Billing Matters: March 20, 2018, Issue 002

March 20, 2018

In this issue:

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How many hours are there in a day?

It seems like a silly question but you’d be surprised at how many days physicians claim for more than 24 hours (or 25 hours on the day we switch from daylight savings time).

How did we get that answer? The PRC reviewed data for time-based services and the data included time-based codes and complex modifiers. In the review, the minimum amount of time is calculated to determine the total time spent. For example, if the code is described as per 15 minutes or major portion thereof, only eight minutes was used for the calculation. If two calls of the same time-based service were claimed, only 23 minutes were used. The time assigned to non time-based services was one minute.

Case study

In this case study of a particular physician, the PRC noted the following billing practices:

  • 267 days of billing activity in a year
  • 75 days had more than 24 hours in a single day billed
  • 46 hours in a single day was the highest number of hours.
    • The day prior to this day had a minimum of 30 hours of time.
    • The day following this had a minimum of 8 hours of time.
  • 21 hours of time based services claimed on the median day.

The time calculations for this case study used the minimum amount of time to determine the hours per day and the calculations do not include other non-time-based services that were provided on the same day.

Focus on Education

There are a couple of things you need to know about billing for time based services:

1. Know the rules for time based codes

2. Record your time

  • GR 2.3.6 says that you have to record your start time and end time for the day. That doesn’t mean start and end time for each patient; rather it’s the time period from when you enter to when you leave the hospital or the clinic for the day. Some physicians review or complete charts from home prior to the start of their day or complete charting, etc., at the end of the day. This physician time can be included in the calculation of time spent using complex modifiers. You need to record the time you started the day and when you call it quits for the day. It is a record you keep for yourself and you must be able to be produce it on demand should it be requested. There are a number of apps that will do this for you if you choose or a notepad that is kept in chronological order can also be used. Basically any type of recording that date stamps your recording will suffice.

3. Calculate billable time

  • Once you know how many hours you worked each day (minus meal break if applicable, and any other standby time) you know about how much time for which you can bill. For example, you have 10 hours start and end time, you took 30 minutes for meal break, therefore you have 9.5 hours of “billable” time. If you claim for time-based services you cannot exceed 9.5 hours. This will help you calculate the maximum amount of time for complex modifiers, time-based codes and modifiers and even after hours time premium (03.01AA), if applicable.
  • When claiming time-based modifiers such as CMGP, CMXV, COINPT and CMXC, the time incudes all the physician time spent on patient management activities (charting, reviewing lab or diagnostics, checking information on NetCare) on the same date of service that the patient was seen. Remember to include modifier time in your calculation of time.

4. Double check

  • Once you have your claims figured out, recount your time-based claims and modifiers to be sure that they add up to approximately the amount of time that you figured out in point 2. It is possible, and within the rules, for cumulative and major portion thereof claims that you would be one or two units over your total calculated billable time.

Comprehensive Assessment 03.04A – what is included?

Every specialty is different and requires a different examination in order for it to be considered a comprehensive. Comprehensive examinations are just that, comprehensive. Comprehensive Assessment includes:

  • Full history
  • Full physical
    • GP’s must examine all organ systems (GR 4.1). It is not satisfactory to examine 3 systems and bill 03.04A.
    • In the context of GR 4.1, Psychiatry, dermatology and the surgical specialties are required to complete an examination of the relevant customary systems. What is considered customary may be judged by peer review 

The idea of virtual care is becoming popular and there are a few codes in the SOMB that can be claimed for electronic messaging and videoconferencing with patients. These services are not billable as comprehensive visits or any other kind of visit services regardless of how long they take. These are examples of a videoconference service and may be claimed using HSC 03.01T if the criteria are met.

Let's review

Billing Matters: December 15, 2017, Issue 001 focused on encounter numbers and surcharges. Test your understanding:


A specialist is called from home to the emergency department at 2 p.m. on a Saturday to assess a new patient. They attend the patient at 2:25 p.m., and once a complete assessment is provided (total 25 minutes on exam and patient care) they determine that the patient requires surgery. The surgeon will be notified when the next available OR time is later that same day. The surgeon is called and told the OR is available at 8 p.m..


1. What would you bill for the emergency encounter?

a. If the call to attend the patient was requested after the emergency physician had examined the patient and determined that skills of a specialist were required, a consult by the specialist may be claimed (03.08A) with a WK surcharge (WEEKEND AND STATUTORY HOLIDAY - Between 0700 and 2200 hours).

2. Is this the same encounter or two separate encounters?

a. The consult would be considered encounter one and the surgery would be considered encounter two. The reason being that there is a long lag between the consult and the surgery, the availability of the OR is not in the control of the surgeon and he/she returns on a priority basis when notified of the OR time.

3. Is a surcharge billable on either of these encounters?

a. A surcharge may be claimed on both encounters as the surgeon met the criteria for both encounters: called specifically to attend; attended on an urgent priority basis; responds on an unscheduled basis from outside the facility; and direct attendance by the surgeon.

Questions? Comments? Please direct any inquiries to our new Peer Review Committee email address:

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