Partial Assessment

 This shall consist of the necessary history, an enquiry concerning and the necessary examination of the affected part, region or system. This includes visits for following the progress of treatment and initial visits wherein the patient’s condition does not clinically warrant a General Assessment/Reassessment, or a Specific Assessment/Reassessment. 

 Follow-up visits for monitoring the use of birth control pills qualify as Partial Assessments, with or without fee code 54614, depending on the nature of the examination performed. 

 A visit for a requested Pap Smear and/or breast examination, without other significant medical complaints or illness, qualifies as a Partial Assessment, with or without fee code 54614, depending upon the nature of the examination performed.

Partial Assessment of a Patient who is 65 to 74 Years of Age 

This is a Partial Assessment of a patient who is 65 to 74 years of age. 

 Partial Assessment of a Patient who is 75 Years of Age and Older This is a Partial Assessment of a patient who is 75 years of age and older. 

 Partial Assessment of a Patient Who Received a WHSCC Service during the Same Office Visit 

This applies when a physician performs a Partial Assessment of a patient for an MCP insured problem(s) immediately before or after examination/treatment of a problem covered by the WHSCC during the same office visit. This fee code (126) is only billable for non-WHSCC, MCP insured services and should only be billed to MCP. 

If the service provided is more extensive than a Partial Assessment (e.g. a General Assessment or Reassessment, Psychotherapy), it should be billed IC giving the reason(s) why a more extensive examination was necessary. 

Interviews

Fee code 359 may only be claimed by Psychiatrists providing continuing care of hospital in-patients as the attending physician. 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. It can be billed in addition to fee code 352 or 353 if applicable. The billing physician is responsible for:

 preparing the discharge summary at the time of discharge and forwarding a copy to the patient’s family physician. The discharge summary must include: 

o psychiatric diagnosis;

o medical diagnosis; 

o medication recommendations including: 

- list of medication trials including reasons for discontinuing (i.e. intolerances, allergies, etc);

- current medications including recommendations for dosage adjustment and duration of treatment;

- monitoring that will be required while taking specific medications; and 

- any cautions regarding medications

o relevant risk management recommendations (i.e. suicide, psychosis, driving, urine drug screening, etc); and 

o relevant information from other mental health services to include: - interventions utilized; - ongoing psycho-social needs; and - follow-up required with mental health services.

  providing information and advice to the patient or patient’s representative on matters related to the patient’s diagnosis/care; and 

 arranging follow up care as necessary. 

Interviews

In specific clinical settings, interviews are insured services and may be claimed using the appropriate visit code and the patient’s MCP number. Eligibility of claiming for these services is limited to the following specialties: 

 Developmental Neurology* 

 Paediatrics 

 Developmental Paediatrics* 

 Physiatry* 

 Psychiatry* * 

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.

A General Assessment cannot be claimed

(a) only one is payable per nursing home resident per year, 

(b) no other home visit or premium is payable in addition for the same visit to the same resident, 

(c) where applicable, the first patient seen may be claimed as an elective home visit (visit code 246 or 286), rather than as a General Assessment, and

(d) extra residents seen in addition to the first patient and residents who required admission or annual General Assessments should be claimed using code 252 or code 292.

 A General Assessment cannot be claimed: 

(a) by physicians when they are providing dedicated on-site Emergency Department coverage at designated hospital facilities listed in Appendix A. 

(b) solely because a patient presents for assessment 90 or more days after a general assessment was previously performed. 

(c) for screening of patients with chronic disease(s) who do not have acute signs or symptoms involving all the body systems.

Not more than one major examination (Consultation, General Assessment, or Specific Assessment) per patient per physician may be claimed within a 90-day period regardless of diagnosis and referral source, except in case of true emergency. Such claims must be submitted IC clarifying the nature of the emergency.

Escort of a Critically Ill Patient

Claims for this visit code must reflect the time in actual transit with the patient using the code listed for the service in the “Hospital Out-Patient and Emergency” Section for each specialty. Fee code 482 should be billed regardless of the point of origin or destination of the escort.

All Claims must be submitted IC and should include:

(a) the actual start and finish time for the in-transit period (finish time is defined by the time the patient is transferred to the care of a physician willing to accept responsibility of the patient), and 

(b) the critical nature of the illness requiring physician presence. 

A minimum of one unit should be claimed for any escort. Additional units may be claimed for each completed 15-minute period after the first 15 minutes.

General Assessments 

A General Assessment shall consist of a full history, an enquiry into, and an examination of all systems.

Note: 

The “clinical need” for a General Assessment rather than a Partial Assessment is also reviewed by the MCP Consultant’s Committee and such relevant notation should also be included in the patient’s record. 

Concurrent Care

This refers to the clinical situation where care by more than one physician is required for a hospital in-patient. Concurrent Care must be verifiable as having been requested by the attending physician. The documentation requirements for Concurrent Care are the minimum documentation requirements for visits as described in this Preamble.

Concurrent Care of a registered hospital in-patient is an assessment by a consultant following the consultant’s first major assessment. The attending physician continues to be responsible for ongoing care but requests Concurrent Care by the consultant. Concurrent Care in settings other than ICU, NICU or CCU must be billed using fee code 360.

Concurrent Care for a patient in an ICU, NICU or CCU must be billed using fee code 51790. Concurrent Care visits made on multiple days should be billed as multiple units of fee code 51790. The date the final visit was made should be used as the date of service for claiming purposes.

When a non-IOP surgical procedure is performed on an in-patient by a physician other than the attending physician, the fee payable includes post-operative care for 14 days in hospital. In this case, the patient is considered to have been transferred to the care of the operating physician and the attending physician may not continue to claim for daily care unless the need for such Concurrent Care can be verified. The claim must be billed as fee code 360

Detention

Detention may be charged in addition to a visit when the physician is required to spend extra time in continuous active bedside treatment of a seriously ill patient to the exclusion of all other work, except as noted below.

Detention is not payable for:

(a) usual preoperative or postoperative care by the operating surgeon, 

(b) the same physician in addition to fees for ICU, CCU and NICU care for the same day unless so specified elsewhere in this Payment Schedule, 

(c) procedural fee codes or in lieu of procedural fees, and 

(d) time spent waiting for x-rays, lab reports, the operating room, patient arrival or for patient transfer to another facility. 

Claims for detention must be billed IC and include information as to the nature of the patient’s condition requiring physician presence, actual time spent in continuous attendance and a brief description of the service(s) rendered.

Chronic and Convalescent Care

The physician shall be remunerated for this care on a per visit basis with a maximum of one visit every five days. If the patient is seen for the first time on admission, a general or specific assessment may apply in addition to the above fees. In acute illnesses requiring special visits, premiums also apply in addition to fees allowable under the above formula.

Complex Assessment

A Complex Assessment is payable to physicians when they are providing dedicated On-Site Emergency Department Coverage at designated hospital facilities . The following services qualify for claiming a Complex Assessment:

 (a) Evaluation of a new or existing medical condition that necessitates a detailed medical history, review of previous medical records and necessary physical examination of three or more organ systems. It may include a review of diagnostic tests and the initiation of appropriate therapy/treatment. For the purposes of claiming this code the organ systems are defined as: cardiovascular, respiratory, digestive, genitourinary, musculoskeletal, hemolymphatic, integumentary, nervous, ears-nose-throat, ophthalmic and mental. 

OR 

(b) Prolonged observation and/or continuous therapy and multiple reassessments (not including discharge assessment) of patients whose illness requires it. Please note that payment for the discharge assessment is included in the complex assessment fee and is not billable in addition. 

OR

 (c) Management of patients presenting with life or limb threatening illness or injury that requires immediate evaluation and/or intervention and/or emergent treatment by the physician.