Fee Navigator

    Health Service Code 03.08A

    Comprehensive consultation

    NOTE:
    1. May not be claimed in addition to a surgical assist (SA, SAQS, SSOS) for the same patient by the same physician.
    2. A comprehensive consultation may not be claimed for a transfer of care.
    Category:V Visit
    Base rate:$79.23

    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.

    • 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$115.00
    SKLLANPAReplace Base$163.37
    SKLLCARDReplace Base$175.00
    SKLLCLIMReplace Base$198.70
    SKLLCMSPReplace Base$198.70
    SKLLCRCMReplace Base$164.67
    SKLLCRSGReplace Base$160.80
    SKLLCTSGReplace Base$160.80
    SKLLDERMReplace Base$79.23
    SKLLE/MReplace Base$195.12
    SKLLEMSPReplace Base$122.55
    SKLLFTERReplace Base$122.55
    SKLLGASTReplace Base$186.95
    SKLLGNSGReplace Base$153.19
    SKLLGPReplace Base$124.25
    SKLLHEMReplace Base$198.70
    SKLLHEPAReplace Base$163.37
    SKLLIDISReplace Base$199.97
    SKLLINMDReplace Base$198.70
    SKLLMDBIReplace Base$163.37
    SKLLMDGNReplace Base$200.40
    SKLLMDMIReplace Base$163.37
    SKLLMDONReplace Base$198.70
    SKLLNEPHReplace Base$210.41
    SKLLNEURReplace Base$197.86
    SKLLNPMReplace Base$200.40
    SKLLNUPAReplace Base$163.37
    SKLLNUSGReplace Base$133.85
    SKLLOBGYReplace Base$92.55
    SKLLOCMDReplace Base$198.70
    SKLLOPHTReplace Base$120.88
    SKLLORTHReplace Base$109.88
    SKLLOTOLReplace Base$98.16
    SKLLPATHReplace Base$163.37
    SKLLPDGEReplace Base$200.40
    SKLLPDNRReplace Base$200.40
    SKLLPDSGReplace Base$200.40
    SKLLPEDReplace Base$200.40
    SKLLPEDCReplace Base$200.40
    SKLLPEDNReplace Base$210.41
    SKLLPHMDReplace Base$200.48
    SKLLPLASReplace Base$103.65
    SKLLRHEUReplace Base$198.38
    SKLLROSPReplace Base$124.25
    SKLLRSMDReplace Base$207.31
    SKLLTHORReplace Base$191.40
    SKLLUROLReplace Base$94.12
    SKLLVSSGReplace Base$160.56
    CARECMXC30YesIncrease Base By$31.43
    SURCEVYesIncrease By$48.70
    SURCNTAMYesIncrease By$116.83
    SURCNTPMYesIncrease By$116.83
    SURCWKYesIncrease By$48.70
    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.
    • 4.1 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.

    • 4.3.1

      Comprehensive Consultation: An in-depth evaluation of a patient with a written report to the referring physician, audiologist, Alberta registered midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner. This service includes the recording of a complete history, 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 and/or the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner.

    • 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.

    • 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.
    • 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.

    • 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.

    • 4.4.7

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

    • 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.

      01.01A01.0301.04A01.05A01.0901.12A
      01.12B01.1401.16A01.16B01.16C01.22
      01.22A01.22B01.22C01.24A01.24B01.24BA
      01.24BB01.3201.3402.82A02.84A02.84B
      *03.01O*03.01LJ* 03.01LK* 03.01LL* 03.03D*03.03F*   
      *03.03FA*03.04Q*03.05B*03.07A*03.07B*03.07C*
      **03.08A03.08B*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
    • 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.

    • 4.6.2

      Notwithstanding GR 4.6.1, 03.08A may only be claimed for patients under 12 months of age once every 90 days per patient by the same physician. There must be an interval of 90 days between the first and second consultation.

    • 4.12.2

      If newborn and premature care is provided by a pediatrician,

      1. HSC 03.05G may be claimed for care of a healthy newborn infant referred by anyone practising obstetrics and in this instance no consultation benefit may be claimed;
      2. if an infant appears initially well but becomes ill after a number of days and consultation is required as well as continuing daily care, benefits may be claimed for consultation under HSC 03.08A and for the appropriate number of hospital days involved;
      3. if consultation is requested during the newborn period and continuing care is not required, a consultation benefit may be claimed, but not HSC 03.05G and
      4. subject to GR 4.12.1 routine care of a premature infant may be claimed as HSC 03.07A for the initial visit and continuing daily care benefits may be claimed as HSC 03.03D.
    • 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

    • 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.

    • 15.9

      The unscheduled service benefit (modifier SURC) may be claimed for the services outlined in GRs 15.9.1 through 15.9.3.

    • 15.9.1

      selected "V" category code services:

      1. consultations, including telehealth (except those provided using store and forward videotechnology);
      2. intensive care unit visits (HSC 03.05A);
      3. psychiatric mental status determination requiring complete mental health status examination and investigation (HSC 08.11A);
      4. for complex patient, requiring complete mental status examination and investigation (HSC 08.11C);
      5. certification under the Mental Health Act (HSC 08.12A);
      6. trauma assessment, multiple trauma, severely injured patient (HSC 13.99GA);
      7. hyperbaric oxygen therapy detention time (HSC 13.99I);
      8. medical emergency detention (HSC 13.99J);
      9. management of complex labor, per 15 minutes (HSC 13.99JA);
      10. donor maintenance prior to cadaveric harvesting of organs (HSC 13.99L);
      11. examination and crisis counseling for sexual/physical abuse (HSC 13.99V);
      12. attendance at delivery (HSC 87.98E).