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    Health Service Code 03.04M

    Pre-operative history and physical examination in relation to an insured service

    NOTE:
    1. May only be claimed when an examination and a standard form for pre-operative assessment have been completed.
    2. A copy of the form must be retained in the patient's chart.
    3. May not be claimed in addition to a surgical assist (SA, SAQS, SSOS) for the same patient by the same physician.
    4. HSC 03.04M may not be claimed for a pre operative physical examination when the request is for a cataract procedure (HSC 27.72A) that will not require the use of a general anesthetic.
    Category:V Visit
    Base rate:$104.60

    AMA billing tips:

    • The 03.04M is intended to be billed when a patient is required to have a pre-operative examination and history before receiving treatment for an insured service. AND The physician performing the pre-operative examination is NOT the physician performing the procedure within the inclusive care period.

      03.04M may NOT be claimed by the anesthetist performing the anesthetic for the procedure (this is considered to be part of the pre-anesthetic evaluation) (GR 12.2).

      Pre op medicals may not be claimed as consultations (03.08A)

      Pre op medicals may not be claimed in lieu of a consultation as the 03.04M is a visit and will be rejected if it is billed within the pre op inclusive care period.

    • The pre op for cataract procedures performed under local and or topical anesthetic is still required but will have to be completed by the operating surgeon. The only time the pre op medical (03.04M) will be paid in relation to cataract procedures, is if the patient is having their cataract performed under a general anesthetic. In those rare cases that require a general anesthetic, the operating surgeon will have to communicate the unique situation to the physician completing the pre op medical so that the information can be included in the text on the claim for the 03.04M pre op medical. If text is not submitted on the 03.04M for cataracts requiring a general anesthetic, the 03.04M will not be paid.

    Fee modifiers:

    TypeCode# of callsExplicitActionAmount
    CARECMXC30YesIncrease Base By$31.43

    Governing Rules:

    • 12 ANESTHESIA
    • 12.2

      The anesthetic benefit listed is for professional services, including pre- evaluation and post-anesthetic follow-up and all immediate supportive measures. The following are exceptions:

    • 12.2.1

      Consultations may be claimed up to but not including the date of surgery by the anesthesiologist administering the anesthetic, providing the provisions outlined in GR 4.3 are met. They may also be claimed on the day of surgery for urgent and emergent cases/circumstances only, by the anesthesiologist administering the anesthetic, where the provisions of GR 4.3 are met and where another physician or dentist who provides oral and maxillofacial surgery services (or their agent) specifically requests the anesthesiologist's evaluation, consultation or opinion prior to the surgery proceeding. Consultations may not be claimed for routine pre-operative evaluations.

    • 13.5

      Consultation benefits (HSCs 03.08A or 03.07A) or preoperative assessments (HSC 03.04M) may not be claimed in addition to a surgical assist (SA, SAQS, SSOS) for the same patient by the same physician.