MSI PHYSICIAN'S User Manual

PHYSICIAN'S

MANUAL

2011

TABLE OF CONTENTS

PREAMBLE ............................................................................................................................................. 1

GENERAL CONSI DERATIONS ....................................................................................................... 1

TERMS AND DEFINITIONS ............................................................................................................. 2

SERVICES INSURED BY MSI ......................................................................................................... 6

SERVICES NOT INSURED BY MSI ................................................................................................ 7

PRINCIPLES OF ETHICAL BILLING ............................................................................................... 9

TARIFF ........................................................................................................................................... 10

ASSESSMENT RULES FOR VISITS AND RELATED SERVICES ............................................... 11

ASSESSMENT RULES FOR SPECIALIZED SERVICES ............................................................. 21

ASSESSMENT RULES FOR PROCEDURES ............................................................................... 30

PROCEDURES FOR AMENDMENTS TO THE PREAMBLE AND FEE SCHEDULE .................. 42

EXPLANATORY CODES ........................................................................................................................ 1

MISCELLANEOUS .................................................................................................................................. 1

UNIT VALUES .................................................................................................................................. 1

HEALTH SERVICE CODES ............................................................................................................. 1

Additional Services..................................................................................................................... 1

Community Services .................................................................................................................. 1

Other Dental Operations NEC ................................................................................................... 1

Workers' Compensation Board .................................................................................................. 1

PROLONGED CONSULTATIONS ................................................................................................... 3

MULTIPLES ...................................................................................................................................... 3

DETENTION ..................................................................................................................................... 3

PREMIUM FEES .............................................................................................................................. 3

OUTDATED SERVICE ENCOUNTERS ........................................................................................... 3

OUTDATED RECIPROCAL SERVICE ENCOUNTERS .................................................................. 3

TERMINATION DATE ...................................................................................................................... 3

SPECIALTY ABBREVIATIONS ....................................................................................................... 4

CATEGORY ABBREVIATIONS ....................................................................................................... 4

MODIFIER DESCRIPTIONS ............................................................................................................ 5

PREAUTHORIZATION SERVICE ENCOUNTERS ........................................................................ 12

RADIOLOGY .................................................................................................................................... 1

NON-PATIENT-SPECIFIC BULK BILLING FEES ............................................................................ 1

PATHOLOGY ................................................................................................................................. 19

INTERNAL MEDICINE ................................................................................................................... 23

ANAESTHESIA ................................................................................................................................ 1

DERMATOLOGY ............................................................................................................................ 11

DIAGNOSTIC & THERAPEUTIC ................................................................................................... 19

FAMILY PRACT ICE ....................................................................................................................... 40

INTENSIVE CARE UNIT ................................................................................................................ 54

MEDICINE ...................................................................................................................................... 56

NEUROLOGY ................................................................................................................................. 65

NEUROSURGERY ......................................................................................................................... 74

OBSTETRICS & GYNAECOLOGY ................................................................................................ 90

OPHTHALMOLOGY ..................................................................................................................... 108

ORTHOPAEDICS ......................................................................................................................... 124

OTOLARYNGOLOGY .................................................................................................................. 155

PAEDIATRICS .............................................................................................................................. 169

PATHOLOGY ............................................................................................................................... 179

PHYSICAL MEDICI N E ................................................................................................................. 181

PLASTIC SURGERY .................................................................................................................... 189

PSYCHIATRY ............................................................................................................................... 207

RADIOLOGY ................................................................................................................................ 217

SURGERY .................................................................................................................................... 219

UROLOGY .................................................................................................................................... 259

NUMERIC INDEX ............................................................................................................................. 1

ALPHABETICAL INDEX ................................................................................................................ 30

PREAMBLE

The Preamble is the authority for the proper interpretation of the Fee Schedule. Fees will not be correctly interpreted without reference to the Preamble. This Fee Schedule is maintained through mutual agreement by the Department of Health and Doctors Nova Scotia.

1. GENERAL CONSIDERATIONS

Physicians may be paid by the Nova Scotia Department of Health using various remuneration methods. The MSI Physician’s Manual details Fee-For-Service remuneration. Remuneration methods, other than Fee-For-Service, follow the conditions of the contracts or agreements as agreed to by the physician(s), the Nova Scotia Department of Health and Doctors Nova Scotia with respect to the specific arrangement.

1.1 Each physician who participates in the care of a patient is entitled to fair and appropriate compensation for the services rendered to the patient.

1.2 The Fee Schedule identifies the amounts prescribed as claimable for insured services rendered by physicians. Insured services means all services that are medically necessary and are not specifically excluded by legislation or regulation. The listing of any service or procedure in the Fee Schedule does not ensure payment by Nova Scotia Medical Services Insurance (MSI) if the service is provided when it is not medically necessary.

1.3 Unless otherwise indicated, fees listed are for professional services only.

1.4 Professional services provided to a patient may be claimed by a physician only when he or she renders the visit or procedure or when he or she supervises the procedure.

1.4.1 All insured services include, where appropriate, any necessary discussion or advice to the patient or

their agent, completion of a medical record, prescribing of medication or therapy, requisitioning of diagnostic services, arranging referrals, including a letter of referral where required, and similar activities normally associated with providing insured services to patients.

1.4.2 Where provision of a service generates charges for long-distance telephone calls, unusual postal or

other expenses, the physician may deem them to exceed the normal allowance made in the tariff and bill the patient directly, subject to the conditions for billing non-insured services.

1.5 Physicians are required to submit service encounters for insured services provided to eligible patients in the format prescribed by MSI. Non-participating physicians are required by Regulation under the and Insurance Act to give reasonable notice of this fact to a patient or someone acting on his or her behalf, before providing a service.

1.6 Service encounters submitted beyond 90 days from date of service shall not be payable and will be adjudicated to pay “zero” unless MSI is of the opinion the delay is justified. Resubmission of refused service encounters must be within 185 days of the date of service. The only exception to this policy will be through special consideration in exceptional extenuating circumstances.

Claims for registered hospital in-patients must also be submitted within the 90 day time limitation whether or not the patient has been discharged or continues as an inpatient. In situations where the physician knows that the claims will not be submitted within the prescribed time period, loss of revenue can potentially be avoided by contacting MSI to request an extension.

1.7 Service encounters for services to patients from other provinces that are covered under the reciprocal billing agreement must be submitted within 1 year of date of service. See the Billing Instructions Manual for further details on reciprocal billing.

personally

Health Services

May 2011 PREAMBLE - 1

1.8 PHYSICIAN RECORD REQUIREMENTS TO SUPPORT CLAIMS

1.8.1 An appropriate medical record must be maintained for all insured services claimed. The minimum

record must contain, for MSI purposes, the following:

(A) Patient’s name; (B) Patient’s Nova Scotia Health Card Number; (C) Date of the service for which the claim is being made; (D) Reason for the visit/presenting complaint(s); (E) Any clinical findings appropriate to the presenting complaint(s) and reflective of the service

code(s) claimed; (F) Working diagnosis; (G) Treatment prescribed; (H) Time and duration of visit in the case of time-based fees; (I) Name of referring physician, where appropriate; (J) Name of consultant and rationale of referral, where appropriate; and whether referred for

diagnosis or treatment; and (K) A Consultant will send a report to the referring physician where appropriate and retain same on

file.

1.8.2 Where a procedural code is claimed, the patient record of that procedure must contain information which is sufficient to verify the type and extent of the procedure according to the fees claimed.

1.8.3 All claims submitted to MSI must be verifiable from the patient records associated with the services claimed and be billed in accordance with the Preamble. If the record does not substantiate the claim for the service, then the service is not paid for or a lesser benefit is given.

1.8.4 Where a differential fee is claimed based upon time, location, etc., the information on the patient record must substantiate the claim.

1.8.5 Where the fee claimed is calculated on a time basis, start and finish times must be part of the patient record of that service.

1.8.6 Documentation of services which are being claimed to MSI must be completed before claims for those services are submitted to MSI.

1.8.7 For MSI purposes, it is required that physicians maintain records supporting services claimed to MSI for a period of five years in order to substantiate claims submitted. For medicolegal purposes adult patients’ records should be retained for a minimum of ten years from the date of the last entry in the record. For patients who are children, physicians should keep the record until ten years after the day on which the patient reached or would have reached the age of 19 years (the age of majority in Nova Scotia).

1.8.8 All service items claimed to MSI are the sole responsibility of the physician rendering the service with respect to appropriate documentation and claim submission.

2. TERMS AND DEFINITIONS

2.1 MEDICAL NECESSITY

Medically necessary services may be defined as those services provided by a physician to a patient with the intent to diagnose or treat physical or mental disease or dysfunction, as well as those services generally accepted as promoting health through prevention of disease or dysfunction.

The provision of a service listed in the Schedule of Benefits does not ensure payment by Medical Services Insurance. Services provided in circumstances where they were not medically necessary are not insured. For the purpose of this Preamble, Medical services, which are explicitly deemed to be non-insured under the Health Services and Insurance Act or its Regulations, remain uninsured regardless of individual judgments regarding their medical necessity.

May 2011 PREAMBLE - 2

2.2 SCHEDULE OF BENEFITS The Schedule lists all insured procedures, their descriptions and codes, any special conditions, and the value in units. When the term schedule is used in this Preamble, it means the Schedule of Benefits. (This refers to the electronic document).

2.3 PHYSICIAN “Physician” means a legally qualified medical practitioner whose name is entered in the register kept by the College of Physicians and Surgeons of Nova Scotia as being qualified and licensed to practice medicine. He/She must be in good standing and not under suspension pursuant to any of the provisions of the Medical Act.

2.4 GENERAL PRACTITIONER “General Practitioner” means a physician who engages in the general practice of medicine or a physician who is not a specialist as defined by the

2.5 SPECIALIST / SPECIALTY A “specialist” is defined as one whose name appears in the Specialist Register of the College of Physicians and Surgeons of Nova Scotia. However, when the term "specialty" is used, it means any or all specialties, including General or Family Practice. For the purpose of this Preamble, the terms General and Family Practice are used interchangeably.

2.6 STATUTORY HOLIDAYS Holidays are defined for the purpose of claiming special rates as New Year's Day, Good Friday, Easter Monday, Victoria Day, Canada Day, Civic Holiday, Labour Day, Thanksgiving, Remembrance Day, Christmas

2.7 TERMS USED FOR REPORTING OR DESCRIBING SERVICES TO MSI

Day and Boxing Day. The list of dates designated as statutory holidays will be issued annually by MSI. Note: If a physician chooses to provide routine, scheduled services during a statutory holiday, he/she is not

entitled to payment at the holiday rate.

(See Section 6 and the Billing Instructions Manual)

2.7.1

2.7.2

2.7.3

2.7.4

2.7.5

2.7.6

Service When the term “service” is used in this manual, it is in the context of an insured visit or procedure that is identified by a specific service code in the MSI Schedule of Benefits.

Modifier Modifiers are special codes added to the record of a service that identify the generic context within which the service was provided (specialty, time, place, etc.). Some modifiers are for the purpose of clarification; others affect the tariff applied to the service. A detailed list of modifiers may be found in the miscellaneous section of this manual.

Qualifier A qualifier is an Alpha character appended to some service codes to subdivide the code and thereby distinguish differences specific to that procedure. e.g. 03.26A, 98.12B.

Units / Unit Value The MSI Schedule of Benefits uses units to represent the value of a service. The value of a unit varies according to the applicable Tariff. Two unit values exist, an Anaesthetic Unit Value used specifically for claiming anaesthetic services, and a Medical Service Unit Value specifying the dollar value of all other services.

Tariff The MSI Tariff is the actual monetary value of a service. It is derived from the number of units applicable to a service (which may vary according to relevant modifiers), the Medical Service Unit Value, and any individual billing factors based on practice location or billing thresholds, or other factors that may exist from time to time.

Rate When the tariff for a service is modified by specialty, time, or some other factor, the applicable tariff may vary according to the specific circumstances.

Medical Act.

May 2011 PREAMBLE - 3

2.7.7 Add-On

An “add-on” is a procedure which is always performed in association with another procedure and never by itself. An “add-on” procedure is paid at full fee.

2.8 AGE Where age is a factor in determining eligibility for payment, or modifies the service, the following age ranges are defined:

• Premature - 2500 grams or less at birth

• Neonate/Newborn - the 10 days following delivery

• Infant - up to and including 23 months

• Child - up to and including 15 years of age

• Adult - 16 years of age and over See the Billing Instructions Manual for how to claim services that use age modifiers.

2.9 HOME/RESIDENCE “Home” includes patient's home, group homes, seniors lodges, personal care homes and provincial correctional centres. It does not include institutions as defined in Section 2.12.

2.10 GROUP PRACTICE/CLINIC A group practice is defined as the arrangement whereby two or more physicians are in practice, and each physician maintains and has access to medical records and histories of the patients.

2.11 HOSPITAL For the purposes of this Preamble, hospital means a facility for the observation, care, and treatment of persons suffering from a psychiatric disorder; a hospital for treatment of persons with sickness, disease or injury, including maternity care, as approved under the

2.12 INSTITUTION Licensed and approved chronic care hospitals, residential centres, nursing homes and homes for special care.

2.13 OFFICE An "office" is defined as the location where a physician is practicing his or her profession. An office may be located in the physician's home, in a hospital, in an institution, or in other facilities or buildings.

2.14 HOME CARE NOVA SCOTIA PROGRAMS

2.14.1

2.14.2

2.15 PARTICIPATING PHYSICIAN A physician who is registered with MSI to receive compensation for insured medical services.

2.16 NON-PARTICIPATING PHYSICIAN A physician who has elected not to receive compensation for insured medical services from MSI. Patient reimbursement is described in the Billing Instructions Manual.

2.17 TECHNICAL COMPONENT Some diagnostic procedures have separately listed technical and interpretive components. When a physician must perform the technical component of a procedure that is normally carried out by a technician, the physician may claim a fee for the technical component. If a technician carries out the technical component the physician may claim for the interpretive component only.

Acute Home Care The Acute Home Care program is a provincial program designed to provide to patients in their homes, with acute episodic illnesses, short term acute care involving nursing and other services available normally only in hospital, thereby preventing or shortening a hospital admission.

Chronic Home Care Chronic Home Care is a provincial program which provides home support services, personal care services, nursing services and home oxygen services to persons with assessed unmet needs who are convalescing, chronically ill, disabled, or experiencing debilities of old age. Services provided have the objectives of maintaining or improving the individual’s level of functioning; addressing the individuals’ needs during rehabilitation or convalescence; delaying or preventing admission into institutions; and/or providing family relief services to the individual’s informal caregivers.

Health Services and Insurance Act.

May 2011 PREAMBLE - 4

2.18 INTERPRETIVE COMPONENT This is the interpretation of the results of a diagnostic procedure for which a fee may be claimed separately from performing the procedure itself.

2.19 FUNCTIONAL CENTRE A standard area or site within a hospital or institution; e.g. outpatient department, intensive care unit, etc. Assigned functional centre modifier will be required as part of a service encounter for services provided in such areas.

2.20 INTENSIVE CARE UNIT Intensive care units are special areas recognized and funded by the Department of Health to provide high intensity care. These units would include Neonatal, Paediatric, Coronary, and such other units as are recognized by the Department. Generally, special fees apply to patients in such areas unless the patients no longer need the care of such a unit, but remain in the intensive care area (e.g., due to lack of beds on general ward or recovery room).

2.21 PREMIUM FEES Premium Fees are additional amounts paid above normal or customary rates on eligible services provided on an emergency basis during designated times. An emergency basis is defined as services, which must be performed without delay because of the medical condition of the patient. (See Item 7.4)

2.22 INDEPENDENT CONSIDERATION Independent consideration is a process for assessing services where a unit value is not listed. Refer to Billing Instructions Manual. (See Item 6.3.1)

2.23 INTERIM FEE The tariff temporarily assigned to a new procedure during the process of adding it to the schedule of benefits. (See Item 6.3.2)

2.24 EXCEPTIONAL CLINICAL CIRCUMSTANCES Allowance is sometimes made for alteration of the tariff associated with individual service encounters when a physician can demonstrate significantly increased difficulty, time, or other factors involved in providing care. (See Item 6.3.3)

2.25 THIRD PARTY A person or organization other than the patient, his/her agent, or MSI that is requesting and/or assuming financial responsibility for a medical or medically related service.

2.26 EMERGENCY CARE CENTRES An Emergency care centre is a special designation provided by the Department of Health to Emergency departments meeting certain standards including 24-hour on-site on-call.

2.27 ANTENATAL (PRENATAL) The term antenatal (prenatal) applies to pregnancy related visits from the time of confirmation of pregnancy to delivery.

2.28 POST PARTUM The term Post Partum describes in-hospital-limited visits to the mother following delivery.

2.29 POST NATAL The term Post Natal describes a single limited visit performed approximately 6 weeks following delivery for the purpose of assessment and advice to the mother.

2.30 OTHER LOCATIONS This modifier applies to locations of service not defined elsewhere, such as recreational facilities, watercraft, or roadside.

2.31 TRAVEL Travel means movement from one geographic location to another. Interpretations specific for travel to certain locations:

2.31.1 Within an apartment building, movement from one unit to another is considered travel.

May 2011 PREAMBLE - 5

2.31.2 Movement within a hospital, even between separate buildings on one contiguous site, is not

considered travel. If a hospital has several geographically separate sites, movement between sites is considered travel.

2.31.3 Movement between rooms or units of a licensed nursing home or special care institution is not

considered travel.

2.31.4 If a physician maintains a medical office within or adjoining his or her place of residence, entering the

office for the purpose of rendering emergency treatment is considered travel during certain time periods.

2.31.5 If a physician has arranged to have an office in a hospital or in an attached building, going from the

office to the hospital to attend a patient is not considered travel.

2.32 DETENTION AND OFFICE VISITS Medical detention occurs when a practitioner’s time is given exclusively to one patient for active treatment and/or monitoring of that patient at the sacrifice of all other work. Detention time may only be claimed for emergency care and/or treatment provided outside of the office. (See Section 7.3)

2.33 TRANSFER OF CARE Transfer of care occurs when the responsibility for the care of a patient is completely transferred, either temporarily or permanently, from one physician to another. (See Section 7.8.1)

2.34 MOST RESPONSIBLE PHYSICIAN The most responsible physician is the attending physician who is primarily responsible for the day to day care of the patient in hospital.

2.35 LOCUM TENENS A physician who temporarily replaces another physician who is absent from the practice. (See Billing Instructions Manual)

Note: The locum physician may not claim under the billing number of the physician being replaced.

2.36 SESSIONAL FEES

Sessional fees apply to pre-approved services of a physician engaged on a time basis; e.g., approved group immunization and Well Women's Clinics, public health medicine or other professional services to a government department, agency or public body. For proper submission of service encounters refer to the Billing Instructions Manual.

3. SERVICES INSURED BY MSI

3.1 Physicians' services rendered to persons registered with MSI in a recognized clinical setting; e.g., the patient's home, the doctor's office, at a hospital, clinic or institution, or scene of an emergency. This includes all diagnostic, medical, psychiatric, surgical, or therapeutic procedures, including the services of anaesthetists and assistants as per the definition of medical necessity in Item 2.1. Some services may require prior approval.

3.2 Family planning or contraceptive advice, insertion of intrauterine devices and similar appliances, and sterilization procedures. Therapeutic abortion is an insured service.

3.3 Completion of a medical certificate for observation for the purpose of a patient's admission for psychiatric evaluation.

3.4 Services that are insured, but with restrictions:

routine

3.4.1 Coverage for

10 years of age and for those 65 years of age and over. For all others, routine refractive vision analysis is an uninsured service.

3.4.2 Age specific preventive services where indicated as determined by current guidelines for well baby

care, vaccinations, inoculations, etc. This would include examinations offered to individuals who

refractive vision analysis is limited to once every 24 months for persons under

May 2011 PREAMBLE - 6

have a family history, symptoms or signs or other diseases that put them at risk for preventable target conditions.

3.4.3 Group sessional clinics, e.g., immunization or “well person”, when pre-approved by MSI. (See Billing

Instructions Manual for details)

3.4.4 Complete history and physical examinations, but only when medically necessary to establish a

diagnosis (See “Services Not Insured by MSI”).

3.4.5 The services of an anaesthetist when required in conjunction with specified dental surgical

procedures listed in Schedule A of the Regulations of the Health Services and Insurance Act and only when medical necessity requires these services to be performed in a hospital.

3.5 When complications occur following a non-insured procedure, treatment which is medically necessary is an insured service.

4. SERVICES NOT INSURED BY MSI

Fees for the following services are not insured by MSI. The physician must determine who has responsibility for payment, if any. When complications arise following an uninsured procedure see Section 3.5.

4.1 Services available to residents of Nova Scotia under the of Veterans' Affairs, Canadian Forces, RCMP, the Canada or under any statute or law of any other jurisdiction either within or without Canada.

4.2 When a prescription or a requisition for a diagnostic or therapeutic service is provided to a patient without a clinical evaluation of the patient, the requirements of an insured visit service have not been met and no service encounter should be submitted.

4.3 Diagnostic, preventive or other physician's services available through the Nova Scotia Hospital Insurance Program, the Department of Health, or other government agencies.

4.4 Autopsy services, except by alternate service encounter submission mechanisms. (See Billing Instructions Manual)

4.5 Services at the request of Third Parties Health examinations or provision of health information required in connection with employment, insurance, admission, legal proceedings, etc., or any similar request by a third party are not insured. Responsibility for payment may lie either with the patient or the third party requesting the examination or information. This excludes Third Party as defined in Section 18 of the

The following are examples only, and do not represent a complete list:

4.5.1 Insurance company examinations and requests for medical information

4.5.2 Examinations requested by educational institutions, youth groups, summer camps

4.5.3 Employer requested examinations, sick certificates

4.5.4 Examinations required to support legal claim

4.5.5 Services required by a legal proceeding including preparation of records, reports, letters or certificates, or appearance and/or testimony in a court or other tribunal

4.5.6 Department of Immigration - Passport or Visa

4.5.7 Any diagnostic services associated with the above

4.6 Services, supplies, and other materials provided through the physician's office when such supplies are not normally considered part of office overhead.

4.6.1 Photocopying or other costs associated with transfer of records

Workers' Compensation Act, through the Department

Hospital Insurance Act, any Act of the Parliament of

Health Services and Insurance Act.

May 2011 PREAMBLE - 7

4.6.2 Long distance telephone charges incurred specifically on the patient's behalf

4.6.3 Items such as drugs, injectable materials, biological sera, dressings, strapping, tray fees, etc. used in

rendering medical care, except for pap smear tray fees and Provincial Immunization tray fees

4.6.4 Medical/Heal th devic es (e.g., eye glasses, contact lenses, hearing aids, surgical appliances, trusses,

wheelchairs, crutches and prosthetic appliances)

4.6.5 Physician's advice by telephone, letter, fax or e-mail is an uninsured service.

However, telephone, fax or e-mail advice for Home Dialysis, Acute Home Care, Chronic Home Care, Anticoagulant Supervision and Palliative Care are insured services under certain circumstances

4.6.6 Mileage or travelling time except as defined in Item 7.3 relating to Detention Time or blended

mileage/travel detention for Acute Home Care home visits

4.7 Physicians’ services provided to their own families

4.8 Gender Reversal (Trans-sexual surgery)

4.9. Services which, in the opinion of the Department of Health, have been performed for cosmetic purposes only.

4.9.1 Cosmetic Surgery is defined as a service done solely for the purpose of altering the appearance of the patient and not medically necessary

4.9.2 When there is doubt as to whether the proposed surgery is medically required or cosmetic, the operating surgeon should obtain prior approval from MSI. Anaesthetic and other fees associated with non-insured services are non-insured as well. MSI will pay for a visit or consultation to determine if a treatment method is insured, even though the proposed procedure is non-insured.

4.10 Group immunizations performed without receiving pre-approval by MSI

4.11 Acupuncture

4.12 Electrolysis

4.13 Reversal of Sterilization

4.14 In-vitro fertilization

4.15 Comprehensive visits when there are no signs, symptoms, or (family) history of disease or disability, which would make such an examination medically necessary. This excludes those examinations performed in accordance with guidelines in 3.4.2 relating to preventive health exams.

4.16 Services provided by other health care workers, with certain exceptions, which are not insured under MSI. This would include services of chiropractors, podiatrists, physiotherapists, psychologists, nurses or other paramedical personnel.

4.16.1 Dental services, except those which are described as benefits under the MSI Dental Program.

Information can be obtained by contacting MSI office.

4.16.2 Ancillary services, such as charges for an ambulance, etc.

4.16.3 Optometric services, exc ept those, which are described as benefits under the MSI Optometric

Program. Information can be obtained by contacting MSI office.

4.17 Costs of medical services, which are primarily related to research or experimentation, are not the responsibility of the patient or MSI.

4.18 There are alternate submission methods for Holter, ECG, Pathology, Diagnostic Radiology and other services performed and billed to MSI. See non-patient specific bulk billing sections of the Physician’s Manual.

4.19 Blood Alcohol Sampling and Documentation at the request of the Department of Justice

May 2011 PREAMBLE - 8

4.19.1 Claims for Blood Alcohol Sampling on impaired drivers will be processed by Medavie Blue Cross

Accounting Department, for reimbursement by the Department of Justice. The total fee should

include: (a) venipuncture, if performed by the physician, at the rate listed in the Schedule of Benefits (b) kilometers to be paid at the current government rate. Information on the current rate may be

obtained from the Department of Health or any other Provincial Department

Schedule of Benefits

(d) where appropriate documents are completed, a fee of 45 units may be claimed

4.19.2 Where insured medical services are provided to the impaired driver, the physician should cl aim under the appropriate MSI code in the usual manner. Where insured medical services are not provided to the impaired driver, the appropriate visit fee may be added to the above and billed to the Department of Justice. Under no circumstances should a visit be claimed to both the Department of Justice and MSI.

4.19.3 Service encounters based on the rates above should be submitted on the physician's letterhead to: Accounting Department

Medavie Blue Cross

P. O. Box 2200

Halifax, NS B3J 3C6

4.20 Sexual Assault Examination

4.20.1 This is an assessment of a patient in which the physician follows the protocol prescribed by the

Department of Justice for the investigation of alleged sexual assault.

4.20.2 The forensic examination portion of the treatment of a sexual assault victim is not insured under MSI,

but can be billed to the Medavie Blue Cross Accounting Department for reimbursement by the Department of Justice in the same manner as for Blood Alcohol sampling above. The police agency requesting the forensic examination must be indicated. (See Billing Instructions Manual re: fees) Where insured medical services are provided to the sexual as sault victim, the physician should cl aim under the appropriate MSI code in the usual manner.

5. PRINCIPLES OF ETHICAL BILLING

5.1 A physician who provides professional services to a patient is entitled to compensation commensurate with the services provided to the patient. These services are des ignated as ei ther insured or non-insured. Insured services are those listed in the MSI Physician's Manual.

5.2 Ethical principles of billing for non-insured services are outlined in the publication “Guide to Billing Non-Insured Services,” Doctors Nova Scotia. Information can be obtained by contacting Doctors Nova Scotia.

5.3 The following principles apply to service encounters for insured services:

5.3.1 All insured services claimed must reflect services rendered personally by the physician in an

appropriate clinical setting. Certain delegated medical acts done under supervision of the physician present on the premises may also be claimed.

5.3.2 A physician will not claim for services rendered to members of his or her family.

5.3.3 As part of the provision of an insured service, patients may be charged directly for the provision of

consumable items not covered by MSI, completing forms, photocopying, long distance telephone, and similar charges. These charges must be explained and agreed to by the patient before the insured service is provided. (See Item 4.6)

5.4 Billing for insured and non-insured services at the same visit.

May 2011 PREAMBLE - 9

5.4.1 A physician must exercise caution whenever billing MSI and the patient or a third party during the

same visit. In principle, under no circumstances should any service, or any component of a service, be claimed for twice.

5.4.2 Whenever possible, the attending physician must acquaint the patient, or person responsible for the

patient, with the financial obligation involved in the patient's care.

5.4.3 If the insured service is the primary reason for the visit, any additional charges for non-insured

services must be explained to, and accepted by, the patient before provision of these services. Charges for non-insured services will reflect only those services over and above those provided on an insured basis. It is not appropriate to bill both MSI and WCB for the same service.

5.4.4 At no time should provision of insured services be contingent upon the patient agreeing to accept

additional non-insured services.

5.4.5 When physicians are providing non-insured services, they are required to advise the patient of

insured alternatives, if any exist.

5.4.6 Incidental findings

(a) If an inconsequential health matter or finding is discovered or discussed during the provision of a

non-insured service, it is not appropriate to claim for an insured service.

(b) If a significant health matter or finding becomes evident, necessitating additional insured

examination(s) or treatment(s), then these subsequent medically necessary services may be claimed to MSI.

5.4.7 When a non-insured service is the primary reason for the visit, any service encounter for insured

services provided, as a medical necessity will reflect only services over and above those provided on a non-insured basis.

6. TARIFF

The MSI tariff is negotiated between the Department of Health and Doctors Nova Scotia.

6.1 The Canadian Classification of Diagnostic Therapeutic and Surgical Procedures (CCP) forms the basis for descriptions of services in the Schedule of Benefits insured by MSI.

6.2 The MSI adaptation of CCP does not include all possible CCP codes and MSI uses two additional levels of detail as follows:

6.2.1 Qualifiers are appended to a CCP code to distinguish between related procedures applied to the

same anatomic area or condition, or to accommodate procedures that are a composite of two or more services.

6.2.2 Modifiers describe the context of a service according to who performed the service, who received the

service and when, where, and sometimes how the service was provided.

6.3 Units per service are determined through the Fee Schedule Advisory Committee, a standing committee of the Master Agreement Steering Committee with representation from Doctors Nova Scotia, Department of Health and the District Health Authorities. An attempt is made to set the number of units for a service relative to other services in the schedule, reflecting factors such as duration, complexity, overhead, specialty status, and time of day or week. Practitioners are expected to use the published units for insured services except in the following instances:

6.3.1 Independent consideration is applied to certain services recognized to have wide variation in case to

case complexity and time. Refer to Billing Instructions Manual. Independent consideration services must be accompanied by complete details, including duration of service, adequate to explain and justify the number of units requested. (See Item 2.22)

May 2011 PREAMBLE - 10

Note: Independent consideration no longer refers to situations where an interim tariff has been

established or for exceptional clinical circumstances as explained below.

6.3.2 Interim Fees may be established in certain circumstances with approval by Department of Health. A

CCP Code will be activated to describe the new service and an Interim Fee assigned. Interim Fees will be published in the MSI Physicians’ Bulletin.

6.3.3 Exceptional Clinical Circumstances may warrant a fee other than that listed. In the event a

practitioner performs a service he or she believes should be insured, but is unable to find an appropriate service code, or finds an appropriate service code but feels the listed tariff does not adequately compensate the service, a request for an exceptional fee may be submitted. The request must be accompanied by complete details, including the duration of the service, adequate to explain

6.3.4. If a physician feels a particular fee is under or overvalued in relation to similar services, he or she

and justify the number of units requested. Note: The exceptional fee process is not intended for use on a routine basis when a physician

disagrees with the listed tariff for a service.

should request Doctors Nova Scotia consider renegotiating the fee with the Department of Health.

7. ASSESSMENT RULES FOR VISITS AND RELATED SERVICES

7.1 “Visit” is a generic term used for service encounters where there is an evaluation of a patient either as the sole service, or in association with one or more procedural services. A visit may not be claimed where the procedural service includes a visit component or where claiming a visit is otherwise prohibited. Visits are governed by a common set of rules, and more specific rules apply to diff erent categories of visits. Visits may occur in all locations; and include consultations; counseling; and care, as in directive, continuing, or supportive care.

There are several different CCP codes that apply to visits and multiple factors that modify these codes. Care must be taken to identify the appropriate code for the visit service provided, and any modifying factors. Not all combinations of codes and modifiers are valid.

7.2 VISIT TYPES

7.2.1

7.2.2

7.2.3 (a) When the sole reason for the visit is to provide a procedure to a patient, only the listed

(b) Only one visit may be claime d from a single service encounter. (c) A Comprehensive or Initial Limited Visit may not be claimed within 30 days of a Comprehensive

A Limited Visit or an Initial Limited Visit may be claimed when the physician provides a limited assessment for diagnosis and treatment of a patient's condition. It includes a history of the presenting problem and an evaluation of relevant body systems.

A Comprehensive Visit or a subsequent comprehensive visit is an in-depth evaluation of a patient necessitated by the seriousness, complexity, or obscurity of the patient’s complaint(s) or medical condition. This service includes ensuring a complete history is recorded in the medical record and performing a physical examination appropriate to the physician’s specialty and the working diagnosis.

General Visit Rules

procedure fee will apply.

Consultation on the same patient for the same condition.

(d) A Comprehensive Visit may not be claimed within 30 days of a previous Limited or

Comprehensive Visit. However, a Subsequent Comprehensive Visit service may be claimed by the specialties of Internal Medicine, Neurology, and Paediatrics. These restrictions do not apply to General Practice.

(e) An Initial Limited Visit service used by certain specialties may not be claimed within 30 days of

any visit or procedure. A Limited Visit only will apply.

May 2011 PREAMBLE - 11

(f) Visits requested in one time period and performed in another time period must always be

(g) When follow-up visits are made at the convenience of the physician, the 0800 to 1700, Monday

(h) If more than one visit is provided by the same physician to the same patient on the same day in

(i) A Pap Smear may not be claimed in addition to a visit, consultation or procedure for a

(j) When a visit was made solely for an injection, then only an injection may be claimed. The

(k) A visit is not claimable with Psychotherapy or Counseling codes at the same service encounter.

7.2.4

(a)

(b)

(c)

(d)

(e)

Limited Visits by Location (See Section 7.2.6)

claimed using the lesser of the two rates.

to Friday visit rate will apply.

separate service encounters, documentation of the necessity for the extra visit(s) must be recorded on the chart. Time of service occurrence must be provided on second and subsequent visits.

gynecological or obstetrical diagnosis, nor is it payable in addition to a complete physical exam.

injection must be provided under the direct supervision of a physician physically present on the premises.

Office - A Limited Visit may be claimed when the physician sees the patient and performs a limited assessment for a new condition or when monitoring or providing treatment of an established condition.

OPD - Emergency Department - A Limited Visit may be claimed when the physician provides medical treatment to a patient presenting to an OPD - Emergency Department. It is payable at the appropriate fee for the time at which the service is provided.

Hospital - A Limited Visit may be claimed when the physician provides dail y care to the patient. Daily limited visits may be claimed by more than one physician when different conditions are being treated. A weekly maximum applies to routine hospital visits to patients after 56 days hospitalization except for paediatricians. Multiple unscheduled visits on the same day are excluded from the weekly maximum.

Discharge Fee - A hospital Discharge Fee may be claimed by the physician (either a general practitioner or a specialist when a patient is admitted for non-surgical hospitalization) who performs the activities involved in discharging a hospital in-patient. These activities include, as necessary, the completion of the patient’s chart, discharge summary, writing prescriptions for the patient, providing discharge instructions to the patient and arranging for follow up care for the patient.

The fee is not payable where major surgery, minor surgery, major fracture and/or minor fracture care is provided in a hospital setting unless a patient is transferred to a general practitioner for follow-up care after surgery/fracture care. In this case, the general practitioner may claim the discharge fee if the general practitioner performs the discharge duties. This fee cannot be claimed by the operating surgeon in association with any surgical code being billed.

A hospital visit fee may be claimed in addition to the discharge fee where a hospital visit is provided on the same day.

Acute Home Care - A Limited Visit may be claimed when the physician provides daily care to the patient and may occur at the patient’s home or OPD. Acute care services may be provided for up to 15 days but are to be discontinued when no longer required. The patient’s requirement for Acute Home Care is reviewed regularly. An average length of stay of 5 to 7 days in Acute Home Care is anticipated. If appropriate, patients may be transferred to Chronic Home Care if they require ongoing home care services for convalescence or continuing care following the period of acute illness.

In exceptional circumstances, extended admissions for up to a total of 30 days may be authorized by the Care Co-ordinator in consultation with the attending physician.

May 2011 PREAMBLE - 12

(f)

(g)

7.2.5

(a)

(b)

(c)

(v) Acute Home Care - A Comprehensi ve Visit may be claimed for the direct admission to the

(d)

(e)

7.2.6

(i) First Patient Seen: The rate for the first patient seen is only applicable for those cases

(b)

Home or Other Locations - A Limited Visit may be claimed when the physician provides a limited examination for diagnosis and treatment of a patient's condition or provides ongoing treatment of an established condition.

Institutions (See Section 7.2.6(d))

Comprehensive Visits by Location

Office - Comprehensive Visits in the office may not be claimed more than once every 30 days when diagnosing and treating a new condition or further complications of an existing condition. Visits provided within a 30-day period for the same condition or complication should be claimed as a Limited Visit. (See Item 7.2.3)

OPD or Emergency Department - A Comprehensive Visi t may be claimed, when appropriate, in the OPD or Emergency when a patient is seen for the first time that day by that physician. Follow-up visits for the same condition on the same or subsequent day should be claimed as a Limited Visit.

Hospital - A Comprehensive Visit may be claimed for the first examination in hospital for diagnosis and treatment once per patient per admission for each specialty involved in the care of the patient. If a patient has a comprehensive visit in the Emergency Department by the family doctor covering the ED and is then admitted and has a second comprehensive visit by a different (admitting) family doctor, the ED physician may claim the Complete Examination code and the admitting physician may claim the First Examination code.

(i) If a specialist readmits a referred patient within 30 days for the same or related condition,

only a Limited Visit may be claimed. (ii) There are no restrictions on Paediatricians readmitting referred patients. (iii) If a specialist readmits an un-referred patient within 10 days for the same or related

condition, only a Limited Visit may be claimed. (iv) If a General Practitioner readmits any patient within 10 days for the same or related

condition, only A Limited Visit may be claimed.

Acute Home Care Program from the office, home, OPD and unscheduled emergency

locations. This must follow notification to the appropriate Home Care Nova Scotia

Coordinators. The service will include the first examination for diagnosis and treatment once

per patient, per admission. Home or Other Locations - A Comprehensive Visit may be claimed when diagnosing and

treating a new condition or further complication of an existing condition, but may not be claimed more than once every 30 days. Comprehensive Visits provided within a 30-day period will be approved at the appropriate Limited Visit fee.

Institutions (See Section 7.2.6(d))

Rules Specific to Location (a)

OPD and Emergency Department - If the patient is kept in OPD or Emergency under observation for more than 4 hours, an additional Limited Visit may be claimed when the need can be supported by the patient's condition and documentation on the chart.

requiring the physician to make a separate trip to the OPD or Emergency Department. (ii) Additional Patients: An Extra Patient Limited Visit is applicable for additional patients seen

following the first patient. The rate for extra patients is applicable for additional patients seen

following each separate trip to the hospital. An Extra Patient Limited Visit applies in those

situations where a physician is in the hospital for any purpose and is asked to see a patient

in the OPD or Emergency Room. The Emergency Care Centre visit rates may only be claimed in designated Emergency Care

Centres approved by the Department of Health.

May 2011 PREAMBLE - 13

patient's home. The patient or patient's representative must request the physician to visit. A Home Visit may only be claimed when the patient's condition or situation justifies the service. If the nature of the patient's condition requires periodic scheduled home visits, a daily home visit can be claimed. (See Items 7.2.3(f), 7.2.3(g))

(i) Additional patients seen in the same apartment or private dwelling: The first person seen is

claimed at the Appropriate Home Visit. Other patients seen are claimed as additional

patients. However, a visit to another apartment in the same building is regarded as a

separate home visit and the appropriate fee should be claimed for the first person seen

therein.

(d)

7.2.7

7.2.8

7.2.9

Definitions:

An Institutional First Visit arises when, at the specific request of an appropriate institutional authority, patient or patient's family or guardian, the physician visits and renders services to the patient in an institution.

(i) Additional patients seen at the same visit should be claimed at the appropriate Limited Visit

fee.

(ii) When prearranged routine trips are made to an institution, Limited Visit Fees shall be

claimed only for those patients where medical necessity exists.

(iii) If the physician believes his or her services are inadequately compensated under the

institutional visit rules, he or she may enter into a contractual agreement with the institution

for a form of “retainer” or other remuneration method to supplement his or her income from

visit fees. This supplemental remuneration would be a non-insured service.

Urgent Visits (All locations) The underlying principle is that the demands of the patient’s condition and/or the physician interpretation of that condition, is such that the physician must respond immediately. Immediate attendance because of personal choice or availability does not constitute an Urgent Visit. (See the definition of travel in Item 2.31)

Urgent Visit - Hospital Inpatient - Request by hospital staff. An Urgent Visit applies when a

(a)

physician travels to see a registered inpatient at the request of hospital staff. Urgent Care in Office - Request by Patient. An urgent care visit applies when the physician is

(b)

called to see the patient and must travel to his or her office outside the hours of 0800 to 1700 Monday to Friday or during other scheduled office hours. An Urgent Care Visit does not apply to a patient attending the office during scheduled office hours regardless of the patient’s condition. If additional patients are seen at the same time, a limited visit applies.

Urgent Visit - Sacrifice of Office Hours - All other locations. An Urgent Visit may be applied

(c)

when the physician is called to see a patient and interrupts his or her regular office hours and travels from one location to another to attend the patient.

Management of Closed Head Injury - Initial examination and recommendation re further treatment. This service may be claimed only by a Paediatrician or Neurosurgeon.

General Practice Complex Care Visit A complex care visit code may be billed a maximum of 4 times per patient per year by the f amily physician and/or the practice (not by walk-in clinics) providing on-going comprehensive care to the patient who is under active management for 3 or more of the following chronic diseases: asthma, COPD, diabetes, chronic liver disease, hypertension, chronic renal failure, congestive heart failure, ischaemic heart disease, dementia, chronic neurological disorders, cancer. The physician must spend at least 15 minutes in direct patient intervention and the visit must address at least one of the chronic diseases either directly or indirectly. Start and finish times are to be recorded on the patient’s chart.

The term active management is intended to mean that the patient requires on-going monitoring, maintenance or intervention ro control, limit progression, or palliate a chronic disease.

The term chronic neurological disorders is intended to include progressive degenerative disorders (such as Multiple Sclerosis, Amyotropic Lateral Sclerosis, Parkinson’s disease, Alzheimer’s disease),

May 2011 PREAMBLE - 14

stroke or other brain injury with a permanent neurological deficit, paraplegia, or quadriplegia and epilepsy.

7.2.10

7.3 DETENTION TIME (See Definition Item 2.32) Detention commences 30 minutes after the practitioner is first in attendance and may be claimed in 15-minute increments thereafter. This may include travel time spent with the patient travelling from one location to another. However, travel time to transport donor organs from a donor site to the recipient site for transplantation, begins at the time the retrieving surgeon accompanied by the donor organs leave the donor site. Where any service is performed during the time spent with the patient, either the service, or the Detention Time, but not both, should be claimed. The circumstances in each case, and the time involved, should be documented with the service encounter. When claimed with a Comprehensive or Limited Consultation, Detention Time commences after one hour.

7.3.1 Detention Time Does Not Apply To:

7.3.2 Detention Time Is Not Payable In Conjunction with Fees Paid for the Following on the Same Day:

(a) Intensive Care or Critical Care (See Items 7.9.2 and 7.9.3 )

7.4 PREMIUM FEES (See Definition Item 2.21) Premium fees may be claimed for certain services provided on an emergency bas is during designated time periods. An emergency basis is defined as services, which must be performed without delay because of the medical condition of the patient.

7.4.1 Premium Fees May Be Claimed For:

(a) Consultations, except where a consult is part of the composite fee (b) Surgical procedures except those performed under local or no anaesthetic (c) Fractures regardless of whether an anaesthetic is administered (d) Obstetrical deliveries (e) Newborn Resuscitation (f) Selected Diagnostic Imaging Services (g) Pathology Services

Case Management Conference Fee A case management conference is a formal, scheduled, multi-disci plinary health team meeting. It is initiated by an employee of the DHA/IWK , or a Director of Nursing or Director of Care of an eligible Long Term Care facility to discuss the provision of health care to a specific patient. Neither the patient not the family need to be present.

It may be claimed by more than one physician simultaneously as necessary for case management. The case conference must be documented in the health record with a list of all physician participants. To claim the case conference fee, the physician must participate in the conference for a minimum of

15 minutes and remuneration will be calculated in 15 minute time increments based o n the sessional rate. Start and finish times are to be recorded on the patient’s chart.

(a) Waiting time for an operating room, x-rays, laboratory results or administrative duties (b) Counseling or Psychotherapy (c) Advice given to the patient or patient's family or representative(s) (d) Waiting time for a patient's arrival for assessment or treatment (e) Waiting time for attendance by another medical practitioner or consultant (f) Return trip if the physician is not in attendance with a patient (g) Time spent in completing or reviewing patient charts (h) More than one patient at a time (i) Office visits

(b) Diagnostic and therapeutic procedures (c) Obstetrical Delivery

May 2011 PREAMBLE - 15

Time Period

Time

Payment Rate

Monday to Friday

17:00 - 23:59

US=PREM (35%)

Tuesday to Saturday

00:00 - 07:59

US=PR50 (50%)

Saturday

08:00 - 16:59

US=PREM (35%)

Saturday to Monday

17:00 - 07:59

US=PR50 (50%)

Recognized Holidays

08:00 - 23:59

US=PR50 (50%)

7.4.2 The designated times where premium fees may be claimed and the payment rates are:

Premium fees also apply to emergency anaesthesia for a surgical procedure (not a diagnostic or therapeutic) provided by a non-certified anaesthetist at the interruption of his or her regularly scheduled office hours.

Premium fees are paid at 35% or 50% of the appropriate service code but at not less than 18 units for patient-specific services and at not less than 9 units for non-patient-specific diagnostic imaging and pathology services paid through the hospital by special arrangement with MSI (See Section 9.7)

7.4.3 If a service requires use of an anaesthetic, the anaesthetic start time determines if a premium fee

may be claimed.

7.4.4 Premium fees may not be claimed with: (a) Detention (b) Critical Care/Intensive Care (c) Diagnostic and Therapeutic Procedures other than Selected Diagnostic Imaging Services (See

Section 7.4.1)

(d) Surgeons and assistants fees for liver transplants

7.5 REFERRED SERVICES Referred services include all types of Consultations and any Visits subsequent to the original referral. In the absence of a proper referral, specialty rates may not apply.

7.5.1

7.5.2

A consultation is a service resulting from a formal request by the patient's physician, nurse practitioner, midwife, optometrist or dentist, after appropriate evaluation of the patient, for an opinion from a physician qualified to furnish advice. This may arise when the complexity, obscurity or seriousness of the patient's condition demands a further opinion, when the patient requires access to specialized diagnostic or therapeutic services, or when the patient, or an authorized person acting on the patient's behalf, requests another opinion.

A consultation requires a written report to the referring physician, nurse practitioner, midwife, optometrist or dentist; an evaluation of relevant body systems; 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, other persons relevant to the case, and the referring physician, nurse practitioner, midwife, optometrist or dentist. The composition of a consultation will vary with a particular specialty.

Health Services and Insurance Act, Item 33, provides that Nova Scotia Medical Services

The Insurance has the authority to require a copy of the consultation report for administrative purposes.

A Comprehensive Consultation is a Comprehensive Visit as per Section 7.2.2 with a written report to the referring physician, nurse practitioner, midwife, optometrist or dentist. This service includes performing and recording of a complete history and a complete physical examination appropriate to the physician's specialty.

May 2011 PREAMBLE - 16

7.5.3 A Limited Consultation is performed when the nature of the patient's problem does not warrant a

comprehensive consultation. A limited consultation includes a history limited to and related to the presenting problem, and an examination, which is limited to relevant body systems.

7.5.4

7.5.5

7.5.6 Consultations for Non-Specialist Physicians will usually be paid at the general practitioner

7.5.7 A consultation may not be claimed in the circumstances listed below:

7.5.8 Some services may not be claimed in addition to a consultation. (See Section 9.2.9(b))

7.6 CARE BY MORE THAN ONE PHYSICIAN Care by more than one physician refers to ongoing visit services provided to a patient where some form of coordination of the responsibility for the patient's care between a referring physician and the consultant(s) is implied. All care visits are coded as Limited Visits, and the nature of the responsibility of the physicians involved determines the role claimed. (See Definition for Transfer of Care in Item 2.33)

7.6.1

A Repeat Consultation applies only where there has been a re-referral of the patient by the same physician, nurse practitioner, midwife, optometrist or dentist to the same consultant for the same condition, or complication thereof within 30 days of the initial consultation. A repeat consultation requires all the elements of a limited consultation and implies interval care by another physician.

The situation where the repeat consultation.

A Prolonged Consultation for comprehensive consultations and a half-hour for repeat consultations. A prolonged consultation cannot be claimed with a limited consultation. Prolonged consultations are paid in 15-minute time blocks or portion thereof. Prolonged consultations are not to be confused with active treatment associated with detention.

A prolonged consultation may be claimed only by the following specialties:

(a) Anaesthesia (b) Internal Medicine (c) Neurology (d) Physical Medicine (e) Paediatrics (f) Psychiatry

consultation rate except where alternative arrangements have been made with the Department of Health.

(a) Where ongoing care is provided without an original referral the appropriate non-referred visit is

payable.

(b) The patient's regular attending physician cannot claim a consultation and must claim the

appropriate visit.

podiatrists. However consults may be claimed for referrals from nurse practitioners, midwives, optometrists and dentists.

Supportive Care is defined as a Limited Visit provided by the family physician or referring physician in a situation where the responsibility for the medical and surgical care of a registered hospital in-patient has temporarily been transferred to a consultant.

(a) Service encounters are limited to only once every three days from the date of hospital admission

up to and including the ninth day, and twice weekly thereafter for the remainder of the patient's hospital stay.

(b) If medical complications develop or are present which require active management by the

referring physician, regular Hospital Visits, not Supportive Care, should be claimed.

consultant requests the patient to return for a later examination is not a

may be applied to cases where the consultation extends beyond one hour

May 2011 PREAMBLE - 17

7.6.2 Directive Care is defined as a Limited Visit following a consultation that can be claimed for services

provided in the office, home or to registered in-patients by specialist consultants. It is intended that the referring physician is responsible for the general condition of the patient and that the consultant is directing only the care relevant to his/her specialty. In such cases the consultant may claim Directive Care and the referring physician may claim the appropriate home, office or in-patient visit. More than one specialist at a time may claim directive care on a patient.

7.6.3

7.7 SUPERVISION Supervision of treatment by a physician, without actually having a “face-to-face” interaction with the patient, is a service that may be claimed in the following special cases.

7.7.1 Supervision of Home Dialysis refers to supervision by a nephrologist of patients registered in a Home

(a) Home Dialysis P rogram registration is initiated when a patient begins training or is accepted into

(b) No in-patient chronic dialysis supervision fees may be charged on the registered patients.

(d) Supervisory fee is claimed monthly by the supervising nephrologist for each home dialysis

7.7.2 Supervision of a patient on long term anticoagulant therapy may be claimed once monthly if the

7.7.3 Payment for supervision of a registered Acute Home Care patient can include medical chart review,

7.8 OTHER CARE OR VISITS

7.8.1

(a)

Continuing Care is defined as a Limited visit following a consultation that can be claimed for services provided in the office, home or to registered in-patients by specialist consultants. It is intended that the consultants assume responsibility for the care of the patient's medical condition. When the patient remains in the hospital and the consultant is providing Continuing Care the general practitioner or paediatrician may claim Supportive care. Only one consultant per specialty may claim Continuing Care for a patient at a time. When a specialist is providing continuing care in the home or office, the General Practitioner may claim the appropriate visit code.

Dialysis Program.

a program, and terminates with successful transplantation, change to in-centre dialysis, loss of resident status, or death.

However if a registered patient is admitted to a centre without an attending nephrologist and the patient is incapable of performing their own dialysis the attending physician may claim the treatment of chronic renal failure by any dialytic method. Other in-patient visits and procedures may be claimed during hospital admission.

registered patients, including all scheduled or emergent out patient visits, direction of care by phone or other means, and liaison with other treating physicians.

program patient registered as of the first day of that month. For newly registered patients, service encounters commence the following month.

patient's treatment is managed by telephone, fax or e-mail advice. If the date of service falls within a complete month of hospitalization, this service may not be claimed.

telephone calls, fax or e-mail advice and blended mileage/travel detention. (See Billing Instructions Manual)

Transfer of Care

A transferal, as distinguished from a referral, takes place when there is formal transfer of responsibility for the patient’s care from one physician to another. (See Item 2.33)

Temporary transfer would include situations where the first physician must be absent (e.g., holiday or illness) and arranges patient coverage by the second physician with the intention of resuming care of the patient upon return.

Permanent transfer would involve any situation where the physician has no intention of resuming care of the patient.

May 2011 PREAMBLE - 18

(b) Regardless of specialty, the physician to whom the patient is transferred is not entitled to a

consultation or comprehensive visit fee. When transfers occur from one specialty to another, or from one hospital to another occur, the receiving physician may be entitled to a consultation or comprehensive visit fee.

responsibility for the patient’s care is transferred with, or subsequent to the referral, it is appropriate for the receiving physician to claim a consultation.

7.9 INTENSIVE CARE UNIT

7.9.1 Intensive Care Unit (ICU) services refers to services rendered in intensive care units (ICUs) approved by the Department of Health by physicians who have been assigned by a hospital to the ICU staff by reason of special training or experience.

7.9.2 (a) The 24-hour time period for claiming ICU services is from 8 a.m. to 8 a.m. of the following day.

7.9.3

General Rules

(b) There should only be one Day 1 (First Day) claimed during the same ICU admission even if the

patient’s status changes. Day 1 is normally the date of admission to the ICU. However if the physician does not actually see the patient until the next day (e.g., because a resident is covering), then Day 1 can be the date when the patient is first seen by the physician. Day 1 can only be claimed again if the patient is re-admitted to the ICU at least 24 hours after discharge. This does not preclude Ventilatory Care Day 1 and Critical Care Day 1 being claimed on the same day.

code; e.g., one can claim Critical Care and the other can claim Ventilatory Care. However, no other ICU fee code may be claimed in addition to Comprehensive Care. Also, the Intensive Care daily rate may not be claimed in addition to Critical Care.

(d) If a patient is transferred from one ICU to another in the

ICU fees on the same day. However, this precludes billing another Day 1.

(e) When a transfer to a

can claim in a 24-hour period.

(f) ICU fees can be claimed up to and including the day that the patient is medically suitable for

transfer from the ICU or off ICU care. Then the Intensive Care daily rate or continuing care, depending on the condition of the patient, should be claimed if the patient remains in the ICU after the transfer order is written.

(g) To claim ICU fees under ordinary circumstances, intensivists should be immediately available to

the ICU.

(h) A surgeon can claim ICU fees, except for ICU Day 1 codes immediately following surgery, for

his/her own post-operative patient if he/she is the sole providing physician to the patient in the ICU. Surgeons do not ordinarily claim ICU fees during the postoperative period because other physicians provide care in the ICU. However, some facilities do not have enough staff available for separate coverage of the ICU and, under these circumstances, a surgeon can claim ICU

fees. This does not prevent a surgeon from claiming ICU fees for non-operative patients. Critical Care Codes (Critical Care, Ventilatory Care and Comprehensive Care) These codes may only be claimed for daily care of critically ill patients admitted to intensive care units

approved by the Department of Health. The Critical Care, Ventilatory Care and Comprehensive Care services listed below include initial consultation and assessment and daily management of the patient. Use of these codes precludes claiming for detention on any patient on the same day.

different hospital occurs, more than one physician (in different hospitals)

same institution, both sites can claim

May 2011 PREAMBLE - 19

(a) Critical Care - Critical Care comprises all aspects of care of a critically ill patient in a designated

intensive care area. Critical Care excludes ventilatory support except as designated below.

These fees do not apply when patients who are not

area; or when patients who were critically ill recover but remain in the intensive care area (e.g.,

lack of beds on general ward or recovery room).

Ventilatory Care - This includes provision of all types of ventilatory care including face mask

(b)

ventilation; e.g., bipap ventilation; management of the intubated airway, including tracheal toilet

by suction catheter with or without instillation; and use of mechanical ventilation of the critically ill

patient; as well as the supervision and obtaining of blood for blood gas assessment.

Comprehensive Care - When a physician provides both critical care and ventilatory support

(c)

services to a patient, a service encounter claim should be submitted for Comprehensive Care.

(d) The following specific procedures are included within the critical care tariff:

• Arterial puncture

• Blood gases

• Cardiac arrest

• Cardioversion and non-invasive transthoracic pacing

• Defibrillation

• Emergency resuscitation

• Haematology and biochemistry

• Insertion of arterial lines percutaneously or by cut down

• Insertion of chest tube

• Insertion of CVP catheters percutaneously or by cut down

• Insertion of intravenous lines

• Insertion of urinary catheters and nasogastric tubes

• Interpretation of laboratory tests

• Interpretation of rhythm strips

• Intracranial pressure monitoring interpretation

• Lumbar puncture

• Management of cardiac arrhythmias

• Paracentesis

• Stress test

• Thoracentesis

• Venipuncture of peripheral and central veins (e) The following procedures are excluded from critical care and may be claimed separately:

• Bronchoscopy

• Insertion of temporary pacemakers

• Intra aortic balloon catheters

• Left heart catheterization with angiograms and coronary arteriograms

• Esophago-gastroscopy

• Peritoneal dialysis for acute renal failure

• Radionuclide scans

• Selective coronary graft angiography

• Selective pulmonary angiogram

• Swan Ganz Catheterization

• Ultrasonography

7.9.4

Intensive Care The Intensive Care daily rate may be claimed by one physician per patient per twenty-four hours. Should a procedure be performed on the patient during this time, then the physician has the option of claiming for the procedure or for the intensive care but not for both.

Intensive Care Detention may be claimed on an hourly basis, if needed, when a patient de-stabilizes. If codes for detention are claimed for a patient, then the Intensive Care daily rate cannot be claimed for that patient. The daily rate may be charged for other patients. A duration of service must be provided on these service encounters. An hourly sessional fee may be claimed in certain circumstances.

critically ill are admitted to an intensive care

May 2011 PREAMBLE - 20

7.9.5 Beating Heart Donor If the support of a beating donor (03.05A) does not require continuous attendance by an ICU physician and the physician can attend to other patients, then the regular Intensive Care Unit Codes are to be claimed for the support of the beating donor.

7.10 PALLIATIVE CARE

7.10.1

7.10.2

7.10.3

Consultation The Palliative Care Consultation can only be claimed by designated physicians (general practitioners or specialists) with recognized expertise in palliative care. The service provided must fulfill the normal requirements for a consultation as specified in the Preamble. The consultation includes a psychosocial assessment, comprehensive review of pharmacotherapy, appropriate counselling, and consideration of appropriate community resources where indicated. A prolonged consultation cannot be claimed. Specialists can claim the palliative care consultation fee or the consultation fee appropriate to their specialty. It is payable once per patient per physician. Physicians billing the Palliative Care Consult must forward a letter to MSI indicating his/her credentials.

Physicians providing palliative care must have completed a minimum of six days of intensive didactic or small group training in palliative care, and a one-week clinical practicum in palliative care with a qualified physician supervisor.

Support Visit The Palliative Care Support Visit is a time-based all-inclusive visit for the purpose of providing pain and symptom management, emotional support and counselling to patients with terminal disease. The physician must spend at least 80% of the time claimed with the patient and cannot claim for any other visits with the patient on the same day. Palliative care support can be claimed for the last 90 days before the patient’s death and is billed retroactively. The physician must keep records to support the claims, as well please be advised to include text on any outdated claims.

As physicians billing Palliative Care Support visits will be unable to determine the 90 day previous to death he/she must initially submit the appropriate visit fee when seeing the patient. Once date of death is indicated the physician must delete the previously billed appropriate visit and then bill the Palliative Care Support Visit for any visit service provided in the previous 90 days.

Chart Review and/or Telephone Call The Palliative Care Medical Chart Review and/or Telephone call, fax or e-mail advice eligible for payment are those initiated by health care professionals involved with the care of the palliative care patient. Telephone calls, fax or e-mails initiated by the palliative patient or his/her family members are not eligible. Physicians and health care professionals involved should keep a detailed record of telephone calls, fax or e-mails. Palliative care medical chart review and/or telephone calls, fax or emails can be claimed for the last 90 days before the patient’s death and are billed retroactively.

8. ASSESSMENT RULES FOR SPECIALIZED SERVICES

8.1 GENERAL RULES REGARDING SPECIALIZED SERVICES:

8.1.1

Payment of Specialist Fees Under MSI, insured services provided by specialists would only be payable at the rate listed for visits under that particular specialty when the service provided is within the field of the specialty concerned. If such services are not considered to be within the specialty field, payment will be made at appropriate Family Practice rates. Physicians who are not specialists but do specialist work will not be paid specialist rates. Specialist visit rates are payable only to those physicians whose names appear on the Specialist Register of the College of Physicians and Surgeons of Nova Scotia and where there has been a referral of the patient to the specialist by the attending physician, nurse practitioner, midwife, optometrist or dentist. Patients seen at the initiative of the specialist without a referral will not entail payment of specialist rates.

The MSI physician number of the referring doctor, the MSI midwfe number of the referring midwife, optometrist provider number, dentist provider number or the MSI nurse practitioner number of the referring nurse practitioner, who is subject to a Collaborative Practice Agreement with a physician as approved by the Diagnostics and Therapeutics Committee of the College of Registered Nurses of

(See referred services Item 7.5)

May 2011 PREAMBLE - 21

Nova Scotia (“the Nurse Practitioner” ) and who has the agreement of the physician to refer patients to specialists, must appear on the service encounter. If the number of the referring doctor, the nurse practitioner, midwife, optometrist or dentist is not indicated, then the service encounter will be returned for resubmission. Where no prior service by the referring doctor, nurse practitioner, optometrist, dentist or midwife can be identified, a confirmation of referral may be requested.

8.1.2

8.2 ANAESTHETIC SERVICES

8.2.1 An Anaesthetic Consultation applies if a registered anaesthetist is requested by another physician to

8.2.2

Clinical Supervision A teaching physician is entitled to receive payment for the services he or she provides in a teaching setting with the assistance of a resident or medical student. He or she shall be present at, and assist in, the performance of such services or shall be immediately available to render assistance when necessary.

No fees shall be payable to a medical specialist for seeing a patient within the framework of his or her teaching and research functions.

A physician may claim either for the resident's procedure or for his or her own services, but not both, when they are performed at the same time.

No visit or procedural fee may be claimed if the patient is not seen by the teaching physician at the time that the visit or procedure is rendered except under the following circumstances:

(a) In psychotherapy, where the presence of the attending physician would distort the

psychotherapy milieu, it is appropriate for the attending physician to claim for psychotherapy when a record of the interview is carefully reviewed with the resident and the procedure thus supervised. However, the time charged by the attending physician may not exceed the total time spent by him or her in both such interview and direct supervision and should not exceed the total time spent by a physician with the patient.

(b) In other departments or services , the attending physician should only cl aim for visits on the days

when actual supervision of that patient's care takes place through the presence of that attending physician in the clinical teaching unit on that day. This, of course, involves a physical visit to the patient and/or a chart review with detailed discussion with the other member(s) of the health team.

multiple procedures or services through the use of other members of the team, the total service encounters made by the attending physician shall not exceed the amount that the attending physician might claim in the absence of the other members of the team.

Any service encounter rendered should be in the name of the responsible attending physician.

see a patient in consultation because of the complexity, obscurity, or significance of pre-existing medical problems prior to the administration of an anaesthetic. In these circumstances, the anaesthetist may claim a consultation fee as well as the anaesthetic fee.

An Anaesthetic Consultation may also apply in situations where the anaesthetist has been referred a patient for the purpose of pain control, or other anaesthesia specialty related services.

The routine pre-anaesthetic evaluation does not qualify as a consultation, regardless of where and when this evaluation is performed, as this evaluation is included in the fee for the anaesthesia. Preanaesthetic clinic assessments for same day surgery shall not be deemed to form part of the fee for anaesthesia services.

General Rules for Anaesthetic Services The fees listed are for all types of anaesthetic services required for the performance of an insured procedure by another physician.

May 2011 PREAMBLE - 22

(a) A physician cannot claim for both the anaesthesia and the procedure(s) performed under that

anaesthesia, except where the procedure is an anaesthesia-related procedure; e.g., fibreoptic bronchoscopy for airway management, pulmonary toilet, etc.

(b) All anaesthetic services are time-based composite fees which normally include a preoperative

evaluation, administration of anaesthetic substances, injections, transfusions, IV's, procedures such as intubation, laryngoscopy, use of anaesthesia monitoring equipment, other procedures related to the anaesthetic technique used and post operative attendance.

longer in personal attendance, having determined that the patient can safely be placed under the customary post-operative supervision. Additional time for repeat visits to the patient in the

recovery room, as the need occurs, may be added to the anaesthesia time. (d) Approved preanaesthetic clinics for same day surgery are paid as sessional fees. (e) Anaesthetic services must be provided in a hospital or facility approved by the Department of

Health.

8.2.3

(b)

Calculation of Anaesthetic Fees Anaesthetic fees are determined by adding the Basic Units and Anaesthesia Time Units.

A Basic Unit is listed for most procedures. It is the value assigned to each procedure to cover

(a)

all anaesthetic services except the time actually spent either in administering the anaesthesia or

in unusual detention with the patient. Additional procedures, not routine components of an

anaesthetic procedure, will be billed either as additional anaesthesia procedures, or as

replacements for, or additions to, the basic units. These procedures include the following items,

for which the basic rate will be increased or replaced by a unit value specific to the factors listed

below (See Billing Instructions Manual): (i) Controlled Hypotension - when using a specific technique to produce hypotension in

association with an anaesthetic, the units will be increased.

(ii) Resuscitation of Newborn - When providing anaesthesia for a delivery, it becomes

necessary to provide active resuscitation of the newborn, an additional fee may be added to the mother's service encounter for anaesthetic. If the anaesthetist was not involved in the mother's care, service encounters for resuscitation should be claimed under resuscitation in

the normal manner. (iii) Anaesthesia for infants under 5000 grams - the units are increased. (iv) Anaesthetic for pacemakers - When monitoring of pacemaker function with pacemaker

monitoring programming equipment is performed in addition to the anaesthesia for

pacemaker insertion, an additional fee may be claimed. (v) Cardiac Bypass - When a pump with or without an oxygenator and with or without

hypothermia is employed in conjunction with an anaesthetic, the anaesthetic Basic Units will

be replaced. Note: Arterial catheterization, right cardiac catheterization (Swan Ganz) and central venous

pressure monitoring may not be claimed in addition to the basic units for cardiac bypass.

(vi) Hypothermia - When employed in conjunction with anaesthesia, the Basic Unit will be

replaced. (vii) Epidural Anaesthesia - The basic units for obstetrical or non-obstetrical pain management

for the introduction of catheter and maintenance care are different and will be distinguished

by an appropriate modifier.

Anaesthetic Time Units, except where otherwise specified, are computed by allowing one unit for each fifteen minutes, or part thereof, of anaesthesia time. Double time units apply when anaesthetic time extends beyond one hour for procedures with basic anaesthetic values of 4 or 5 units and after two hours when the basic is 6 units or greater. Anaesthesia time begins when the anaesthetist is first in attendance with the patient for the purpose of creating the anaesthetic state and ends when the patient has been placed under customary post operative supervision and the anaesthetist is no longer in personal attendance.

If resuscitation is necessary during the anaesthetic time, add the time for resuscitation to the anaesthetic time. Resuscitation and anaesthesia time cannot be claimed simultaneously.

May 2011 PREAMBLE - 23

8.2.10

8.2.11

8.2.4

8.2.5

8.2.6

8.2.7

8.2.8

8.2.9

Claiming for Procedures in Addition to Anaesthetic Fees When an approved add-on procedure is performed for the purpose of monitoring a patient intra operatively or post operatively; e.g., insertion of an arterial line, pulmonary artery catheter (SwanGanz) or central venous pressure catheter, nerve block or insertion of epidural catheter for postoperative pain management, the appropriate CCP codes may be claimed in addition to the usual anaesthetic fee according to rules for payment of multiple diagnostic and therapeutic procedures.

Anaesthetist's Presence Required Where a physician requests an anaesthetist to be available to provide monitored anaesthesia care at any period during which the physician is carrying out a procedure without general or regional anaesthesia, he or she shall be paid the usual anaesthetic fee for basic and time value for the complete period, whether or not anaesthesia is administered for any or all of that period.

The anaesthetist should be in the operating room area. During this time no other procedures may be claimed.

More than One Anaesthetist Present at the Same Time When special circumstances require the services of more than one anaesthetist in the interest of the patient, the second anaesthetist will be entitled to claim 50% of the applicable anaesthetic fee, except in the case where specific second anaesthetist fee schedules exist; e.g., liver transplantation.

Consecutive Anaesthetist Where one anaesthetist starts a procedure and is replaced by another during an anaesthetic procedure, the first anaesthetist should claim the appropriate basic fee plus time units for the time he or she is present and the second anaesthetist should claim the time units for which he or she is present. The start time of the first anaesthetist shall dictate when double time units begin, for either and both anaesthetists. The second anaesthetist will start to claim double time units when the double time unit point is reached, based on the case start time (if not already beyond this point, in which case double time units would be claimed at the time of takeover). Accordingly the consecutive anaesthetist must indicate the case start time as well as the consecutive start time. The end time for the first anaesthetist and the start time for the consecutive anaesthetist should coincide.

Anaesthetic Stand-By Fee This fee applies only when a scheduled anaesthesia is not given or is delayed for more than one hour. The stand-by fee is claimed using the Medical Service Unit Value rather than the Anaesthetic Unit Value and is calculated in half hour intervals or portion thereof. The specific Anaesthetic standby fee code is to be used.

Cancelled Surgery (a) If an anaesthetist examines a patient prior to surgery and (i) determines the patient is not a candidate for surgery and the operation is cancelled prior to

the induction of anaesthesia, the anaesthetist may claim a Limited Consult; or (ii) if the surgery is cancelled for some other (non-anaesthetic) reason prior to the induction of

anaesthesia, he or she may claim a Limited Visit (formerly hospital subsequent visit) for this

service. (b) If the operation is cancelled after induction, regardless of whether the Surgeon has started, the

procedural basic units plus time units shall apply, except in the case where a higher basic fee would apply, as might occur for example, in the case of a cardiac arrest resuscitation.

Bilateral/Multiple Procedures When bilateral or multiple surgical, diagnostic, or therapeutic procedures are performed during the same anaesthetic, the anaesthetist shall claim the Basic Units corresponding to the procedure having the highest Basic, plus Time Units. When procedures are performed at separate times with separate anaesthetics, the anaesthetist is entitled to claim full anaesthetic units for each procedure.

Anaesthetic Detention When the safety and welfare of the patient necessitates the presence of an anaesthetist immediately before or after anaesthesia for services not considered usual pre or post operative care, it is appropriate to claim this time as anaesthetic time and add it to the total time claimed.

May 2011 PREAMBLE - 24

8.2.12 If an epidural has not been inserted for labour or for the surgical delivery (C/S) but is inserted post delivery for pain control, an anaesthetist may claim for maintenance of post op epidural pain control using time units only.

8.2.13 An anaesthetist may claim a new basic for post op pain control following an initial anaesthetic service if there has been a time lapse from the time that he/she released the patient to the recovery room staff.

8.2.14

8.3 OBSTETRICAL SERVICES

8.3.1

(a) Routine prenatal care includes care for less serious obstetrical complications incidental to the

(b) Only one prenatal Comprehensive Visit may be claimed per pregnancy. (c) No more than 12 limited (routine) Prenatal Visits may be claimed for one patient's pregnancy

(d) All prenatal visits include pregnancy related counselling or advice to the patient or patient's

(e) Any prenatal visit, limited or comprehensive, includes a pap smear. The Prenatal

(f) Complicated pregnancies may require additional visits. (See Billing Instructions Manual )

8.3.2

8.3.3

Anaesthetic Independent Consideration For procedures indicated that have no listed value, the basic portion of the calculated value will be the same as that listed for a comparable procedure. Consideration for region and modifying conditions or techniques may be requested. Documentation of the modifying factors is required by MSI. (See Billing Instructions Manual)

Routine Prenatal Care

pregnancy; e.g., cystitis and simple anaemia, false labour, mild hypertension, leucorrhea, vaginal discharge and obesity.

regardless of the number of physicians involved.

representative(s).

Comprehensive Assessment includes venipuncture, as well.

Prenatal care does not include services rendered for major complications related to pregnancy requiring hospital care, visits or services for conditions unrelated to pregnancy, nor care of the newborn.

Attendance at Labour and Delivery This is a service involving constant or periodic attendance on a patient during the period of labour to provide all aspects of care. This includes the initial assessment, and such subsequent assessments as may be indicated, including ongoing monitoring of the patient's condition.

Obstetrical Delivery covers services rendered during delivery, including medical or surgical inductions by the attending physician, suturing of minor lacerations, hypnosis, detention time during labour, local or regional anaesthesia and manual removal of placenta by the attending physician, and all obstetrical maneuvers that may be required (e.g., use of forceps).

Obstetrical Delivery - Specific Rules (a) All deliveries performed between 1700 to 0800 hrs; all day Saturdays, Sundays and holidays (as

defined in 2.6) qualify for the appropriate premium fee. (See Section 7.4.2)

(b) Multiple Deliveries

(i) Multiple vaginal births are paid additional fees.

(ii) In the c ase of multiple births, when both a vaginal delivery and a Caesarian Section must be

performed, the C-section is claimed at full fee and the vaginal delivery at 65%.

(ii) When multiple babies are delivered by Caesarian Section, only one service encounter may

be made.

May 2011 PREAMBLE - 25

post operative visits with a pregnancy-related diagnosis are paid in addition to the surgical procedure.

(d) Obstetrical Non Surgical Deliveries

Pre-delivery consultations may be claimed only in exceptional clinical circumstances.

(e) (i) When the term of pregnancy has been 20 weeks or more, the delivery fee is paid in full. (ii) When the gestation period is less than 20 weeks, the appropriate procedural or visit code is

payable.

8.3.4

8.3.5

8.3.6

8.3.7

8.3.8

8.4 PAEDIATRIC SERVICES

8.4.1

Postpartum Care In hospital postpartum care is the routine care of a well mother in the postpartum period. Visits may be billed starting on the first calendar day following birth. Although not normally claimed by more than one physician, general practitioners and delivering specialists may charge postpartum visits concurrently.

Post Natal Care Visit A Post Natal Care Visit usually occurs about 6 weeks following delivery. The service may include a pelvic examination with pap smear. It may be billed only once following delivery by one physician. It is not considered a post-operative visit in the context of surgical/procedural rules. A diaphragm fitting or insertion of an IUD can be claimed with a postnatal visit.

Specialist Obstetrical Care Specialist rates may be claimed only when there is both a referral referral. The fact that the patient has been referred does not in itself indicate the presence of obstetrical difficulties necessitating referral. The indications for the medical necessity must be stated on the service encounter. Where there is no medical necessity, transfer of a patient to an obstetrician by a doctor who does not practice obstetrics is not a referral.

Obstetrician (or GP) Present to Assist at Delivery The following services may be claimed in addition to the service encounter for delivery by the physician receiving assistance.

(a) When an obstetrician’s presence is requested at a delivery performed by another physician,

he/she should claim an Obstetrical Delivery using the assistant modifier.

(b) When an obstetrician is present at a delivery to assist a General Practitioner, he/she may claim

a Specialist Obstetrical Delivery.

obstetrical services as being allowed to claim obstetrical assistance to another physician during labour and delivery. The rate claimed is equivalent to the Specialist Obstetrical Delivery.

Obstetrical Patients Transferred During Labour A transfer fee may be claimed for situations where a general practitioner admits and provides care for an obstetrical patient and then transfers that patient to another facility for delivery because of complications of the mother and/or fetus requiring specialist intervention. general practitioners only.

Detention may be claimed with this fee if the general practitioner accompanies the patient by ambulance to the second facility, but is only payable for the time the physician spends on route to the second facility.

The transfer fee, with or without detention, is not payable if the referring general practitioner attends the delivery at the second facility and is paid the delivery fee.

Newborn Care Newborn Care is the routine in-hospital care of a healthy infant on a daily basis up to the first five days after birth. It includes a Comprehensive Assessment, Limited Visits as appropriate and

and medical necessity for the

This fee is billable by

May 2011 PREAMBLE - 26

+ 399 hidden pages