ICU and CCU Care

These fees apply to the services of being in constant or periodic attendance during a one day period, to provide all aspects of care to patients in Intensive or Coronary Care Units designated by the DHCS. There are four levels of care depending upon the procedures performed: 

(a) Comprehensive Care - This is the service rendered by a physician who provides complete care (both Critical Care and Ventilatory Support) to Critical Care Area patients. Comprehensive Care fees are not payable for services rendered to stabilized patients in ICUs or patients admitted for ECG monitoring or observation alone. 

(b) Critical Care - This is the service rendered by a physician who provides all aspects of care to a Critical Care Area patient except Ventilatory Support. Critical Care fees are not payable for services rendered to stabilized patients in ICUs or patients admitted for ECG monitoring or observation alone. 

(c) Observatory Care - This is the service rendered to stable ICU or CCU patients without invasive monitoring and without assisted ventilation. 

(d) Ventilatory Support - This is the service provided by a physician other than the one claiming Critical Care. It includes management of the intubated airway, tracheal toilet by suction catheter with or without instillation, and supervision of mechanical ventilation of the critically ill patient. 

These are team fees which apply to physicians providing complete daily care and should be claimed by the physician in charge of the patient. The daily fee includes payment for the initial consultation, subsequent assessments, and the ongoing monitoring of the patient’s condition, including the following procedures as required:

(a) insertion of IVs, intraosseous, arterial and CVP lines,

(b) use of pressure infusion sets, 

(c) endotracheal intubation and tracheobronchial toilet, 

(d) insertion and maintenance of urinary catheters and nasogastric tubes, 

High Risk Prenatal Assessment

A high risk prenatal assessment is an assessment by a maternal-fetal medicine specialist requiring a minimum of 20 minutes in direct contact with the patient for the management of a documented significant maternal and/or fetal risk factor(s) where the mother and/or fetus are at significant risk for serious complications during the pregnancy. The service is eligible for payment only if start and stop times of the service are recorded in the patient’s permanent medical record.

Home Visits by General Practitioners 

An Elective Home Visit rendered by a General Practitioner is a visit to a patient’s home or normal place of residence which is initiated by the physician in the management of known illness. The fee for elective home visits is the same regardless of the time that the service is rendered, or the type of service provided.

A Non-Elective Home Visit rendered by a General Practitioner is a visit that is requested by the patient or by the patient’s attendant and which is made by the physician on the same day. The fee payable for a non-elective home visit is determined by the time or day that the service is rendered. The time of service must be documented on the record for the visit.

For Extra Patient(s) Seen, only fee code 252 or 292 as applicable may be claimed. 

In-Patient Surcharges 

Fee code 355 may be claimed by General Practitioners providing continuing care of hospital in-patients. It is payable during the first seven days of an admission on a per diem basis. It can be billed in addition to the applicable admission assessment code, or SHV code, and code 359.

Fee code 359 may be claimed by General Practitioners providing continuing care of hospital in-patients. It is payable once during a period of admission on the day the patient is discharged from hospital. It can be billed in addition to the applicable SHV code and code 355. The billing physician is responsible for preparing the discharge summary, the discharge prescriptions and follow up care as necessary.

Referral and Transferral

A referral takes place when one physician requests for their patient the services of another physician. The services of the latter may consist of:

(a) an opinion (i.e. a consultation), 

(b) diagnostic tests or procedures (e.g. skin test, biopsy, etc.), and 

(c) treatment (surgical or medical) 

A referral also takes place when a primary care physician is not available and a Nurse Practitioner requests for his or her patient the services of a specialist physician and it is appropriate to the patient needs and practice setting to do so as described in the Nurse Practitioner Primary Health Care Regulations. 

A transferral, as distinguished from a referral, takes place where the responsibility for the care of the patient is completely transferred permanently or temporarily, from one physician to another (e.g. where the first physician is leaving temporarily on holidays and is unable to continue to care for the patient). Transferral to a physician in the same specialty or discipline should be considered as continuing care and the physician to whom the patient is transferred is not entitled to claim for a consultation.

 For hospital in-patients, transferral to a physician in the same specialty or discipline should be considered as continuing care and SHV rates are payable as for one period of hospitalization. The visit fee on the date of transfer is payable only to the second physician. In such cases, the physician to whom the patient is transferred is not entitled to claim for a major exam. When a patient is transferred to a physician in another specialty, the patient is deemed to have been referred and the rates payable are as for a new admission. Where the family physician transfers the day-to-day responsibility for the care of the patient to the consultant for a period of time, the consultant should claim on a per diem basis and the family physician should not claim for that period.