100.24
    SKLLPLASReplace Base$90.69
    SKLLRHEUReplace Base$99.16
    SKLLROSPReplace Base$104.60
    SKLLRSMDReplace Base$93.12
    SKLLTHORReplace Base$41.38
    SKLLUROLReplace Base$68.45
    SKLLVSSGReplace Base$40.14
    CARECMXC30YesIncrease Base By$31.43
    TELETELESYesIncrease Base To120%

    Governing Rules:

    • 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.

    • 4.2.3

      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.

    • 4.6.1

      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.

    • 4.14 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.

    • 9.1.1

      The following examinations are included in the complete examination (03.04A, 03.08A, 03.08H, 09.04) and may not be claimed in addition:

      • Measurement of vision
      • Refractive error
      • Extra-ocular muscle balance
      • 03.12A Intra-ocular pressure measurement
      • 09.01A Biomicroscopy (slit lamp examination)
      • Retinal examination
    • 9.1.2

      Three technical services and three interpretive services from the following examinations may be claimed in addition to HSCs 03.04A, 03.08A, 03.08H and 09.04:

      • 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