| Category: | V Visit |
|---|---|
| Base rate: | $80.00 |
Consultations may only be claimed when ALL of the following criteria have been met:
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.
| Type | Code | # of calls | Explicit | Action | Amount |
|---|---|---|---|---|---|
| SKLL | ANES | Replace Base | $121.39 | ||
| SKLL | ANPA | Replace Base | $175.59 | ||
| SKLL | CARD | Replace Base | $175.00 | ||
| SKLL | CLIM | Replace Base | $202.94 | ||
| SKLL | CMSP | Replace Base | $202.94 | ||
| SKLL | CRCM | Replace Base | $165.67 | ||
| SKLL | CRSG | Replace Base | $161.95 | ||
| SKLL | CTSG | Replace Base | $161.95 | ||
| SKLL | DERM | Replace Base | $80.00 | ||
| SKLL | E/M | Replace Base | $195.12 | ||
| SKLL | EMSP | Replace Base | $122.55 | ||
| SKLL | FTER | Replace Base | $122.55 | ||
| SKLL | GAST | Replace Base | $186.95 | ||
| SKLL | GNSG | Replace Base | $154.07 | ||
| SKLL | GP | Replace Base | $129.01 | ||
| SKLL | HEM | Replace Base | $202.94 | ||
| SKLL | HEPA | Replace Base | $175.59 | ||
| SKLL | IDIS | Replace Base | $201.13 | ||
| SKLL | INMD | Replace Base | $202.94 | ||
| SKLL | MDBI | Replace Base | $175.59 | ||
| SKLL | MDGN | Replace Base | $204.52 | ||
| SKLL | MDMI | Replace Base | $175.59 | ||
| SKLL | MDON | Replace Base | $202.94 | ||
| SKLL | NEPH | Replace Base | $210.92 | ||
| SKLL | NEUR | Replace Base | $197.86 | ||
| SKLL | NPM | Replace Base | $204.52 | ||
| SKLL | NUPA | Replace Base | $175.59 | ||
| SKLL | NUSG | Replace Base | $131.52 | ||
| SKLL | OBGY | Replace Base | $115.01 | ||
| SKLL | OCMD | Replace Base | $202.94 | ||
| SKLL | OPHT | Replace Base | $121.58 | ||
| SKLL | ORTH | Replace Base | $109.88 | ||
| SKLL | OTOL | Replace Base | $102.89 | ||
| SKLL | PATH | Replace Base | $175.59 | ||
| SKLL | PDGE | Replace Base | $204.52 | ||
| SKLL | PDNR | Replace Base | $204.52 | ||
| SKLL | PDSG | Replace Base | $204.52 | ||
| SKLL | PED | Replace Base | $204.52 | ||
| SKLL | PEDC | Replace Base | $204.52 | ||
| SKLL | PEDN | Replace Base | $210.92 | ||
| SKLL | PHMD | Replace Base | $204.69 | ||
| SKLL | PLAS | Replace Base | $103.80 | ||
| SKLL | RHEU | Replace Base | $198.38 | ||
| SKLL | ROSP | Replace Base | $129.01 | ||
| SKLL | RSMD | Replace Base | $207.31 | ||
| SKLL | THOR | Replace Base | $193.46 | ||
| SKLL | UROL | Replace Base | $95.33 | ||
| SKLL | VSSG | Replace Base | $160.56 | ||
| CARE | CMXC30 | Yes | Increase Base By | $31.51 | |
| SURC | EV | Yes | Increase By | $48.82 | |
| SURC | NTAM | Yes | Increase By | $117.12 | |
| SURC | NTPM | Yes | Increase By | $117.12 | |
| SURC | WK | Yes | Increase By | $48.82 | |
| TELE | TELES | Yes | Increase Base To | 120% |
"Active Practice" is defined as a physician that has fulfilled both of the following criteria in the previous 12 months:
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 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.
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.
The need for a consultation can arise as a result of the following:
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:
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:
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.
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.
When a physician sends a member of his family to another physician, a consultation benefit may not be claimed.
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.
| 01.01A | 01.01B | 01.03 | 01.04A | 01.05A | 01.09 |
| 01.12A | 01.12B | 01.14 | 01.16A | 01.16B | 01.16C |
| 01.22 | 01.22A | 01.22B | 01.22C | 01.24A | 01.24B |
| 01.24BA | 01.24BB | 01.32 | 01.34 | 02.82A | 02.84A |
| 02.84B |
| 03.01O* | 03.01LJ* 03.01LK* 03.01LL* 03.03D* | 03.03F* | ||
| 03.03FA* | 03.03FT* 03.03FV* 03.03FZ* 03.04Q* | 03.05B* | ||
| 03.07A* | 03.07AZ* 03.07B* | 03.07C* | *03.08A | 03.08AZ* |
| 03.08B* | 03.08BZ* 03.08C* | 03.08CV* 03.08F* | 03.08H* | |
| 03.08K* | 03.08L* | 03.08M* |
| 10.04 | 10.08A | 10.33B | 13.99CC 13.99GA* | 14.49A | |
| 14.82 | 14.85B | 14.88A | 14.88B | 15.94A | 16.83A |
| 16.83B | 16.83C | 16.89A | 16.92B | 17.81B | 19.81 |
| 22.81 | 24.89A | 24.89B | 28.8 A | 28.81A | 29.0 A |
| 30.81A | 33.22B | 37.81 | 37.82A | 37.82B | 38.89A |
| 38.89B | 39.21A | 39.62A | 39.83A |
| 40.92A | 41.29A | 41.29B | 42.09B | 43.81 | 43.82 |
| 44.3 B | 45.81A | 45.83 | 45.84B | 45.86A | 46.5 A |
| 46.81A | 46.82 | 46.84A | 46.88A | 48.92A | 48.98A |
| 48.98B | 49.93A | 49.95A | 49.96A | 49.96B | 49.98B |
| 49.98C | 49.98D |
| 60.82C | 60.89A | 62.12A | 62.12B | 62.81A | 63.86A |
| 63.96B | 64.95A | 64.97A | 66.19A | 66.3 C | 66.83 |
| 66.89A | 66.89B | 66.89C | 67.81 | 67.86 | 67.87A |
| 67.89A | 68.95 | 69.83A | 69.83B | 72.91 | 72.92A |
| 74.82A | 75.83A | 76.89A | 78.7 A | 79.29E |
| F7 |
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.
If newborn and premature care is provided by a pediatrician,
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:
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:
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.
The unscheduled service benefit (modifier SURC) may be claimed for the services outlined in GRs 15.9.1 through 15.9.3.
selected "V" category code services:
