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

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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.

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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.

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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.

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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.

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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.

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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

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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

(c) if travel time is involved, the rate will be paid based on the fee for detention as listed in the

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.

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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

(c) A Home Visit is a service rendered by a physician to a patient or patients following travel to the

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.

(c) A consult may not be claimed for referrals from other health care professionals; e.g., nurses,

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.

(c) The supervisory fee is for comprehensive management of all aspects of home dialysis care for

(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.

(c) However, if the patient has a medical problem necessitating referral to another physician, and

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.

(c) Two physicians may claim ICU fees for the same patient on the same day but not the same fee

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.

(c) In those situations where on a regular basis an attending physician might supervise concurrently

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.

(c) Post operative attendance is interpreted as terminating at that time when the anaesthetist is no

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

(c) Obstetrical Surgeries do not follow the usual surgical rules as stated in Section 9.3. Pre and

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.

(c) MSI recognizes and pre-authorizes certain non-obstetricians in areas without specialist

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

necessary parental advice. Care of unhealthy infants who are born with an existing medical condition,
or whose condition deteriorates after birth, should be claimed as any other hospitalized patient.
Newborn Care includes treatment of minor conditions.

Newborn Care may not normally be claimed for the same patient by more than one physician per
day. When a well baby is transferred to another hospital, service encounters for newborn care by a
physician at each hospital may be appropriate.

The fee for a circumcision or a release of tongue tie is payable in addition to a newborn care visit,
when medically necessary, and should be submitted as EC (Exceptional Circumstance) with text.

8.4.2

8.4.3

8.4.4

8.4.5

Well Baby Care
Well Baby Care refers to periodic office visits of a well baby for routine measurement of growth and
development, necessary parental instructions and necessary immunizations. Well Baby Care visits
are payable as one per month during the first six months; one visit during each three-month period up
to one year of age; and one visit at eighteen months of age. The visit fee at twelve months of age
have a four week buffer on either side of the first birthday for billing. The visit fee at eighteen months
of age have a two week buffer on either side of the date of eighteen months of age for billing.

Paediatric Care by a Paediatrician
(a) If newborn and premature care is provided by a paediatrician (care of a healthy newborn in

hospital), the paediatrician must claim at the same rate as Newborn Care for a General
Practitioner. No consultation is payable to the paediatrician if the infant is referred for the care
of a healthy newborn.

(b) If newborn and premature care is provided by a paediatrician to an infant who appears initially

well but becomes ill after a number of days with a condition that would normally require a
consultation, a Consultation may be claimed.

(c) Routine care is considered to include minor conditions; e.g., mild jaundice, cradle cap and mild

skin conditions.
Attendance at High Risk Delivery
(a) Paediatrician

Attendance by a paediatrician at a high-risk delivery is payable as a Comprehensive

Consultation and if it is extended beyond 1 hour, it is payable as a Prolonged Consultation.
(b) Non-Paediatrician

Attendance by a non-paediatrician at a high-risk delivery is payable as a Limited Visit in hospital

modified with the role of resuscitation.
Paediatric Care of Over-age Patients Age 16 up to and Including 18 Years of Age
(a) Services associated with the care of over-age patients in hospital by a paediatrician are to be

paid at paediatric rates.
(b) Paediatric consultations, whether comprehensive or limited, at any location for over-age patients

are to be paid at paediatric rates.
(c) Visits, excluding paediatric consultations, outside hospital for over-age patients are not to be

paid at paediatric rates except for:
(i) Behavioral management.
(ii) Follow-up visits in a paediatrician’s office for approved over-age patients with complex multi-

system medical problems. Application must be made in writing to the MSI Medical
Consultant and prior approval obtained for each patient.

May 2011 PREAMBLE - 27

8.5 PSYCHIATRIC SERVICES

8.5.1

8.5.2

8.5.3

8.5.4

8.6 PSYCHOTHERAPY
The following services apply to General Practitioners (See Definition in Section 2.4) and Psychiatrists.

Restrictions apply to General Practitioners only.
The provision of psychotherapeutic services by General Practitioners is limited to 20 hours per patient or

family or group per physician per year. To exceed this limit for individual patients or families or groups, the
General Practitioner must either: document on the chart and notify MSI, through the text field on the service
encounter, that a Psychiatrist concurs that extended psychotherapeutic services are needed; or, if the General
Practitioner is unable to access a Psychiatric Consultant directly, then the option will be available to obtain an
exemption in a timely manner through MSI from a Psychiatric Consultant(s) skilled in psychotherapy and its
applications.

8.6.1

Psychiatric Care
Psychiatric Care is any form of assessment or treatment by a psychiatrist on the Register of
Specialists of the Province of Nova Scotia, in which there is consideration and attempted alteration of
the patient's bio-psychosocial functioning.

Psychiatric Assessment
Psychiatric Assessment of an accused person when requested by the court requires the name of the
judge involved in the case.

Therapeutic/Diagnostic Interview
This service relates to a specific child and may take place with allied health professionals, education,
correction, or other community resources. This applies to interviews by psychiatrists but does not
preclude resident involvement.

Salaried/Contract (Facility-based) Psychiatry
This refers to non-Fee for Service psychiatric care provided in the context of public mental health
services.

(a) Physicians providing these services are remunerated on a salaried or contract basis.
(b) No physician providing Salaried/Contract Psychiatric services may claim on a Fee for Service

basis for any services to a patient registered as a public mental health services client except by
special arrangement between the director of the facility at which the patient is registered, MSI,
and the psychiatrist involved.

Individual Psychotherapy
Individual Psychotherapy is any form of treatment for mental illness, behavioral maladaptions and/or
other problems that are assumed to be of an emotional nature in which a physician deliberately
establishes a professional relationship with a patient for the purposes of removing, modifying or
retarding existing symptoms, of attenuating or reversing disturbed patterns of behavior and of
promoting positive personality growth and development.

(a) Individual Psychotherapy is claimed in 15-minute intervals. The therapist must spend at least

80% of the time claimed in therapeutic intervention with the patient.
Restrictions (Apply to General Practitioners only)

(b)
(i) A minimum of 2 intervals must be claimed per visit.
(ii) Treatment for medical complaints, acute adjustment reactions or bereavement reactions do

(iii) Unless unusual clinical circumstances can be demonstrated to the Medical Consultant at

• More than 90 continuous minutes (or 6 continuous fifteen minute intervals) per patient per

• A patient younger than 4 years old

• More than one General Practitioner treating the same illness for a particular patient

not qualify as psychotherapy. They should more appropriately be claimed as counselling.
MSI, individual psychotherapy may not be claimed for the following:

day

May 2011 PREAMBLE - 28

8.6.2

8.6.3.

8.7 HYPNOTHERAPY

The following services apply to General Practitioners and Psychiatrists.
Practitioners only.

Hypnotherapy is therapy undertaken with a patient who has been placed in an altered state of consciousness.
(a) Hypnotherapy is claimed in 15-minute intervals. The hypnotherapist must spend at least 80% of

(b) Physicians practising hypnotherapy should have appropriate training equivalent to that provided

(c)
(i) A minimum of two intervals must be claimed per session.
(ii) Unless unusual clinical circumstances can be demonstrated to the Medical Consultant at

Group Psychotherapy
Group Psychotherapy differs from individual psychotherapy in that it is provided to a group of 4 to 8
individuals per session.

(a) Group Psychotherapy is claimed in 15 minute intervals. The therapist must spend at least 80%

of the time claimed in therapeutic intervention with the group of patients.
Restrictions (Apply to General Practitioners only)

(b)
(i) A minimum of 2 intervals must be claimed per group session.
(ii) Unless unusual clinical circumstances can be demonstrated to the Medical Consultant at

MSI, Group Psychotherapy may not be claimed for the following:

• More than 2 continuous hours (or 8 continuous fifteen minute intervals) per group per day

• A group member younger than 4 years old

• More than one General Practitioner treating the same illness for a particular group of
patients

Family Therapy
Family Therapy is defined as psychotherapy in which the therapist regards the patients as a
subsystem of a “family” and in which the therapeutic responsibility is not only to the patients but to
other family members as well.

(a) The assessment rules are the same as for Group Psychotherapy, but 2 or more members of the

family must be present for the session to qualify as Family Therapy.

(b) Family Therapy is claimed in 15 minute intervals. The therapist must spend at least 80% of the

time claimed in therapeutic intervention with the family.
Restrictions (Apply to General Practitioners only)

(c)
(i) A minimum of 2 intervals must be claimed per family session.
(ii) Unless unusual clinical circumstances can be demonstrated to the Medical Consultant at

MSI, Family Therapy may not be claimed for the following:

• More than 2 continuous hours (or 8 continuous fifteen minute intervals) per family per day

• A patient younger than 4 years old

• More than one General Practitioner treating the same family group

Restrictions apply to General

the time claimed in direct therapeutic intervention with the patient.

by the Nova Scotia Society of Clinical Hypnosis workshops.
Restrictions (Apply to General Practitioners only):

MSI, hypnotherapy may not be claimed for the following:

• More than 10 hours per patient per physician per year

• More than 90 continuous minutes (or 6 continuous intervals) per patient per day

• A patient younger than 4 years old

• More than one General Practitioner treating the same illness for a particular patient

May 2011 PREAMBLE - 29

8.8 COUNSELLING
The following services and restrictions apply to General Practitioners only.

(a) Counselling is a prolonged discussion directed at addressing problems associated with

adjustment reactions or bereavement reactions.

(b) Counselling may be claimed in 15-minute intervals. At least 80% of the time claimed must be

spent in direct patient intervention.

(c)

8.9 LIFESTYLE COUNSELLING
The following services and restrictions apply to General Practitioners only.

Lifestyle Counselling is a prolonged discussion where the physician attempts to direct the patient in the proper
management of health related concern; e.g., lipid or dietary counselling, AIDS advice, smoking cessation,
healthy heart advice, etc.

(a) Lifestyle Counselling may be claimed in 15-minute intervals. At least 80% of the time claimed

(b)

at the same service encounter

Restrictions
Unless unusual clinical circumstances can be demonstrated to the Medical Consultant at MSI,
counselling may not be claimed for the following:

• More than 5 hours per patient per physician per year

• More than 1 hour per patient per day

• A patient younger than 4 years old

• More than one General Practitioner providing counselling to a particular patient

must be spent in direct patient intervention.
Restrictions

Unless unusual clinical circumstances can be demonstrated to the Medical Consultant at MSI,
lifestyle counselling may not be claimed for the following:

• More than 2 hours per patient per physician per year

• More than 30 minutes per patient per day

• A patient younger than 4 years old

• More than one General Practitioner providing lifestyle counselling to a particular patient

9. ASSESSMENT RULES FOR PROCEDURES

9.1 Procedures are a type of patient service distinguished from visits by several features. They generally have a
specifically defined technique involving either a physical therapeutic intervention with the patient; the obtaining
of some diagnostic sample, image or biophysiological measurement; or the interpretation of a sample,
measurement, or image. A procedure may include elements of a visit, evaluation, or care depending on the
specific procedure and the clinical setting.

9.1.1 Procedures fall into three categories for assessment purposes: Diagnostic and Therapeutic

procedures, Surgical procedures, and Fractures. Subject to the rules in this section, procedures may
be claimed in association with visit services, or with other procedures.

9.1.2 Procedures may be claimed only when they are carried out by, or under the supervision of, a

physician.

9.2 DIAGNOSTIC AND THERAPEUTIC PROCEDURES

9.2.1 No premium fees may be claimed for Diagnostic and Therapeutic procedures other than selected

Diagnostic Imaging Services (See Section 7.4.1)

9.2.2 Diagnostic and Therapeutic procedures can be performed in any location, with the exception of the

following procedures which have location-specific restrictions and may be claimed only when
performed by a physician in the appropriate (sub) specialty:

acute

May 2011 PREAMBLE - 30

(a) When performed outside of a hospital
(i) Electrocardiogram - Internist and Paediatrician.
(ii) Electromyogram - Neurologist (including Paediatric Neurologist), Physiatrist and

Neurosurgeon

(iii) Electroencephalogram - Neurologist (including Paediatric Neurologist) and Neurosurgeon.
(b) When performed in hospital

(i) Stress Test - Internist and Physiatrist in approved centres (See Billing Instructions Manual)
(ii) Procedures performed in a catheterization lab - Cardiologist (including Paediatric

Cardiologist) and Radiologist

(iii) Intensive care associated with Respiratory Insufficiency - Anaesthetist.

9.2.3 Submaximal Exercise Testing

(a) This service may only be claimed in approved centres as noted in Item 9.2.2 (b)(i) above.
(b) If the patient has been seen in consultation by the specialist performing the test within the

previous 14 days, no visit service or consultation may be claimed.

(c) If the patient has not been seen by the specialist within the previous 14 days, a Comprehensive

Initial Visit or consultation service may be claimed.
However, it should be noted that there must be a medical necessity for the comprehensive visit

and components of this visit (as outlined in section 7.2.2 of the Preamble) must be performed
and documented in the patient’s chart. Similarly, if a consultation is claimed with an exercise
test, the rules governing referred services (section 7.5 of the Preamble) must be followed.

(d) If the patient has been examined by another specialist within the previous 14 days for a problem

related to the condition for which the exercise test is being performed, a Comprehensive Initial
Visit service, but not a consultation, may be claimed.

9.2.4 Interpretation of Holter Monitoring may be claimed only when abnormalities are present. (Billed

through Facilities - not to MSI)

9.2.5 Where multiple diagnostic and therapeutic procedures are performed at the same service encounter,

the procedure with the greater value is claimed at 100% and subsequent procedures at 50%.
Procedures defined as “Add-Ons” in the schedule text may be claimed at 100%.

9.2.6 Service encounters by assistants are not normally applicable to Diagnostic and Therapeutic

procedures with the following exceptions. Assistant fees should be claimed at the current surgical
assistant rate (See Section 9.5.1).

(a) Excisional breast biopsy after localization of a mammographic abnormality.
(b) Mediastinoscopy: when assisting with a mediastinoscopy, regardless of whether a flexible or

rigid bronchoscopy is also performed, claim the assistant fee for mediastinoscopy alone.
(c) Fetal procedures under ultrasound guidance.
(d) Catheter ablation of cardiac arrhythmias.
(e) Percutaneous Endoscopic Gastrostomy.
(f) Percutaneous Endoscopic Gastro-jejunostomy.

9.2.7 Venipuncture for the purpose of blood collection is not an insured service when performed by a
physician with the following exceptions:

(a) The physician's office is greater than 24 km (15 miles) from the closest laboratory blood

collection service.

(b) When the physical condition of the patient makes it medically necessary for the physician to

personally take the sample.

9.2.8 Nasogastric (Levine) tube insertion is considered part of the appropriate visit service encounter.

May 2011 PREAMBLE - 31

9.2.9 Diagnostic and therapeutic procedures are divided into two groups, procedures that cannot be
claimed with a visit code, and those where a visit service may be claimed if one is provided.

(a) Procedures designated as “visit excluded” cannot have a service encounter for any visit service

from the same service encounter.

(i) When a visit excluded procedure is the sole reason for the service encounter, the procedure

alone should be claimed.

(ii) If a visit service and a visit excluded procedure are provided at the same service encounter,

only the service of greater value should be claimed.

(b) Procedures designated as “visit allowed” may have a service encounter for any visit-related

service from the same service encounter with the exception that the following procedures may

not be claimed in association with a consult:
(i) Cerumen - removal of - unilateral or bilateral
(ii) Tonometry
(iii) Gonioscopy
(iv) Visual fields (tangent, screen and/or perimetry)
(v) Flexible fibre - optic endoscopy of the nose, nasopharynx, and larynx
(vi) Pap smear
(vii) Venipuncture of a person 7 years or older
(viii) Medical certificate for observation for psychiatric evaluation 1st doctor
(ix) Medical certificate for observation for psychiatric evaluation 2nd doctor

9.2.10

9.2.11

Provincial Immunizations
Physicians may claim for the administration of immunizations covered by the Provincial Immunization

Program. These services may be claimed by any registered physician.
If one vaccine is administered but there is no associated office visit billable, i.e. the sole purpose of

the visit is the immunization, one injection can be claimed at a full fee.
If one or more vaccines are administered in conjunction with an office visit, the office visit and the first

injection can be claimed at full fee. All subsequent injections will be paid at 50% of the specified
MSU.

If two vaccines are administered at the same visit but there is no associated office visit, a claim for
each specific immunization can be submitted at full fee. All subsequent injections will be paid at 50%
of the specified MSU.

For children eighteen months of age and under, if a vaccine is administered in conjunction with a well
baby care visit, the well baby care visit and the immunization may be claimed.

Tray Fees

Provincial Immunization Tray Fee - When a physician has incurred the cost of supplies when

(a)

administering an immunization covered by the Provincial Program, a tray fee can be claimed for

each injection. There is to be no charge to the patient/family for the supplies and/or disposables

associated with any of these immunizations. Maximum of four tray fees can be claimed per

service encounter.

Pap Smear Tray Fee - When a physician has incurred the cost of supplies when performing a

(b)

pap smear, a tray fee can be claimed. There will be no charge to the patient for any supplies,

equipment or disposables associated with the performance of a pap smear.
The following billing guidelines should be used:

(i) A pap smear tray fee can be claimed when a pap smear is performed alone or as part of a

comprehensive examination, an office visit, or a gynecological procedure.

(ii) An office visit may be claimed in conjunction with a pap smear only if the visi t is for a

nongynecological complaint.

(iii) A visit for a pap smear and an unrelated medical condition can include a claim for the office

visit, pap smear, and pap smear tray fee.

May 2011 PREAMBLE - 32

9.2.12
(a) When referring to electromyography with muscles of more than one region, or

(b) When referring to nerve condition studies, per nerve studied: “per nerve studied” is

branch are required.

9.3 SURGICAL SERVICES

9.3.1 Surgical procedures are described as Major if they have a value in excess of 50 units:

9.3.2 Surgical procedures are described as Minor if they are less than or equal to 50 units:
(a) When a visit service is provided during the same service encounter as a minor surgical

(b) A consultation prior to surgery may be claimed, even if the surgery is on the same day, except

Electromyography

examination of a specific region, “region” is intended to mean one or more of the four following

anatomical areas: head and neck, both upper limbs, both lower limbs; trunk (anterior and

posterior).

intended to mean both the motor and sensory never conduction examination of a single nerve

(mixed, motor or sensory). Multiples may be claimed when another nerve (mixed, motor

or sensory) is examined and when separate nerve conduction studies of a major nerve

(a) The procedure fee is intended to cover the operation and customary pre-operative, operative

and post-operative care by the surgeon or a designated covering physician.
(i) A consultation at any time prior to surgery may be claimed, even if the surgery is on the

same day. A visit other than a consultation is not payable the same day as a major surgical
procedure.

(ii) Preoperative care includes:

• Comprehensives visit (the admission history and physical exam).

• Hospital visits for up to two calendar days immediately prior to and including the day of

surgery.

• Hospital visits in a preoperative period that extends beyond two days should be claimed

using the appropriate visit codes.
(iii) Postoperative care includes care during the postoperative hospital stay up to 14 days.
(iv) Urgent Visits or Emergency Hospital Visits (See Item 7.2.7) to attend the patient for an

unrelated condition are not included in the surgical benefit and may be claimed accordingly.

(v) Hospital Visits may be claimed starting on the 15th postoperative day for visits if the

postoperative in hospital stay exceeds 14 consecutive calendar days. For the purpose of
calculation, the day of the last operative procedure is considered day 0. Weekly routine visit
maximums beyond 56 days apply starting from the date of admission.

(vi) When a patient is readmitted to hospital during the first 14 days of the post surgical period

because of post-operative complications which do not require a surgical procedure, the
surgeon or other physician attending this readmitted patient should claim hospital visits as
for a new admission.

Note: There will be no reduction in the surgical payment when a service related to the

surgery is claimed by another physician in the post-op period.

procedure for a reason other than the condition for the minor surgery, the greater of either the
visit or the minor surgery may be claimed, otherwise only the minor surgery service encounter
applies. However, in the case of a service encounter for suture of a laceration with a value less
than or equal to 50 units, the appropriate visit may also be claimed.

where the consultation is explicitly included as part of the procedure.

May 2011 PREAMBLE - 33

(c) Post-operative care following minor surgery may be claimed, except for those minor surgical

procedures which specify “complete care” and include all post-operative visits by the same
physician in the 14 days following the procedure.

(d) The services of an assistant at minor surgery are not usually required.

9.3.3 Special restrictions or interpretations applicable to Major or Minor Surgery:
(a) Procedural codes and their associated tariff are intended to remunerate the physician for all

parts of the procedure that would normally be considered the defined technique for that
procedure. It is not appropriate to de-construct (unbundle) the procedure into constituent parts

and bill MSI for these codes in addition to the procedural codes.
(b) Local anaesthesia is not payable in addition to the surgical fee.
(c) Endoscopic procedures performed on a patient on the same day as major urological surgery by

the same physician may be claimed at 50% in addition to the major surgical fee except where

the surgery is done in a separate operating room. Other diagnostic and therapeutic procedures

may be claimed at 100% with other major urology surgery.
(d) When one physician performs a definitive procedure on an organ or within a body cavity, only

that service should be claimed. The procedure used to provide surgical exposure should not be

claimed; e.g., a laparotomy is not to be claimed to provide access to the abdominal cavity

except when no definitive procedure is performed within the abdomen. When one physician

provides surgical exposure for a procedure performed by a physician in another specialty, the

exposure and definitive procedures may be claimed separately by the respective physicians.
(e) Fees for the application of casts, splints and dressings at the time of surgery may not be

claimed.
(f) Fees for the application or removal, by the operating surgeon, of casts, splints and dressings

during the 30 days following surgery may not be claimed.
(g) Vascular Procedure Service encounters

(i) Repair/bypass/graft includes thromboendarterectomy and/or anastomosis and/or

thrombectomy of the peripheral artery being repaired, and harvesting of vein unless
otherwise specified in the procedure description.

(ii) Common femo ral arter y repair includes repair to the profunda artery before the second

major branch of the profunda artery.

(iii) If the profunda artery repair extends beyond the second major branch of the profunda

artery, an extended profundoplasty fee may be claimed in addition as the second
procedure.

(iv) When resection of an abdominal aneurysm is combined with an aortic graft plus femoral

artery repair (unilateral or bilateral) only one procedure, which ever has the higher unit
value, should be claimed.

(h) Arthroscopy
(i) Composite arthroscopy fees include the procedure and arthroscopy.
(ii) When other or multiple surgical procedures are performed through the arthroscope, only the

major fee applies.

(i) Injections of medication into a bursa, ganglion, joint, or tendon may not be claimed with surgery

performed in the same location. This applies whether the medication is delivered via

arthroscope or directly into the location.
(j) Compression Sclerotherapy (Feganization)

Codes for compression sclerotherapy for varicose veins are designed to cover all services for

that diagnosis, for the same leg, for a period of one year.
(k) Bilateral Procedures

(i) Unless otherwise specified, bilateral procedures are claimed at an additional 50% of the

unilateral procedure.

May 2011 PREAMBLE - 34

9.3.4 Cancelled Surgery

9.4 FRACTURES

9.4.1

9.4.2

9.4.3

(ii) When bilateral procedures are performed subsequent to a major procedure through the

same incision they should be claimed at 50% and 25%.

(iii) When bilateral procedures are performed subsequent to a major procedure through a

separate incision, they should be claimed at 65% and 32.5%.

(iv) When performed under separate anaesthetics at an interval, the full fee will be charged for

each procedure.

(l) Multiple Procedures - Same Physician
(i) When multiple operative procedures are performed through a single incision in the course of

an abdominal operation or on any one organ or cavity, the principal procedure will be
claimed plus 50% for the secondary procedures (secondary incidental procedures, such as
appendectomy, which are not indicated by pathology, shall not be claimed).

(ii) A physician who performs multiple operative procedures simultaneously in different areas

and through different incisions shall claim for the major procedure plus an additional 65% for
each of the lesser procedures. Laparoscopic operations are considered to utilize a single
incision regardless of the number of incisions.

(m) The full procedural fee will apply when subsequent, related operative procedures are performed

during the postoperative period.
(n) Combinations of Multiple and Bilateral procedures should be claimed based on the rules

applicable to the highest valued procedure.
(o) Unrelated Surgical Procedures - Different Physicians

When two or more unrelated procedures are performed through separate incisions or in

unrelated areas, but utilizing the same anaesthetic, by two different physicians in different fields

of practice and with different skills, the fee provided in the Schedule under each procedure will

be paid at 100% to each physician.
(p) An arthrodesis procedure includes bone grafting.
(q) Debridement

All claims for debridement, HSC 98.11, must indicate in electronic text the area debrided, the

start and finish time, and whether performed under a local or general anaesthetic. Only the time

from the start to the finish of the debridement may be claimed.

In the event of cancellation of surgical procedure, regular visit rules apply for surgeons.

Surgical Rules (See Item 9.3) apply to treatment of fractures except:
(a) A fracture procedure (not dislocation) includes necessary after care up to 42 days. The

application and removal of casts or traction devices is included in the fee, even if removal takes

place after the 42 day period.
(b) Regardless of the type of anaesthesia employed, all fracture service encounters are eligible for

premium fees during the designated times.
Major Fractures

Major fractures are defined as those requiring procedures in excess of 50 units. Rules for major
surgery apply and an appropriate consult may be claimed pre-operatively. A comprehensive
consultation is appropriate only for those patients who are referred with significant systemic illness or
requiring general anaesthesia. A limited consultation is appropriate only for those patients who are
referred and where the diagnosis is unclear or management alternatives require prolonged
discussion or assessment.

Minor Fractures
Minor Fractures are defined as those procedures less than or equal to 50 units. Minor surgical rules
apply to minor fractures including preoperative consultation. (See consult guidelines in 7.5) Rules
regarding non-bilateral multiple fractures may be claimed at fee + 65%. However, the 42-day
aftercare rule does apply.

May 2011 PREAMBLE - 35

9.4.4

9.4.5

9.4.6

9.4.7

9.4.8

9.4.9

9.4.10

9.4.11

9.4.12

9.4.13

9.4.14

Fracture and Non Fracture Procedures Performed at the Same Service Encounter
(a) When fracture procedures and non fracture procedures are performed at different sites, claim

100% for the greater and 65% for the lesser procedure.
(b) When performed at the same site, claim 100% for the greater procedure and 50% for the

lesser procedure.
Treatment of Fracture with No Reduction

When a fracture is treated by any method other than an open or closed reduction, visit fees apply.
This shall include the application, changing and removal of casts and/or splints.

Closed Reduction
Closed reduction is the reduction of a fracture by manipulation or traction.

Multiple Closed Reductions
Where multiple closed reductions are carried out for the same fracture, at different service
encounters, the following rules apply:

(a) When performed by the same physician, claim 50% for each reduction.
(b) When performed by different physicians the first physician’s payment will be reduced to 50% of

the listed fee and the second physician's payment will be valued at 100%.
Open Reduction

Open reduction is the reduction of a fracture by an operative procedure and includes exposure of the
fracture site with fixation as indicated. If an open reduction with extensive debridement is necessary,
the appropriate open reduction should be claimed plus a service encounter for independent
consideration or exceptional clinical circumstances covering the debridement portion of the service.
The supporting text should indicate the total duration of service.

Multiple Open Reductions
Multiple open reductions performed at different service encounters may each be claimed at 100%.

Closed followed by Open Reduction
Where a closed reduction is followed by an open reduction, whether performed by the same or
different physician, the service encounter will be reduced to 50% for the closed reduction and the
service encounter for the open reduction will be valued at 100%.

Compound Fractures or Dislocations
The following should be applied when claiming for treatment of a compound fracture or dislocation:

(a) The service encounter for

service encounter for the appropriate (non-compound) fracture or dislocation.
(b) If an
Multiple Fractures

Where multiple major fractures are treated by the same surgeon the greater procedure is claimed at
100% and 50% is claimed for each additional fracture.

Re-Fracture
Where a re-fracture procedure has been performed, a service encounter for exceptional clinical
circumstances may be made.

Bone Grafting for Fractures
(a) For a primary bone graft in a fresh fracture, claim 50% of the appropriate bone graft code in

(b) Treatment of a non-union fracture with bone grafting is claimed under the appropriate bone graft

(c) Reaming is not considered a “bone graft” for assessment purposes and should not be claimed.

open reduction is performed, only a service encounter for the open reduction will apply.

addition to the primary fracture procedure.

procedure code except when there is a new displacement where both the open reduction and

the bone graft are claimed.

closed treatment of a compound fracture or dislocation is 150 % of the

May 2011 PREAMBLE - 36

9.5 SURGICAL ASSISTANTS
A surgical assistant is defined as a physician who assists the operating surgeon throughout a substantial
portion of the operation.

9.5.1

9.6 RADIATION ONCOLOGY
Treatment planning may not be claimed with a consultation on the same day by the same physician.
However, it may be claimed as an additional fee following gold seed and caesium needle implants. Gold seed
and caesium needle implants should be classified as major surgical procedures.

9.7 PATHOLOGY AND DIAGNOSTIC IMAGING SERVICES
Most service encounters for services in the schedule of benefits for these specialties are processed by a
special arrangement with MSI. These service encounters are limited to hospital based physicians in the
appropriate specialties. Procedures not covered by these special arrangements should be claimed on a fee
for service basis as listed in the Schedule of Benefits.

Diagnostic Imaging service encounters should conform to the requirements set out in the Preamble.

Surgical Assistant's Service Encounter
An assistant should render a separate service encounter for services provided. A surgical assistant's
service encounter is 33.8% of the surgical fee regardless of whether the assistant is certified as a
specialist. The service encounter should be calculated to the nearest unit with a minimum of 21
units. However, when a general practitioner that has participated in the prenatal care assists at a
vaginal delivery or a Caesarean Section, he/she will be paid a full general practitioner delivery fee.
The delivery fee would apply to another general practitioner covering the practice.

(a) Surgical assists are not payable for minor procedures or diagnostic and therapeutic services,

except as defined in 9.2.6. When ADON (add on) procedures are done during a major surgical
procedure for which a surgical assistant is payable, the assistant’s service encounter is 33.8% of
the total surgical fee. In unusual circumstances where an assistant fee is not normally paid, the
assistant should submit a service encounter with an accompanying letter from the surgeon
explaining the necessity. In cases of fracture procedures, no visits may be claimed pertaining to
the post fracture care up to 42 days following the fracture procedure. (See Item 9.4)

(b) A surgical assist is not payable for some major surgical procedures. A list of codes is provided in

the Billing Instructions Manual.

(c) Service encounters for routine hospital visits, in the 14 days post-op, are not allowed in addition

to an assist fee. However, service encounters for the following services are allowed:
(i) A home, office or OPD visit on the same day if medical necessity is established
(ii) Comprehensive visit same day as trauma or emergency surgery
(iii) Procedures with visits allowed.
(iv) Supportive Care
(v) Visits in postoperative period for diagnosis unrelated to the surgery
(vi) If transfer of care from the surgeon to the assistant occurs because the surgeon is

unavailable (e.g., out of town) the assistant may claim daily visits for in-hospital post-op
care.

(d) Second Assistant

When a second assistant is necessary, his or her claim is 50% of the stated service encounter

for the first assistant with a minimum of 10.5 units. The need for a second assistant is to be

supported by a letter from the surgeon explaining the necessity.
(e) Cancelled Surgery

(i) When an anaesthetic has begun and the operation is cancelled prior to commencement of

surgery, if the assistant has scrubbed but is not required to do more, only a Hospital Visit
may be claimed.

(ii) If the operation is cancelled after surgery has commenced, the procedural units for the

intended principal procedure will apply.

May 2011 PREAMBLE - 37

9.8 FACILITY NON-PATIENT SPECIFIC BULK BILLING

An agreement between Doctors Nova Scotia and the Department of Health regarding the introduction of a Fee
Schedule for Radiology/Non-Patient specific fees became effective June 1, 1995.

Bulk billing refers to non-patient specific services billed through MSI on approved programs (e.g., radiology,
pathology, internal medicine). The following section provides information on the programs that are approved
and paid through MSI. The appropriate forms outlining the MSI billing codes are available upon request from
the Alternate Funding Department, MSI.

9.8.1

A. Radiographs

Radiology
Interpretation Fee

This represents the benefit for consultation between the radiologist and the referring service provider,
fluoroscopy, interpretation of diagnostic images, fluoroscopic findings and supervision of diagnostic
imaging services by a radiologist. If a formal written report is not generated on a separate document,
the interpretation fee is incomplete and may not be billed. In addition, an immediate oral report may
be given if indicated and/or requested.

Fee Schedule Interpretation
Self referral is not ethical and a consultation with the referring service provider should be held before
performing any further examination. However, where the referring service provider is not immediately
available, in exceptional cases further examination may be provided if considered necessary by the
radiologist.
Although there is no provision for “additional views”, the Fee Schedule recognizes that added views
are sometimes necessary; therefore, this has been taken into consideration for fees where additional
views may be performed.

 When a requisition for one extremity is received, no additional charge shall be made for

comparison x-rays of the opposite site.

 IVP includes an abdominal survey film. No separate claim shall be made for the abdomen. If

tomography is routinely performed there shall be no extra fee.

 The fluoroscopy claim shall not be submitted for an examination performed by the radiologist

where fluoroscopy is an integral part of the examination; e.g., examination of GI Tract, Urinary
Tract, Special Procedures.

 The Fluoroscopy Only charge is for use when no other procedure is claimed.
 Abdomen and chest studies shall not be claimed in gastrointestinal (G.I.) and genitourinary

(G.U.) examinations.

 Sacrum/coccyx, abdomen, S.I. joints and pelvis shall not be claimed in lumbar spine

examinations. Thoracic spine shall not be claimed in chest examinations.

 Chest studies shall not be claimed in mammography cases.
 Nasal bones or sinuses shall not be claimed in skull examinations.
 An Upper G.I. series includes a study of the swallowing mechanism and esophagus. An

esophagus can only be billed if additional special views including video, food bolus, etc., are
made.

 Submitted films are films deemed to be those from another institution whose reinterpretation has

been requested by a service provider.

May 2011 PREAMBLE - 38

 The necessity of having plain film studies available prior to special procedures (e.g.,

myelography) is obvious. It is not essential that they be done at the same institution. If they
have been done at an outside institution, then it is the responsibility of the referring service
provider and the radiologist to have these films available. If, however, they cannot be made
available to the radiologist, it is acceptable practice to repeat the appropriate examination and
claim for it.

 Reasonable effort should be made to review original examinations f rom another centre. No

current outside examination of acceptable quality should be repeated.

 When using the paediatric codes, Upper G.I., Colon and Cystography, it is recognized the added

time these examinations take; however, the age limit for these fee codes is twelve (12) years not
sixteen (16) years as in the workload measurement system.

 When a CT examination is performed with and without contrast, the combined code shall be

used.

B. Ultrasound

 An abdominal general ultrasound includes a study of all appropriate areas and organs. No

restricted or special fees may be added to this examination. Specific fees shall be used as
appropriate; e.g., Pylorus, Appendix, Aorta, Kidneys and Bladder; these fees are not
cumulative.

 An ultrasound examination of the pelvis in the first trimester of pregnancy is to be billed as a

Pelvic Ultrasound.

 Biophysical profile, shall only be charged when films are made and a written report

generated by a radiologist.

 The fee for a radiologist performing a portable examination is an add-on fee to be charged

for studies performed outside the department which require the radiologist to be in
attendance for the entire examination.

 When both pelvic and endovaginal examinations are performed, they shall be as

endovaginal with pelvic.

 The intraoperative code is to be used when the radiologist is present in the operating room

and no other code may be claimed for that examination.

C. Vascular Studies

 Unilateral and Bilateral Venogram studies of the extremities should include a central film. No

additional claim may be made for that film.

 Only one claim should be made for angiography, irrespective of the number of modalities

used; e.g., cut film, DSA, cine.

 No claim may be made for an arch or abdominal aortic angiogram unless a proper flush

study has been performed. An angiographic interpretation fee may only be charged when
the vessel has been specifically selected and films taken.

 The DSA interpretation fees apply to venous injections only.

D. Drainage or biopsy procedures

 Drainage or biopsy procedures charged through MSI billing include imaging and no separate

claim may be made for the imaging or interpretation. Abscess cavity films are part of the
drainage fee.

E. Nuclear Medicine

 A Thyroid Uptake Special includes stimulation and/or suppression studies.

May 2011 PREAMBLE - 39

9.8.2

9.8.3

(a) Surgicals, gross and microscopic

 Bill both Plasma Volume and Red Cell Volume only if they are measured separately.
 A.C.E. Inhibitor Renogram should be billed when the A.C.E. Inhibitor is administered by and

directly supervised by the service provider. If not, a Renal Scan and Renogram should be
billed.

 Renal static imaging is to be billed instead of a renal scan and renogram when only static

(e.g., - DMSA) images are obtained.

 Residual Urine Volume is an add-on fee.
 Tomography will be an add-on fee, every time it is used.
 Hepatobiliary with a pharmacologi cal stimulation includes either morphine stimulation or

C.C.K. Stimulation.

 “One area” for Bone, Bone Marrow and Gallium Scans i ndicates one body area; e.g., skull,

foot, pelvis.

 Flow Studies, when appropriate, will be an add-on fee.
 Computer manipulation is included in the interpretation fee and is no longer recognized as a

separate item.

 Myocardial rest quantitative, myocardial stress and rest quantitative, are add-on fees.

one

 Tumour imaging includes

imaging studies e.g., - labeled antibody studies for the specific detection of tumours. It does
not include other studies with specific codes. It is not an add-on fee.

Internal Medicine
 Electrocardiogram, electroencephalogram and holter monitoring are for interpretation only when

performed in hospital.

 Pulmonary functions: simple spirometry, flow/volume loops, helium dilution, carbon monoxide

single breath, pulmonary stress test, bedside spirometry, body plethysmography are insured
when performed in hospital.

 Echocardiography: M-mode, two di mensional, doppler-quantitative, doppler-qualitative are

insured when performed in hospital.

Pathologists
Effective October 1, 1993, the responsibility for payments to Pathologists for fee-for-service

payments (Pathology Units) was transferred to Medical Services Insurance (MSI). Salary payments,
management fees and sessional payments will continue to be paid by hospitals. All billings are
forwarded to MSI directly by the service providers performing the services.

Pathologists may claim Pathology Units from MSI by submitting the list of services on the claim
forms. Service providers may assign payments to group practices. Each pathologist must submit a
separate form for his/her services.

Third party request for services should continue to be billed directly to the third party (e.g., medical
examiners autopsies or requests from WCB, etc.)

When more than one surgical specimen is received from a patient, the following rules apply:

 P2325 - may be claimed for each specimen taken from anatomically distinct surgical sites.

whole body imaging for thyroid cancer or specialized tumour

May 2011 PREAMBLE - 40

 P2345 - may be claimed when 3 or more separate surgical s pecimens are taken from the

same anatomic site.

 P2346 - may be claimed when a single large complex cancer specimen, which includes

lymph nodes, is examined for the purposes of providing a pathologic cancer staging.

Definitions:

Anatomically distinct site: For the purposes of correctly interpreting anatomic pathology fee code

P2325, the body is considered to be divided into the following distinct anatomical areas: head

and neck; upper limbs; trunk (anterior and posterior). The following organ systems are also

considered to be distinct surgical sites: upper GI tract; female reproductive system; male

reproductive system; separate organs within the abdominal or thoracic cavities may be claimed

as distinct sites. For example, 2 separate skin specimens from the right and left arms are

considered as one site; specimens from uterus and ovary are one site; specimens from colon

and liver are two sites.

Clarifications:

Frozen Sections (intraoperative consult with tissue): For the purposes of correctly interpreting

anatomic pathology fee code P2326, all frozen sections taken from one surgical specimen are

considered to be one frozen section. When separate organs or anatomic areas are sent for

frozen section, then it is appropriate to bill for 2 frozen sections; separate sentinel nodes may

also be considered as separate specimens. For example, examination of several margins from

one skin cancer is one frozen section; examination of multiple margins from two separate skin

cancers (even though they may be within the same anatomically distinct surgical site as defined

above) can be considered as two frozen sections.

9.9 OPHTHALMOLOGICAL SERVICES

9.9.1
(a) An eye examination is payable under MSI when it is medically required. The service encounter

(b) Coverage for

(c) Visual Fields, Tonometry and Gonioscopy are included in the fee for a complete eye exam and

9.9.2

Complete Eye Examination

should show an indication of presenting symptoms or diagnoses.

under 10 years of age and for those 65 years of age and over. For all others, routine refractive

vision analysis is an uninsured service.

ophthalmological consultation.
Contact Lens Fitting
Fitting of medically indicated contact lenses by a physician is an insured service under Nova Scotia

Medical Services Insurance. In view of continuing developments and improvements in contact lens
materials and therapy, it is recognized that they may prove to be of benefit in conditions not as yet
listed.

(a) There are two types of lenses recognized:
(i) Bandage contact lens/lenses should be claimed for Zero prescription lens/lenses applied to

immobilize the eye to enable recovery for certain conditions. Follow-up visits may be
claimed in addition.

(ii) Corrective lenses may be fitted to restore monocular or binocular vision where this cannot

be achieved by other methods and to improve visual fields where this is compromised by
high refractive error.

(b) Conditions for which contact lens fitting is an insured service on the basis of medical necessity:

Albinism, aniridia, anterior membrane corneal dystrophies, aphakia, astigmatism requiring over

5 dioptres of cylindrical correction, bullous keratopathy, chronic corneal edema, corneal

abrasion, corneal burn, corneal lacerations, corneal ulcer, descemetocele, dry eye syndromes,

entropion, high refractive errors (6 dioptres spherical equivalent or over in children under age

16, 10 dioptres spherical equivalent or over in adults), keratoconus, neuroparalytic keratopathy,

nystagmus, old trachoma, paralysis of superior rectus muscle, pemphigus, post penetrating

keratoplasty, postoperative discomfort or lacerations or perforations, prevention of

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

May 2011 PREAMBLE - 41

symblepharon, recurrent cornea erosion, Stevens-Johnson disease, stromal herpes simplex,

thermal burns, trichiasis, vernal conjunctivitis, anisometropia, corneal degeneration, epithelial

defect, pathological myopia, Marfan's Syndrome and pseudophakia.
(c) Conditions for which contact lens fitting may not be claimed:

Macular degeneration, open angle glaucoma, diabetic retinopathy, strabismus, borderline

glaucoma and amblyopia.
(d) Contact lens fitting includes follow up for 90 days by the same physician.

9.9.3 A complete ophthalmological exam including refraction may be claimed before and after cataract
surgery.

9.9.4 When as the result of an error or omission by the patient, an insured service is provided within the
two-year limit, the provider will be notified by MSI that an uninsured service has been rendered. The
provider may then bill the patient the usual and customary fee. If the provider is unable to collect, a
reduced fee will be paid by MSI. This service applies only to patients in the insured age group.

9.10 PRONOUNCEMENT OF DEATH
For attendance on the patient for the purpose of pronouncement of death, a Limited Visit may be claimed.

9.11 DENTAL SERVICES

9.11.1 Referrals from dentists to physician specialists are acceptable provided that the dentist discuss the

patient with the family physician before seeking such consultation and that the physician specialist
send a copy of his or her report to the family physician as well as to the referring dentist.

9.11.2 Other Physicians' services provided at the request of a dentist are regarded as non-referred services;

consultation or referred visit service codes shall not be used when submitting service encounters.

10. PROCEDURES FOR AMENDMENTS TO THE PRE AMBLE AND FEE S CHE DULE

10.1 When it is necessary, in the course of normal program administration, to make interim interpretations of the
Preamble or Schedule of Benefits, MSI will utilize the following process.

10.1.1 Interim interpretations and interim fees will be published in a Physician’s Bulletin.

10.1.2 If permanent fees are negotiated between the Department of Health and Doctors Nova Scotia, the

appropriate section(s) of the fee schedule will be updated.

10.2 Fee Codes will be reviewed every two years. If there is no utilization of a fee code for two years, MSI will
consult with Doctors NS who will inform the appropriate sections. If there is no valid reason for maintaining
the code, MSI will remove the code and communicate this change in a Physician’s Bulletin.

May 2011 PREAMBLE - 42

EXPLANATORY CODES - 1

May 2011

E

C

AD002

Service encounter has been refused as a duplicate billing exists.

AD003

Service encounter has been refused as electronic text is required.

AD004

Service encounter has been refused as this service has previously been approved.

AD005

Service encounter has been refused. A previous service encounter for 13.59L, RO=INPN has been
approved at this same encounter.

AD006

Service encounter has been refused as a previous service encounter has been approved and
includes this service.

RO=INTD.

new service encounter using the appropriate combination modifier value.

encounter for the combination of this immunization and the one from the deleted service encounter.

AD011

Service encounter has been refused. Previous payment has been made this day for a portion of this
combination injection.

AD012

Service encounter has been refused. Previous payment has been made this date for a portion of
this combination injection.

AD013

Service encounter has been refused as electronic text is required for this service to be approved at
location indicated.

AD014

Service encounter has been disallowed as surgery has been performed during this hospitalization.

AD015

Service encounter has been disallowed as a previous service encounter has been approved for the
discharge fee at this hospitalization.

AD016

Service encounter has been disallowed as surgery has been performed by you during this
hospitalization.

AD017

Service encounter has been disallowed as patient history indicates conflicting hospital admit dates.
verified the date.

code.

approved to you.

service.

AD021

Service encounter has been refused. Previous approval has occurred to you under MMRV.

AD022

Service encounter has been refused. Previous approval has occurred to you under PENV.

AD023

Service encounter has been refused. Previous approval has occurred to you under MMQU.

EXPLANATORY CODES

XPLANATORY

ODE

AD001 Service encounter has been refused. When a procedure and the daily rate for intensive care are

both claimed, only one, the procedure or intensive care is approved.

AD007 Service encounter has been refused as previous payment has been approved under 13.59L,

AD008 Service encounter has been refused. Delete original immunization approved this day and submit a

AD009 Service encounter has been refused. Delete one of the original submissions and submit a service

DESCRIPTION

AD010 Service encounter has been refused as previous payment has been made this day for a portion of

this combination.

Check your records to confirm admit date and submit a reassess (action code R) once you have

AD018 Service encounter has been refused as you have been approved this service under a combination

AD019 Service encounter has been refused. A portion of this combination service has previously been

AD020 Service encounter has been refused. Previous payment has been made to you for a portion of this

EXPLANATORY CODES - 2

May 2011

E

CODE

AD024

Service encounter has been refused. Previous approval has occurred under MMR2 and/or QUAD.

AD025

Service encounter has been refused as previous approval has occurred to you under MMQU.

AD026

Service encounter has been refused as you have previously been approved an injection covered in
this service.

AD027

Service encounter has been refused as a portion of this service has been previously approved.

AD028

Service encounter has been reduced to 50%. Only one 13.59L at full fee is payable when a visit is
claimed

AD029

Service encounter has been reduced to 50% as two previous immunizations were paid at full fee on
this date.

AD030

Service encounter has been refused. Two immunizations have been paid at full fee this date. Delete
one immunization and resubmit at LV50 along with your visit/consult claim.

AD031

Service encounter has been refused as the patient's birthdate is inappropriate for this service

AD032

Service encounter has been refused as the maximum number of PENT injections has been reached.

AD033

Service encounter has been refused as patient must be one year of age.

AD034

Service encounter has been reduced to 50% as a visit and previous injection have been billed.

AD035

Service encounter has been refused as the maximum number of PNEC injections have been
approved.

AD036

Service encounter has been refused as the patient has not reached the appropriate age for this type
of injection.

AD037

Service encounter has been refused as the diagnostic code indicated and age of patient does not
warrant payment of the influenza vaccine.

AD038

Service encounter has been refused as a maximum of two 13.59L RO=PNEU immunizations have
been previously paid.

AJ001

Service encounter has been adjusted according to information provided by you.

AJ002

Service encounter has been adjusted according to information provided on another service
encounter.

AN001

Service encounter has been refused. When multiple procedures are performed during the same
time, only one anaesthetic fee applies.

AN002

Service encounter has been refused. When a procedure and the daily rate for intensive care are
both claimed, only one, the procedure or intensive care is approved.

primary fracture procedure.

only one is approved at 100%.

both claimed, only one, the procedure or intensive care is approved.

this same service encounter.

time only one is approved at 100%.

both claimed, only one, the procedure or intensive care is approved.

100% at this same encounter.

XPLANATORY

DESCRIPTION

BG001 Service encounter has been approved at 50% of the appropriate bone graft code in addition to the

BG002 Service encounter has been reduced. When multiple procedures are performed at the same time,

BG003 Service encounter has been refused. When a procedure and the daily rate for intensive care are

BG004 Service encounter has been approved at 50% as another procedure has been approved at 100% for

BG005 Service encounter has been approved at 50%. When multiple procedures are performed at the same

CC001 Service encounter has been refused. When a procedure and the daily rate for intensive care are

CC002 Service encounter has been approved at 50% as another procedure has previously been approved at

EXPLANATORY CODES - 3

May 2011

E

CODE

CN001

Service encounter has been refused. When billing a stress test and a consultation and the patient
has been examined by a different cardiologist in the previous 14 days, a visit fee only applies.

CN002

Service encounter has been refused as a repeat consultation is not payable unless a consultation for
a related diagnosis with the same referring physician has been approved in the previous 30 days.

CN003

Service encounter has been refused as a complete care code includes related visits for the following
14 days.

CN004

Service encounter has been refused as you have previously been paid a visit or consultation this day
under the same service occurrence number.

CN005

Service encounter for a consultation with detention has been refused as you have previously been
approved a visit allowed procedure at the same service encounter.

CN006

Service encounter has been refused as a consultation and psychotherapy or counselling are not
payable at the same service encounter.

CN007

Service encounter has been disallowed as this service is included in the postoperative care.

CN008

Service encounter has been disallowed as this service is included in the postoperative care of
fractures.

CN009

Service encounter has been disallowed as contact lens fitting includes follow up for three months.

claimed, but will be approved at 0 units during the 90 days following major surgery.

care.

year.

CN013

Service encounter has been refused as detention is not payable in the office.

CN014

Service encounter has been disallowed as it is included as postoperative care of a fracture.

CN015

Service encounter has been disallowed. Contact lens fitting includes follow up for three months.

CN016

Service encounter has been disallowed as a consultation is considered included in the procedural
removal of retained placenta.

CN017

Service encounter has been disallowed as this service is payable once per patient per physician.

PACS consultation is disallowed.

obstetrical trauma repair.

CN020

Service encounter has been refused as a 03.09B has previously been approved for this day.

you or another physician on this day.

another physician this day.

CR003

Service encounter has been refused as modifier type {in} value, date of service and admit to intensive
care date do not agree.

CR004

Service encounter has been disallowed. When a procedure and the daily rate for intensive care are
both claimed, only one, the procedure or intensive care is approved.

CR005

Service encounter has been refused as date of service indicated is prior to intensive care admit date
given.

XPLANATORY

CN010 Service encounter has been disallowed. The first postoperative clinic or office recheck should be

DESCRIPTION

CN011 Service encounter has been disallowed as a consultation is not approved the same day as critical

CN012 Service encounter has been disallowed as compression sclerotherapy includes after care for one

code for induction of labor by artificial rupture of membranes as well as the procedural code for

CN018 When a comprehensive or limited consultation is billed within 30 days of a PACS consultation the

CN019 Service encounter has been disallowed as a consultation is considered included in the fee for an

CR001 Service encounter has been disallowed as a comprehensive critical care visit has been approved to

CR002 Service encounter has been refused as another intensive care visit has been approved to you or

EXPLANATORY CODES - 4

May 2011

E

CODE

CR006

Service encounter has been refused as you have previously been approved a consultation or visit
this day.

CR007

Service encounter has been disallowed. Critical care and ventilatory support are included in
comprehensive care.

CR008

Service encounter has been refused as your specialty is not valid for providing intensive care
associated with respiratory insufficiency.

CR009

Service encounter has been refused as modifier type {in} value, admit to intensive care date and date
of service do not agree.

CR010

Service encounter has been refused as modifier type {in} value, date of service and admit to intensive
care date do not agree.

CS001

Service encounter has been disallowed as application of casts and/or splints is not approved
following a fracture procedure.

CS002

Service encounter has been disallowed as application of casts and/or splints is included in the
fracture procedure.

CS003

Service encounter has been disallowed as it is included in the surgery performed.

only one is approved at 100%.

both claimed, only one, the procedure or intensive care is approved.

service encounter, only one is approved.

fracture procedure.

DE001

Service encounter has been refused as payment responsibility is invalid for service provided.

DE002

Service encounter has been refused as payment responsibility is not valid for service indicated.

DE003

Service encounter has been refused. Payment responsibility indicated is not valid for this service.

DE004

Service encounter has been refused as payment responsibility and service indicated do not agree.

DE005

Service encounter has been disallowed as electronic text is required for this service.

the previous 30 days.

DE007

Service encountered has been disallowed as this service is restricted to individuals aged 18-64 years.

DE008

Service encounter has been disallowed as the recipient is 65 years of age or older.

DE009

Service encounter has been refused as this service has already been approved for this year.

this year.

this year.

claim on history.

previously been paid this year.

only one is approved at 100%.

XPLANATORY

CS004 Service encounter has been reduced. When multiple procedures are performed at the same time

DESCRIPTION

CS006 Service encounter has been refused. When a procedure and the daily rate for intensive care are

CS007 Service encounter has been disallowed. When a visit and minor surgery are performed at the same

CS008 Service encounter has been disallowed as application of casts and/or splints is included in the

DE006 Service encounter has been disallowed as C9999 has been approved to you or another provider in

DE010 Service encounter has been refused as two medication reviews have previously been approved for

DE011 Service encounter has been refused as the second condition amount has already been approved for

DE012 Service encounter has been refused as there is already one Unattached Patient Bonus payment

DE013 Service encounter has been refused as two Long-Term Care Clinical Geriatric Assessments have

DL001 Service encounter has been reduced. When multiple procedures are performed at the same time,

EXPLANATORY CODES - 5

May 2011

E

CODE

DL002

Service encounter has been disallowed. When a visit and dislocation are performed at the same
service encounter, only one is approved.

DL003

Service encounter has been refused. When a procedure and the daily rate for intensive care are
both claimed, only one, the procedure or intensive care is approved.

DL004

Service encounter has been approved at 50 % as another procedure has previously been approved
at 100%.

DL005

Service encounter has been reduced to 50% as another procedure has previously been approved at
100% at this same encounter.

DL006

When multiple procedures are performed at the same time, only one is approved at 100%.

DL007

Service encounter has been disallowed as a visit and major surgery are not both payable the same
day.

ED001

Invalid or omitted record type.

ED002

Omitted action code or invalid action code and record sub-type combination.

ED003

Invalid service encounter number. (invalid or omitted submitter ID, year, sequence number, and/or
check digit.)

ED004

Invalid or omitted txn. type.

ED005

Omitted record sub-type or invalid txn. type and record sub-type combination.

ED006

Invalid payment responsibility.

ED007

Invalid or omitted service encounter type.

ED008

Invalid or omitted service start date.

ED009

Invalid or omitted service occurrence number.

ED010

Invalid or omitted diagnostic code 1.

ED011

Invalid or omitted diagnostic code 2 or 3.

ED012

Invalid multiples indicated.

ED013

Invalid modifier type, modifier value or invalid combination of type and value.

ED014

Invalid claimed unit value.

ED015

Claimed unit value must be numeric if unit value indicator contains a value of Y or health service code
contains a value of EC, IC, or IF.

ED016

Invalid claimed amount.

ED017

Invalid unit value indicator.

ED018

Unit value indicator must be blank if claimed unit value is blank.

ED019

Invalid paper support document indicator.

ED020

Invalid or omitted hospital admit date or hospital admit date inappropriate for the location

ED021

Hospital admit date cannot be subsequent to service date.

ED022

Hospital admit date must be present if service is for a registered inpatient.

ED023

Invalid intensive care admit date.

ED024

Intensive care admit date cannot be prior to hospital admit date.

ED025

Intensive care admit date is required when functional centre contains a value of NICU or INCU.

ED026

Invalid start time.

XPLANATORY

DESCRIPTION

EXPLANATORY CODES - 6

May 2011

E

CODE

ED027

Invalid pre-authorization number.

ED028

Invalid injury diagnostic code.

ED029

Omitted or invalid service provider number or number not valid for date of service.

ED030

Invalid or omitted provider type.

ED031

Provider type is not valid for service provider number and/or date of service indicated.

ED032

Invalid referral provider number

ED033

Referral provider number must be present and must be valid.

ED034

Referral provider number and referral provider type must be blank if OOP referral indicator contains a
value of Y.

ED035

Referral provider number must be blank if referral provider type is blank.

ED036

Referral provider number must be present if referral provider type is present.

ED037

Invalid referral provider type.

ED038

Referral provider type must be blank if referral provider number is blank.

ED039

Invalid business arrangement for provider number or provider type; or, ineffective for the service start
date on the service encounter.

ED040

Business arrangement is not valid for service provider number and/or date of service.

ED041

Invalid or omitted specialty code.

ED042

Specialty code not valid for service provider number and/or date of service.

ED043

Specialty code present on service encounter is invalid for business arrangement indicated.

ED044

Invalid or omitted facility number or functional centre

ED048

Invalid or omitted service recipient health card number.

ED049

Invalid service recipient health card number for date of service or recipient is ineligible for the
program

ED050

Duplicate service encounter number previously submitted.

ED051

Service encounter number match not found.

indicated.

ED053

Invalid or omitted referral provider type.

ED054

Referral provider type not valid for date of service for referral provider number indicated.

ED055

Facility number invalid for location code indicated.

ED056

Facility number present on service encounter is invalid for business arrangement indicated.

ED057

Invalid or omitted location code.

ED058

Invalid or omitted program.

ED060

Service recipient birth date is omitted or service start date is prior to birth date.

ED062

Health service code is invalid, omitted or invalid for the business arrangement indicated.

ED063

Invalid or omitted pay to code.

ED064

Invalid pay to health card number.

XPLANATORY

DESCRIPTION

ED052 Referral provider type must be present and valid for service date if referral provider number is

EXPLANATORY CODES - 7

May 2011

E

CODE

ED065

Service encounter has been refused as the service encounter that shares the same text cannot be
found.

ED066

Invalid record sequence.

ED067

Invalid or omitted surname on person data record.

ED068

Invalid or omitted given name on person data record.

ED069

Invalid date of birth on person data record.

ED070

Birth date in person data record must be blank if pay to code is OTHR and birth date must be present
on person data record if pay to code is RECP.

ED071

Invalid gender code on person data record.

ED072

Omitted address on person data record.

ED073

Invalid or omitted city name on person data record.

ED074

Invalid or omitted province/state code on person data record.

ED075

Invalid country on person data record.

ED076

Service encounter has been refused as the person data record is absent.

ED077

Only one CPD1, CBE1, or CTX1 permitted for each service encounter transaction

ED078

Recipient health card number and pay to health card number are the same

ED079

Remuneration method not fee for service or shadow billing.

ED080

Health service code must contain supporting text and claimed unit value.

ED081

Invalid health card number check digit.

ED082

Invalid record length.

ED083

CPD1 record sub-type present when it is not required.

ED084

Out of province referral indicator is not blank or it contains a value other than Y.

ED085

Non-printable characters in chart number field.

ED086

Non-printable characters in unused field.

ED087

Invalid postal code format.

ED088

Guardian/parent HCN is not alphanumeric.

ED089

Supporting text contains unprintable characters.

ED090

Invalid submitter ID.

ED091

Invalid year in the service encounter number on the CTX1 record sub type.

ED092

Invalid sequence number in the service encounter number on the CTX1 record sub type.

ED093

Invalid check digit on the service encounter number on the CTX1 record sub type.

ED094

Unsupported transaction type.

ED095

Transaction badly formed.

ED096

Parent or guardian must contact MSI to validate health card number for preregistered newborn.

ED097

Date of service is subsequent to expiry date for health card number.

ED098

Hospital admit date and intensive care admit date must be blank for action code of P.

ED099

Birth date is blank on base service encounter record and person data record.

XPLANATORY

DESCRIPTION

EXPLANATORY CODES - 8

May 2011

E

CODE

ED100

Duplicate service encounter number previously submitted, currently in held status, waiting for manual
review.

ED101

Provider type not allowed to bill.

ED102

Provider type not allowed to refer.

ED103

Service recipient birth date does not match birth date on health card.

ED104

Service encounter accepted at zero as it is outdated.

GN001

Service encounter has been refused as a similar service has been approved on the same day.

GN002

Service encounter has been refused as hospital admit date is required for services performed on
registered inpatients.

GN003

Service encounter has been refused as this is an excluded service under the reciprocal billing
agreement.

GN004

Service encounter has been refused as self referral is not acceptable.

GN005

Service encounter has been refused as payment responsibility WCB is not valid for patient under
sixteen.

GN006

Service encounter has been refused as hospital admit date is necessary for processing this service.

GN007

Service encounter has been refused as modifier AG value does not agree with age of patient.

GN008

Service encounter has been disallowed as this procedure is included in critical care.

GN009

Service encounter has been refused as patient's sex is invalid for service provided.

GN010

Service encounter has been refused. Please resubmit with text indicating specific areas involved.

GN011

Service encounter has been disallowed as a consultation has been approved to you in the previous
14 days.

GN012

Service encounter has been refused as no preauthorization number was indicated or number
indicated is invalid.

GN013

Service encounter has been refused as it is a duplicate submission.

GN014

Service encounter has been refused as a previously reduced matching service encounter is not
present.

GN015

Service encounter has been reassessed.

GN016

Invalid or omitted health service code.

GN017

Service encounter has been refused as your specialty is not approved for performing this service.

GN018

Service encounter has been refused as first and consecutive anaesthetic start times cannot be the
same.

GN019

Service encounter has been refused as it is an exact duplicate to a previously submitted service
encounter.

GN020

Service encounter has been adjudicated according to information provided.

GN021

Service encounter has been adjudicated according to a decision by the medical claims evaluation
committee.

GN022

Service encounter has been refused as it is an uninsured service under MSI.

GN023

Service encounter has been refused as it is outdated.

GN024

Service encounter has been disallowed as it is an uninsured service under MSI.

GN025

Service encounter has been refused as this service is included in the composite fee.

XPLANATORY

DESCRIPTION

EXPLANATORY CODES - 9

May 2011

E

CODE

GN026

Service encounter has been adjudicated based on duration of service.

GN027

Service encounter has been refused as it requires multiples. Resubmit using the correct number of
multiples.

GN028

Service encounter has been refused. Resubmit indicating duration of service.

GN029

Service encounter has been refused as an assistant is not approved for this service.

GN030

Service encounter has been refused. If resubmitting, provide all details that will assist in determining
payment.

GN031

Service recipient birth date does not match birth date on health card. Birth date from health card
should be used. This does not affect payment.

GN032

Service encounter has been refused. Resubmit using the appropriate health service code(s) as listed
in your Physician’s Manual.

GN033

Service encounter has been refused. Resubmit, indicating in the claimed unit value field, the number
of units required for the procedure performed.

GN034

Service encounter has been refused as the pay to code indicated is not appropriate.

GN035

Service encounter has been refused as pay to code indicated is not valid for payment responsibility
indicated.

GN036

Service encounter has been refused as a previous service under this same service code has been
approved.

GN037

Service encounter has been refused as a previous service has been approved under this same
service code at this service encounter.

GN038

Service encounter has been refused as a previous service encounter has been accepted for this
same service code.

code has been approved.

GN040

Service encounter has been disallowed as a visit and surgery are not both payable.

GN041

Service encounter has been refused as a previous service encounter was approved for this same
health service code.

indicated.

performed.

explanatory text.

encounter number.

GN047

Service encounter has been refused. Submit a reassess (action code R) for the original submission
to aid in the assessment of your claim.

GN049

Service encounter has been disallowed as text provided does not provide sufficient details. If
resubmitting please provide more details to aid in the assessment of your claim.

XPLANATORY

DESCRIPTION

GN039 Service encounter has been refused as a previous service encounter for this same health service

GN042 Service encounter has been refused as payment responsibility is not valid for date of service

GN043 Service encounter has been refused. Resubmit indicating start and finish time for procedure

GN044 Service encounter has been disallowed as a service occurrence other than 1 has been used without

GN045 Service encounter has been disallowed as text provided does not include the original service

GN046 Service encounter had been disallowed as text provided does not include the time of the encounter

GN048 Service encounter has been disallowed. Submit a reassess (action code R) for the original

submission to aid in the assessment of your claim.

EXPLANATORY CODES - 10

May 2011

E

CODE

GN050

Service encounter has been refused. Resubmit under the same health service code using the
appropriate lesser value modifier for the service provided.

GN052

Service encounter has been disallowed. Resubmit with a copy of the time sheet for the surgery

MA001

Service encounter has been approved at 50%. When multiple closed or no reductions are performed
should be claimed.

fracture.

followed by an open reduction.

only one is approved at 100%.

both claimed, only one, the procedure or intensive care is approved.

encounter only one is approved at 100%.

procedures are performed at the same time.

MA008

Service encounter has been refused. Interim service code has expired. Application must be
submitted to Doctors Nova Scotia for establishing a permanent health service code.

MI001

Service encounter has been approved at 50%. When multiple closed or no reductions are performed
should be claimed.

MI002

Service encounter has been refused. 50% of the listed fee for the initial closed or no reduction is
fracture.

MI003

Service encounter for no or closed reduction has been approved at 50% of the listed fee as it has
been followed by an open reduction.

MI004

Service encounter has been reduced. When multiple procedures are performed at the same time,
only one is approved at 100%.

MI005

Service encounter has been refused. When a procedure and the daily rate for intensive care are
both claimed, only one, the procedure or intensive care is approved.

MI006

Service encounter has been reduced. When multiple procedures are performed at the same
encounter, only one is approved at 100%.

MJ001

Service encounter has been reduced to 50%. When multiple surgical procedures are performed at
the same time, only one is approved at 100%.

MJ002

Service encounter has been refused. When a procedure and the daily rate for intensive care are
both claimed, only one, the procedure or intensive care is approved.

MJ003

Service encounter has been refused as this once per lifetime procedure has previously been
approved.

pacemaker insertion.

XPLANATORY

GN051 Service encounter has been refused as a service encounter one (1) has not been claimed for this

day.

performed to aid in the adjudication of your claim.

on the same fracture, at different service encounters, by the same provider 50% for each reduction

MA002 Service encounter has been reduced. 50% of the listed fee for the initial closed or no reduction is

approved when a different physician performs a subsequent closed or no reduction on the same

MA003 Service encounter for closed reduction has been approved at 50% of the listed fee as it has been

MA004 Service encounter has been reduced. When multiple procedures are performed at the same time,

MA005 Service encounter has been refused. When a procedure and the daily rate for intensive care are

DESCRIPTION

MA006 Service encounter has been reduced. When multiple procedures are performed at the same

MA007 Service encounter has been reduced. Only one procedure is approved at 100% when multiple

on the same fracture, at different service encounters, by the same provider 50% for each reduction

approved when a different provider performs a subsequent closed or no reduction on the same

MJ004 Service encounter has been refus ed as this adjustment of leads occurred within 30 days of

EXPLANATORY CODES - 11

May 2011

E

CODE

MJ005

Service encounter has been refused as initial cauterization of the rectum has been approved in the
previous 30 days.

MJ006

Service encounter has been refused as initial photo coagulation has been approved for eye(s)
indicated in the previous 30 days.

MJ007

Service encounter has been refused as this is not the appropriate health service code for post-op
haemorrhage when claimed by the surgeon who performed the tonsillectomy.

MJ008

Service encounter has been refused as a preauthorization number was not indicated.

MJ009

Service encounter has been adjudicated based on the surgeons submission.

MJ010

Service encounter has been refused. Resubmit with a copy of the operative report to aid in the
adjudication of your service encounter.

MJ011

Service encounter has been refused based on the age of the recipient.

MJ012

Service encounter has been refused as this health service is not appropriate for persons 16 years or
older.

MJ013

Service encounter has been refused as this health service is not appropriate for persons under 16
years of age.

MJ014

Service encounter has been reduced to 50%. Only one procedure is approved at 100% when
multiple surgical procedures are performed at the same time.

service.

MJ016

Service encounter has been disallowed as this service is included in a previously approved
procedure.

MJ017

Service encounter has been refused as no preauthorization number was indicated.

number.

been approved.

approved.

adjudication of your service encounter.

has already been claimed by you for this date.

anal sphincter on this date.

this date.

MJ025

Service encounter has been refused as a claim for donor has already been received for this patient.
A patient cannot be both a donor and recipient of a liver.

MJ026

Service encounter has been refused as a claim for recipient has already been received for this
patient. A patient cannot be both a donor and recipient of a liver.

MJ027

Service encounter has been disallowed as the injected substance has not been indicated.

MJ028

Service encounter has been refused as a claim for the ICD insertion team fee has already been made
for this patient.

XPLANATORY

DESCRIPTION

MJ015 Service encounter has been disallowed as thi s procedure is included in a previously approved

MJ018 Service encounter has been refus ed as this service requires electronic text or a prior approval

MJ019 Service encounter has been refus ed as a previous service encounter for a second physician has

MJ020 Service encounter has been refus ed as a previous service encounter for an assist fee has been

MJ021 Service encounter has been refus ed. Resubmit with a copy of the outpatient report to aid in the

MJ022 Service encounter has been refus ed as a total abdominal hysterectomy or repair of inverted uterus

MJ023 Service encounter has been refus ed as you have already claimed a repair of obstetrical trauma or

MJ024 Service encounter has been refus ed as you have already claimed a repair of obstetrical trauma on

EXPLANATORY CODES - 12

May 2011

E

CODE

MJ029

Service encounter has been refused as a claim for the ICD insertion composite fee has already been
made for this patient.

MN001

Service encounter has been disallowed as it is included in the delivery.

MN002

Service encounter has been disallowed as compression sclerotherapy includes after care for one
year.

MN003

Service encounter has been disallowed. When a visit and a surgical procedure are claimed together,
only one is approved.

MN004

Service encounter has been disallowed. When a visit and minor surgery are performed at the same
service encounter, only one is approved.

MN005

Service encounter has been refused as this procedure has been performed within the previous 7
days.

MN006

Service encounter has been refused. When a procedure and the daily rate for intensive care are
both claimed, only one, the procedure or intensive care is approved.

MN007

Service encounter has been reduced. When multiple procedures are performed at the same time,
only one is approved at 100%.

MN008

Service encounter has been refused as it is a deinsured service for patients under one year of age.

encounter, only one is approved at 100%.

MN010

Service encounter has been disallowed as it is included in the fee for the adenoidectomy.

MN011

Service encounter has been disallowed as procedure claimed and a consultation are not both
payable.

MS001

Service encounter has been refused. Complete details are necessary when billing this service.

NR001

Service encounter has been adjudicated based on a decision by the medical consultant.

NR002

Service encounter has been approved under the appropriate code.

NR003

Service encounter has been refused as a second assistant is not approved for this service.

NR004

Service encounter has been adjudicated based on the fee payable for the assistant.

NR005

Service encounter has been adjudicated based on the fee payable to the second assistant.

NR006

Service encounter has been refused. Indicate actual procedure performed when resubmitting.

NR007

Service encounter has been approved at the general practice rate re age of patient.

NR008

Service encounter has been refused. Submit a new service encounter once approval has been
received from the psychotherapy waiver review committee.

NR009

Please delete original submission and submit a new service encounter for a partial eye exam.

NR010

Service encounter has been refused as this visit is not payable during intensive care.

NR011

Service encounter has been refused as date of service appears incorrect according to our records.

NR012

Service encounter has been adjusted based on information provided by MSI audit.

NR013

Service encounter has been refused. Delete original submission and resubmit using the appropriate
modifier of region both.

NR014

Service encounter has been refused. Resubmit with a copy of the pathology report to aid in the
adjudication of your service encounter.

NR015

Service encounter has been approved at the internal medicine rate re age of patient.

NR016

Service encounter has been disallowed as all the requirements for billing this service have not been
met.

XPLANATORY

MN009 Service encounter has been reduced. When multiple procedures are performed at the same

DESCRIPTION

EXPLANATORY CODES - 13

May 2011

E

CODE

NR017

Service encounter has been refused as a previous payment covers all or a portion of this
combination.

NR018

Service encounter has been refused as previous payment covers this submission.

NR019

Service encounter has been refused as this same service has been approved for another provider.

NR020

Service encounter has been refused. Resubmit using the appropriate service occurrence number.

NR021

Service encounter has been adjudicated based on the time indicated for the consecutive
anaesthetist.

NR022

Service encounter has been adjudicated according to the weekly maximum payable after 56 days of
hospitalization.

NR023

Service encounter has been disallowed as a pap smear is not payable with a visit for a
gynaecological or obstetrical diagnosis.

NR024

Service encounter has been adjusted in accordance with the surgical rules described in the
Preamble.

NR025

Service encounter has been adjudicated based on the preamble ruling for outdated submissions.

NR026

Service encounter has been refused as the hospital admit date indicated is incorrect.

NR027

Service encounter has been adjudicated based on preamble rules.

NR028

Service encounter has been adjudicated based on payment for a bilateral procedure.

NR029

Resubmit under the appropriate health service code for this bilateral procedure.

NR030

Service encounter has been disallowed as medical necessity was not indicated.

NR031

Service encounter has been disallowed as the appropriate documentation has not been received.

NR032

Service encounter has been disallowed as copies of the referral letter and consult report are required.

NR033

Service encounter has been disallowed as the required WCB form was not received within the
appropriate time.

NR034

Service encounter has been adjudicated according to the rate set by workers' compensation board.

NR035

Service encounter has been refused as region (right, left, both) was not indicated.

NR036

Service encounter may be readjudicated according to the submission by the surgeon.

NR037

Service encounter has been disallowed as the injection indicated is not on the provincial
immunization list.

NR038

Service encounter has been disallowed as the tray fee is not applicable for service provided.

NR039

Service encounter has been accepted at zero as it is outdated.

NR040

Service encounter has been refused as prior approval number indicated is not valid.

NR041

Service encounter has been disallowed as the maximum number of this type of visit allowed without a
prior approval number have been approved for this episode.

NR042

Service encounter has been disallowed as the maximum number of preauthorized visits for this
episode have been approved.

NR043

Service encounter has been disallowed as the maximum number of encounters for this service per
year has been reached.

NR044

Service encounter has been disallowed as the maximum number of well baby visits allowed have
been approved for payment.

NR045

Service encounter has been refused. Resubmit using the appropriate health service code(s) as listed
in the Physician’s Manual and/or Physicians' Bulletin.

XPLANATORY

DESCRIPTION

EXPLANATORY CODES - 14

May 2011

E

CODE

NR046

Service encounter payment has been calculated based on the percentage payable on the total major
surgical procedural fee(s) excluding the premium fee portion.

NR047

Service encounter has been refused. Resubmit using the appropriate health service code based on
information provided.

NR048

Service encounter has been refused. Resubmit indicating the base units used for the procedure
performed.

NR049

Service encounter has been refused. Resubmit indicating the correct region.

NR050

Service encounter has been disallowed as text provided does not warrant approval.

NR051

Patient history transfer has occurred due to duplicate registration of individual. Patient history will
now appear under the active registration number.

NR052

Service encounter has been refused as previous payment has occurred under an incorrect HCN.
Internal adjustment will be made to correct our records.

NR053

Service encounter has been refused as the business arrangement indicated is incorrect according to
our records.

NR054

Service encounter has been disallowed. Delete the original submission and submit a new service
encounter under the appropriate business arrangement.

verified the date you have indicated is correct.

NR056

Service encounter has been adjudicated based on information published in a Physicians’ Bulletin.

Manual.

NR058

Service encounter has been adjudicated based on information contained in the Physician’s Manual.

modifier used in relation to intensive care admit date indicated.

based on the information you have provided.

NR061

Service encounter has been refused re diagnosis indicated.

medication. An over the counter drug or product is not insured.

comprehensive visit.

NR064

Service encounter has been refused. Referring provider indicated is invalid for referral.

NR065

Service encounter has been adjudicated based on telephone conversation.

NR066

Service encounter has been refused as hospital admit date is incorrect.

NR067

Service encounter has been refused as intensive care admit date is incorrect.

NR068

Service encounter has been adjudicated based on the operative and/or pathology report.

published in the Physicians' Bulletin.

anaesthetist.

NR071

Indicate type of anaesthesia (general or local) for procedure performed.

XPLANATORY

NR055 Service encounter has been disallowed as patient history indicates conflicting intensive care admit

dates. Confirm intensive care admit date and submit a reassess (action code R) once you have

DESCRIPTION

NR057 Service encounter has been adjudicated based on information contained in the Billing Instructions

NR059 Service encounter has been refused as electronic text was not present explaining date of service and

NR060 Service encounter has been refused. Delete the original submission and submit a new encounter

NR062 Service encounter has been refused as this service is only insured in conjunction with prescribed

NR063 Service encounter has been refused as diagnosis indicated does not warrant approval of a

NR069 Service encounter has been refused. Resubmit a new service encounter based on information

NR070 Service encounter has been adjudicated based on the time indicated for the simultaneous

EXPLANATORY CODES - 15

May 2011

E

CODE

NR072

Service encounter has been disallowed. Submit a reassess (action code R) along with a copy of the
operative report to aid in the assessment of your service encounter.

NR073

Service encounter has been disallowed as a pap smear is not payable in addition to a visit,

NR074

Service encounter has been refused. A maximum of one hour only for a Palliative Care Support Visit
is payable per patient per day.

NR075

Service encounter for tray fee has been adjusted to agree with number of injections approved.

NR076

Service encounter has been adjudicated based on diagnosis indicated.

NR077

Service encounter has been adjudicated based on correspondence from MSI.

NR078

Service encounter has been disallowed. Submit a reassess (action code R) along with a copy of the
outpatient report to aid in the assessment of your service encounter.

NR079

Service encounter payment has been calculated based on the percentage payable on the total major
surgical procedure(s).

NR080

Service encounter has been refused as the pay to code is not BAPY.

NR081

Service encounter has been adjudicated according to the weekly maximum of 80 units per week after
56 days from admission.

NR082

Please contact MSI regarding this claim

NR083

Service encounter has been refused as a substance other than air was injected.

both claimed, only one, the procedure or intensive care is approved.

labour.

OP001

Service encounter has been disallowed as routine vision care is uninsured re age of patient.

Payment has been approved to you or another provider in the previous year.

older.

another provider in the previous year.

another provider in the previous year.

OP006

Service encounter has been disallowed as a previous optometric vision analysis has been approved
to you or another provider during the previous year.

OP007

Service encounter has been disallowed as a previous continuing care visit has been approved to you
or another provider during the previous year.

OP008

Service encounter has been refused as this service is not payable for your specialty.

OP009

Service encounter has been disallowed as only one routine optometric vision analysis is payable
during a two year period.

OP010

Service encounter has been disallowed as only one routine optometric vision analysis is payable
during a two year period.

OP011

Service encounter has been refused as electronic text is required with reference to the specific drug
involved.

XPLANATORY

DESCRIPTION

consultation or procedure for a gynecological or obstetrical diagnosis.

OB001 Service encounter has been refused. When a procedure and the daily rate for intensive care are

OB002 Service encounter has been disallowed as you have previously been approved for transfer during

OP002 Service encounter has been disallowed. Only one exam for medical necessity is payable per year.

OP003 Service encounter has been disallowed as this service is not payable for persons 19 years of age and

OP004 Service encounter has been disallowed as an optometric vision analysis has been approved to you or

OP005 Service encounter has been disallowed as a continuing care visit has been approved to you or

EXPLANATORY CODES - 16

May 2011

E

CODE

OP012

Service encounter has been disallowed as this once per lifetime procedure has previously been
approved for either region right, left or both.

OP013

Service encounter has been disallowed as this once per lifetime procedure has previously been
approved for either region left or both.

OP014

Service encounter has been disallowed as this once per lifetime procedure has previously been
approved for either region right or both.

OP015

Service encounter has been disallowed as a routine vision analysis is not an insured service re age of
patient.

OP016

Service encounter has been disallowed as it is routine in nature.

OP017

Service encounter has been disallowed as this service is only payable for a non-routine diagnosis.

OP018

Service encounter has been disallowed re routine diagnosis indicated.

OP019

Service encounter has been disallowed as an optometric vision analysis has been approved in the
past year.

OP020

Service encounter has been disallowed as a continuing care visit is payable only once per year.

OP021

Service encounter has been disallowed as a previous optometric vision analysis was approved during
the previous year.

OP022

Service encounter has been disallowed as continuing care visits are payable once per year only.

OP023

Service encounter has been disallowed as a routine diagnosis has been indicated.

OP024

Service encounter has been disallowed due to routine diagnosis indicated.

OP025

Service encounter has been disallowed as another non-routine vision analysis has been approved
during the previous year.

OP026

Service encounter has been disallowed as a previous continuing care visit has been approved during
the last year.

OP027

Service encounter has been disallowed as diagnosis does not warrant payment of this service.

OP028

Service encounter has been approved at the non referred rate for this service as the referring
provider type is not PH.

OP029

Service encounter has been disallowed as the maximum 6 visits allowed per year for this type of
service have been approved.

OP030

Service encounter has been refused as text is required indicating the name of the prescribed drug or
that no prescription was required.

receiving the referral.

OP032

Service encounter has been refused as your specialty is not valid for service claimed.

included on the service encounter.

indicated.

OP035

Service encounter has been refused as you have previously been paid a visit this day.

this day.

payable at the same service encounter.

XPLANATORY

DESCRIPTION

OP031 Service encounter has been refused as text is required indicating the name of the ophthalmologist

OP033 Service encounter has been refused as the required keratoconus diagnostic code (37160) was not

OP034 Service encounter has been refused as no diagnostic code warranting payment of premium fee was

OP036 Service encounter has been refused as you have previously been paid an Optometric Vision Analysis

PC001 Service encounter has been refused as psychotherapy or counselling and a consultation are not

EXPLANATORY CODES - 17

May 2011

E

CODE

PC002

Service encounter has been refused as psychotherapy or counselling and a visit are not payable at
the same service encounter.

PC003

Service encounter has been refused. A maximum of 90 continuous minutes of individual
psychotherapy only is allowed per patient per day.

PC004

Service encounter has been refused as a minimum of one half hour must be spent per visit for
psychotherapy to be payable.

PC005

Service encounter has been refused as patient is under four years of age.

PC006

Service encounter has been adjudicated according to total hours approved in the previous 365 days.

PC007

Service encounter has been refused as another physician is providing psychotherapy to this patient.

PC008

Service encounter has been refused. A maximum of 2 hours of group psychotherapy only is allowed
per patient per day.

PC009

Service encounter has been refused. A maximum of 2 hours of family therapy only is allowed per
patient per day.

PC010

Service encounter has been refused as you have previously been approved the intensive care daily
rate this day.

PC011

Service encounter has been refused. A maximum of 90 minutes of hypnotherapy only is allowed per
patient per day.

hypnotherapy to be payable.

PC013

Service encounter has been refused. A maximum of one hour of counselling only is allowable per
patient per day.

allowable per patient per day.

approved.

approved.

previously been approved.

PC018

Service encounter has been refused. Maximum limit of 10 hours of hypnotherapy per year has
previously been approved.

PC019

Service encounter has been refused. Maximum limit of 5 hours of counselling per year has
previously been approved.

PC020

Service encounter has been refused. Maximum limit of 2 hours of lifestyle counselling per year has
previously been approved.

PC021

Service encounter has been approved at the maximum allowed per day for this service.

PC022

Service encounter has been disallowed as patient is 19 years of age or greater.

PC023

Service encounter has been disallowed as location and/or provider specialty is not appropriate for
service claimed.

PC024

Service encounter has been refused as you have not indicated that prior approval has been issued.
Maximum limit of 20 hours per year for individual psychotherapy has previously been approved.

PC025

Service encounter has been refused as you have not indicated that prior approval has been issued.
Maximum limit of 20 hours per year for group psychotherapy has previously been approved.

XPLANATORY

DESCRIPTION

PC012 Service encounter has been refused. A minimum of one half hour must be spent per visit for

PC014 Service encounter has been refused. A maximum of 30 minutes of lifestyle counselling only is

PC015 Service encounter has been refused as you have not indicated that a waiver or prior approval has

been issued. Maximum limit of 15 hours per year for individual psychotherapy has previously been

PC016 Service encounter has been refused as you have not indicated that a waiver or prior approval has

been issued. Maximum limit of 15 hours per year of group psychotherapy has previously been

PC017 Service encounter has been refused. Maximum limit of 15 hours of family therapy per year has

EXPLANATORY CODES - 18

May 2011

E

CODE

PC026

Service encounter has been refused. Maximum limit of 20 hours of family therapy per year has
previously been approved.

PC027

Service encounter has been refused as you have not indicated that prior approval has been issued.
Maximum limit of 20 hours per year for family therapy has previously been approved.

PC028

Service encounter has been refused as you have not indicated that prior approval has been issued.
Maximum limit of 20 hours per year for group therapy has previously been approved.

PC029

Service encounter has been refused as you have not indicated that prior approval has been issued.
Maximum limit of 20 hours per year for individual therapy has previously been approved.

PC030

Service encounter has been refused as you have not indicated that prior approval has been issued.
Maximum limit of 10 hours per year for hypnotherapy has previously been approved.

PC031

Service encounter has been refused as you have not indicated that prior approval has been issued.
Maximum limit of 2 hours per year for lifestyle counselling has previously been approved.

PC032

Service encounter has been refused as you have not indicated that prior approval has been issued.
Maximum limit of 5 hours per year for counselling has previously been approved.

PP001

Hospital out-patient and/or emergency room charges incurred outside Canada are not insured.

PP002

Radiology and/or laboratory costs incurred outside Canada are not insured.

PP003

Private facility costs are not insured.

PP004

Services received outside Canada for non-urgent/pre-existing medical conditions are not insured.

PP005

Medical services known to be required prior to departure from your home province are not insured.

PP006

Medical services such as monitoring, stabilizing or continuing treatment of existing medical conditions
are not insured.

PP007

Routine/annual physical examinations or those requested by a third party are not insured.

PP008

Routine eye exams performed outside Nova Scotia are not insured.

PP009

Prescription drugs purchased outside Nova Scotia are not insured.

PP010

Services provided by non-medical personnel are not insured.(examples-chiropractor, physiotherapist,
pac-physician's assistant certified, podiatrist)

PP011

Ambulance services, medical supplies, mileage costs, telephone advice or charges for preparation of
reports, records, certificates are not insured.

PP012

Eye glasses, hearing aids or other prosthetic appliances are not insured.

PP013

This service encounter was submitted by active claims management. Please refer to electronic text.

PP014

This claim is not payable as our records show this patient is registered for MSI on a student visa/work
Scotia.

allowable based on the payment policy of the province where you received treatment.

allowable based on Nova Scotia rates.

allowable based on Nova Scotia rates.

business arrangement is cheque.

review.

XPLANATORY

DESCRIPTION

permit/nato exchange and therefore is eligible for health coverage only in the province of Nova

PP015 Your claim for medical services outside Nova Scotia has been paid at the maximum amount

PP016 Your claim for medical services received outside Canada has been pai d at the maximum amount

PP017 Your claim for medical services received in Nova Scotia has been paid at the maximum amount

PP018 Service encounter has refused as a pay to code of BAPY is not appropriate. Payment method for this

PP019 The remainder of your claims have been forwarded to the Nova Scotia Department of Health for their

EXPLANATORY CODES - 19

May 2011

E

CODE

PP020

Services received outside Canada for non-urgent medical conditions are not insured.

PP021

Services received outside Canada for pre-existing medical conditions are not insured.

PP022

Your claim for medical services outside Nova Scotia has been paid at the maximum amount
allowable based on Nova Scotia rates.

PP023

Your claim for dental services has been forwarded to Quickcard Solutions Inc. for review.

PR001

This claim is not payable as replacement costs have been approved in the previous two years.

PR002

This claim for early replacement has been approved for payment.

PR003

This claim is not payable as replacement costs have been approved in the previous 7 years.

PR004

This claim is not payable as replacement costs have been approved in the previous 2 years.

PR005

This claim for prosthetic services has been approved at the maximum amount allowable, based on
Nova Scotia rates.

PR006

This claim is not payable as replacement costs have been approved in the previous 5 years.

PR007

This claim is not payable as replacement costs have been approved in the previous 2 years.

PR008

This claim has not been approved as your client is over 19 years of age and under 65 years of age,
and is not registered with cnib.

PR009

This claim has been refused as it requires multiples. Resubmit indicating the appropriate number of
multiples.

PR010

Service encounter has refused as pay to code should be BAPY.

PR011

This claim is not payable as replacement costs have been approved in the previous 4 years.

RF001

Service encounter has been refused. No adjustment is warranted.

RF002

Service encounter has been refused. Delete original submission(s) and submit new action code A
transaction based on correct information or information provided by you.

RF003

Request for readjudication has been refused. Approval for this request has been previously
processed.

RF004

Request for readjudication has been refused. Denial of this request has been previously processed.

RF005

Payment under this visit service cannot be approved. Delete the original service encounter and
submit under the appropriate subsequent visit service.

VA001

Service encounter has been disallowed as a pap smear is not payable with a comprehensive
evaluation.

VA002

Service encounter has been refused as this service is included in the consultation.

VA003

Service encounter has been reduced. When multiple diagnostic and therapeutic procedures are
performed, only the fee for one is approved at 100%.

VA004

Service encounter has been disallowed as this procedure cannot be claimed in addition to the basic
units for cardiac bypass.

VA005

Service encounter has been disallowed as it is included in limited prenatal and postnatal visits.

VA006

Service encounter has been disallowed as it is included in the delivery.

VA007

Service encounter has been disallowed as venipuncture is not payable in hospital unless medical
necessity exists.

VA008

Service encounter has been refused as service is not approved in location indicated.

XPLANATORY

DESCRIPTION

EXPLANATORY CODES - 20

May 2011

E

CODE

VA009

Service encounter has been disallowed as the maximum limit per week has previously been
approved.

VA010

Service encounter has been disallowed as local anaesthetic is not approved when performed in
conjunction with minor surgery.

VA011

Service encounter has been refused as you have previously been approved a consultation with
detention at the same service encounter.

VA012

Service encounter has been refused as venipuncture is included in the comprehensive prenatal
exam.

VA013

Service encounter has been refused as modifier value indicated and patients age do not agree.

VA014

Service encounter has been refused. When a procedure and the daily rate for intensive care are
both claimed, only one, the procedure or intensive care is approved.

VA015

Service encounter has been disallowed as this service is included in a visit or consultation.

VA016

Service encounter has been refused as this service is included in the fee for a complete eye exam.

VA017

Service encounter has been refused as your specialty is not approved for performing this procedure.

VA018

Service encounter has been reduced. When multiple diagnostic and therapeutic procedures are
performed, only one is approved at 100%.

VA019

Service encounter has been refused as it is a stand alone procedure and another service has been
approved.

VA020

Service encounter has been refused as a previous stand alone procedure has been approved.

VA021

Service encounter has been refused as you have previously been approved a visit with detention at
the same service encounter.

VA022

Service encounter has been refused as this service is included in the comprehensive visit.

VA023

Service encounter has been refused. This service is included in the comprehensive visit.

VA024

Service encounter has been refused as this procedure is included in the comprehensive visit.

VA025

Service encounter has been disallowed as this service is included in the surgery.

VA026

Service encounter has been refused as the provider must be a qualified allergist.

VA027

Service encounter has been refused as this service is only approved at hospital locations.

VA028

Service encounter has been disallowed as this service is included in the visit previously approved at
this same service encounter.

VA029

Service encounter has been disallowed as this procedure is included in the previously approved visit.

VA030

Service encounter has been disallowed as local anaesthesia is not payable in addition to the surgical
fee.

VA031

Service encounter has been refused as a comprehensive examination for the same or similar
the medical necessity of this complete examination.

the last year.

days for invasive EEG video telemetry.

days for non-invasive EEG video telemetry.

as the insertion of CRT pacemaker/defibrillator device.

XPLANATORY

DESCRIPTION

diagnosis has been approved to you within the past year. Please provide further details regarding

VA032 Service encounter has been refused as a comprehensive examination has been paid to you within

VA033 Service encounter has been refused as you have already claimed the maximum of four subsequent

VA034 Service encounter has been refused as you have already claimed the maximum of four subsequent

VA035 Service encounter has been refused as you cannot claim electrophysiology studies on the same day

EXPLANATORY CODES - 21

May 2011

E

CODE

VE001

Service encounter has been disallowed as visit excluded procedures are included in the consultation.

VE002

Service encounter has been reduced. When multiple diagnostic and therapeutic procedures are
performed, only the fee for one is approved at 100%.

VE003

Service encounter has been disallowed. When a procedure and the daily rate for intensive care are
both claimed, only one, the procedure or intensive care is approved.

VE004

Service encounter has been disallowed as visit excluded procedures and a visit are not payable at
the same service encounter.

VE005

Service encounter has been refused. When a procedure and the daily rate for intensive care are
both claimed, only one, the procedure or intensive care is approved.

VE006

Service encounter has been disallowed as this service applies only to patients in the insured age
group.

VT001

Service encounter has been disallowed as this service is included in the postoperative care of
fractures.

VT002

Service encounter for comprehensive evaluation has been refused as a comprehensive evaluation
has been approved in the previous 30 days.

admission.

been approved and the patient has been readmitted within 30 days for the same or related condition.

or similar diagnosis.

the previous 9 months to you or another physician.

another physician.

VT008

Service encounter has been disallowed as a complete care code includes a visit the same day and
related visits for the following 14 days.

VT009

Service encounter has been disallowed as a fracture procedure has been approved to you on the
same day or in the previous 42 days.

VT010

Service encounter has been disallowed as a well baby visit is not payable after one year of age.

VT011

Service encounter has been disallowed as a well baby visit has been approved to you or another
physician during this age interval.

VT012

Service encounter has been disallowed as after six months of age well baby visits are approved on
the basis of once every three months up to one year of age.

VT013

Service encounter for comprehensive visit has been refused as you have been approved a
consultation in the previous 30 days.

VT014

Service encounter has been disallowed as the maximum number of prenatal visits have been
approved.

VT015

Service encounter has been disallowed as a post partum visit cannot be approved on the same day
as a delivery.

VT016

Service encounter has been refused as you or another physician have previously been approved for
first exam of healthy newborn.

VT017

Service encounter has been refused as newborn care of a healthy infant is only approved for the first
five days after birth.

XPLANATORY

VT003 Service encounter for in-patient comprehensive evaluation has been refused as another in-patient

comprehensive evaluation has been approved to you or another physician in your specialty for this

DESCRIPTION

VT004 Service encounter been has disallowed as an in-patient comprehensive evaluation has previously

VT005 Service encounter has been refused as the patient has been readmitted within 10 days for the same

VT006 Service encounter has been refused as a comprehensive pregnancy exam has been approved during

VT007 Service encounter has been refused as a previous post natal care visit has been approved to you or

EXPLANATORY CODES - 22

May 2011

E

CODE

VT018

Service encounter has been disallowed as visit excluded procedures and a visit are not payable at
the same service encounter.

VT019

Service encounter has been disallowed as another physician has been approved an inpatient hospital
visit on this date.

VT020

Service encounter has been disallowed as this is included in the assist fee.

VT021

Service encounter has been refused as continuing or directive care must be preceded by a
consultation

VT022

Service encounter has been refused as a visit and psychotherapy or counselling are not payable at
the same service encounter.

VT023

Service encounter has been refused as you have previously been approved a visit or consultation
this day under the same service occurrence number.

VT024

Service encounter has been disallowed as this service is included in the preoperative care.

VT025

Service encounter has been disallowed as this service is included in the postoperative care.

VT026

Service encounter has been refused as you or another physician have previously been approved
anticoagulant supervision for this same month.

VT027

Service encounter has been disallowed as contact lens fitting includes follow up for three months.

VT028

Service encounter for a visit on the same day as a stress test has been disallowed as the patient was
seen in consultation in the previous 14 days.

VT029

Service encounter has been disallowed as a visit is not approved the same day as critical care.

VT030

Service encounter has been disallowed as compression sclerotherapy includes after care for one
year.

VT031

Service encounter has been refused as detention is not payable in the office.

VT032

Service encounter for a visit with detention has been refused as you have previously been approved
a visit allowed procedure at the same service encounter.

VT033

Service encounter has been adjudicated according to the weekly maximum of 44 units allowed per
week after 56 days from admission.

VT034

Service encounter has been disallowed as an inpatient comprehensive evaluation has previously
been approved and the patient has been readmitted within 10 days for the same or related condition.

you this day or subsequent day for the same or related condition.

previous 30 days.

days.

days for the same or related diagnosis.

previous 30 days.

VT040

Service encounter has been disallowed as supportive care is approved once every three days up to
and including the ninth day from admission and twice weekly thereafter.

VT041

Service encounter has been accepted at zero. The first postoperative clinic or office recheck should
be claimed, but will be approved at 0 units during the 90 days following major surgery.

VT042

Service encounter has been disallowed. When a visit and surgery are performed at the same service
encounter, only one is approved.

XPLANATORY

DESCRIPTION

VT035 Service encounter has been disallowed as a comprehensive visit has been previously approved to

VT036 Service encounter has been refused as a comprehensive visit has been approved to you in the

VT037 Service encounter has been refused as a previous visit has been claimed by you in the previous 30

VT038 Service encounter has been refused as you have been approved a consultation in the previous 30

VT039 Service encounter for initial limited visit has been refused as you have attended this patient in the

EXPLANATORY CODES - 23

May 2011

E

CODE

VT043

Service encounter has been refused as a newborn care visit has previously been approved for this
day.

VT044

Service encounter has been refused as modifier DA value is inappropriate after 56 days from
admission.

VT045

Service encounter has been refused as this is an invalid service for age of patient.

VT046

Service encounter has been refused as health service code and modifier combination indicated is
invalid for your specialty.

VT047

Service encounter has been refused as the maximum of three services per patient per day has been
approved.

VT048

Service encounter has been disallowed as it is not payable in addition to the assistant fee.

VT049

Service encounter has been disallowed as it is included in the postoperative care of fractures.

VT050

Service encounter has been refused. Resubmit under the visit code using modifier for role of
detention in conjunction with all other required modifiers.

VT051

Service encounter has been refused. You have previously been approved a comprehensive
evaluation during this hospitalization.

VT052

Service encounter has been disallowed as a previous well baby visit has been approved for this three
month period.

encounter.

VT054

Service encounter has been disallowed as it is included in the fracture procedure performed this
same day.

VT055

Service encounter has been disallowed. Contact lens fitting includes follow up care for three months.

physician.

delivery.

VT058

Service encounter has been refused as the patient has not yet reached the age of 65.

immunizations at this same encounter.

surgery.

previously approved at this same service encounter.

VT062

Service encounter has been disallowed as you have previously been approved a delivery fee.

VT063

Service encounter has been disallowed as delivery did occur at the same facility.

VT064

Service encounter has been disallowed as a visit is included in the previously approved procedure.

this provider.

a previous visit by the same provider.

VT067

Service encounter has been disallowed. This service is only approved for general practitioners.

explaining the medical necessity of a comprehensive visit within 30 days of a previous visit.

XPLANATORY

DESCRIPTION

VT053 Service encounter has been disallowed as it is included in the surgery performed at this same

VT056 Service encounter has been disallowed as this service has been approved to you or another

VT057 Service encounter has been disallowed as attendance with patient during labour is included in the

VT059 Service encounter has been refused. Two previous service encounters have been approved for

VT060 Service encounter has been disallowed as a visit the same day as major surgery is included in the

VT061 Service encounter has been disallowed as it is included in a diagnostic and therapeutic procedure

VT065 Service encounter has been disallowed as 30 days has not elapsed since recipient was last seen by

VT066 Service encounter has been disallowed. Comprehensive visits cannot be approved within 30 days of

VT068 Service encounter has been refused. Resubmit as a limited visit or resubmit providing electronic text

EXPLANATORY CODES - 24

May 2011

E

CODE

VT069

Service encounter has been disallowed based on the limitations applied to supportive care visits.

VT070

Service encounter has been disallowed as you have been approved a visit during the previous two
days.

VT071

Service encounter for supportive care has been disallowed as you have been approved two visits
within the previous two days.

VT072

Service encounter for supportive care has been disallowed as you have been approved two visits
within the previous three days.

VT073

Service encounter for supportive care has been disallowed as you have been approved two visits
within the previous four days.

VT074

Service encounter for supportive care has been disallowed as you have been approved two visits
within the previous five days.

VT075

Service encounter for supportive care has been disallowed as you have been approved two visits
within the previous six days.

VT076

Service encounter has been refused as modifier value OV65 does not agree with age of patient.

VT077

Service encounter has been refused. Resubmit under the same health service code using the
appropriate modifiers for the service provided.

VT078

Service encounter has been refused as patient’s age is inappropriate for this service.

previously been approved.

VT080

Service encounter has been refused as modifier DA value is inappropriate after 56 days from hospital
admission.

of life has been approved.

of life has been approved.

VT083

Service encounter has been refused as the patient is not insured for this service at this time.

VT084

Service encounter has been refused as the patient is not insured for this service at this time.

approved.

18 months.

diagnosis.

service for this diagnosis.

VT089

Service encounter has been refused as functional center is not indicated.

duration of the current treatment cycle.

VT091

Service encounter has been disallowed as this service is included in the CGA1 service that has
previously been approved.

WB001

Service encounter has been disallowed according to information provided by workers compensation
board.

approved.

XPLANATORY

DESCRIPTION

VT079 Service encounter has been refused as the maximum number of complex care visits for the year has

VT081 Service encounter has been refused as the maximum of 8 well baby care visits in the first 13 months

VT082 Service encounter has been refused as the maximum of 8 well baby care visits in the first 13 months

VT085 Service encounter has been refused as the maximum of 9 well baby care visits has previously been

VT086 Service encounter has been refused as only one well baby care visit is insured when patient age is

VT087 Service encounter has been refused as you have previously been approved this service for this

VT088 Service encounter has been refused as you or another provider have previously been approved this

VT090 Service encounter has been disallowed as electronic text is required to indicate the start date and

WB002 Service encounter has been disallowed as previous payment under WCB7 or WCB8 has been

EXPLANATORY CODES - 25

May 2011

E

CODE

WB003

Service encounter has been approved at the WCB6 rate.

WB004

Service encounter has been adjusted based on a decision by workers' compensation board.

WB005

Service encounter has been disallowed as payment under WCB7 has been approved.

WB006

Service encounter has been disallowed as payment under WCB8 has been approved.

WB007

Service encounter has been refused as this form code has not been approved for implementation.

WB008

Service encounter has been refused re payment responsibility indicated.

WB009

Service encounter has been disallowed as previous payment under WCB9 or WCB10 has been

WB010

Service encounter has been refused as a consultation service has not been claimed for this date.

WB011

Service encounter has been refused as this type of visit is no longer payable under WCB. Please
resubmit using the appropriate physician assessment health service code.

WB012

Service encounter has been refused as you have previously claimed a physician assessment service
this day.

WB013

Service encounter has been refused as you have previously claimed a physician assessment service
this day.

WB014

Service encounter has been refused as you have previously been paid a special assessment service
for this date.

WB015

Service encounter has been refused as you have previously been paid an assessment service with
completion of form 8/10 this date.

WB016

Service encounter has been refused as a previous assessment has been claimed by you for this
date.

date.

date.

date.

date.

date.

WB022

Service encounter has been disallowed as a previous service for WCB has been claimed this day.

WB023

Service encounter has been disallowed as a previous visit fee for WCB has been claimed this day.

disability and form 8/10 is not applicable.

approved.

WB026

Service encounter has been refused as a previous payment under WCB9 has been approved.

XPLANATORY

DESCRIPTION

approved.

WB017 Service encounter has been refused as a previous assessment has been claimed by you for this

WB018 Service encounter has been refused as a previous chart summary has been claimed by you for this

WB019 Service encounter has been refused as a previous chart summary has been claimed by you for this

WB020 Service encounter has been refused as a previous case conference has been claimed by you for this

WB021 Service encounter has been refused as a previous case conference has been claimed by you for this

WB024 WCB has advised the adjustment of this claim to the appropriate visit fee as the client is on long term

WB025 Service encounter has been refused as previous payment under WCB11 or WCB12 has been

May 2011

MISCELLANEOUS - 1

A

2008

M

31, 2009

A

2009

M

31, 2010

A

2010

M

31, 2011

A

2011

M

31, 2012

A

2012

M

31, 2013

A

2013

M

31, 2014

A

2014

M

31, 2015

MSU

(MSI)

AU

(MSI)

MSU

(WCB)

AU

(WCB)

MISCELLANEOUS

UNIT VALUES

Two unit values exist, an Anaesthetic Unit (AU) value used specifically for claiming anaesthetic services and a Medical
Service Unit (MSU) specifying the unit value of all other services. The chart below reflects the MSU and AU rate
increases scheduled for both MSI and WCB.

PRIL 1,

TO

ARCH

$2.23 $2.26 $2.28 $2.30 $2.32 $2.37 $2.42

$15.91 $16.15 $16.31 $16.47 $16.63 $16.96 $17.30

PRIL 1,

ARCH

TO

PRIL 1,

ARCH

TO

PRIL 1,

ARCH

TO

PRIL 1,

ARCH

TO

PRIL 1,

ARCH

TO

PRIL 1,

TO

ARCH

$2.48 $2.51 $2.53 $2.56 *

$17.68 $17.94 $18.12 $18.30 *

* *

* *

*Values have yet to be determined

For further information refer to th e Physician’s Manual Preamble and/or the Billing Instructions Manual.

HEALTH SERVICE CODES

03.08 - Consultation, described as Comprehensive

03.07 - Consultation, described as Limited

03.05 - Other Diagnostic Interview and Evaluation (includes critical care, ventilatory care, comprehensive care,
intensive care, neonatal intensive care).

03.04 - Diagnostic Interview and Evaluation, described as Comprehensive - In depth evaluation with complete history
and physical examination.

03.03 - Diagnostic Interview and Evaluation, described as Limited - Limited assessment with history of the presenting
problem.

Additional Services

MAAS EC Exceptional Circumstances ....................................................................................... EC

MAAS IC Independent Consideration ....................................................................................... IC

MAAS IF Interim Fee ................................................................................................................ IF

Community Services

DEFT C9999 Community Services Medical Assessment Form ...................................................... $25.00

Other Dental Operations NEC
MAAS 36.99A Assistant for dental surgery performed by a dentist

(RO=DTAS) ............................................................................................................... IC

Workers' Compensation Board

DEFT WCB2 W CB Office Visit Examination for Pneumoconiosis .................................................. 20.5 units

DEFT WCB11 Physician assessment service. Combined office visit and

completion of Form 8/10 .......................................................................................... $123.40

May 2011

MISCELLANEOUS - 2

DEFT WCB12 EPS physician assessment Service.

Combined office visit and completion of Form 8/10 .................................................. $153.55

DEFT WCB13 Chart Summaries / Written Reports. Detailed reports billed in 15 minute intervals

- plus multiples, if applicable ..................................................................................... $37.50 per 15 min

DEFT WCB14 Chart Summaries / Written Reports. Detailed reports billed for the

total number of pages - plus multiples, if applicable .................................................. $125 per page

DEFT WCB15 Case Conferencing and Teleconferencing (Treating Physician)
Conferencing billed by the Treating Physician

- plus multiples, if applicable ..................................................................................... $37.50 per 15 min

DEFT WCB16 Case Conferencing and Teleconferencing (EPS Physician)

Conferencing billed by an EPS physician - plus multiples, if applicable .................... $50 per 15 min

DEFT WCB17 Photocopying of charts. Photocopying of chart notes ............................................. $25.00 *

* Note: $25.00 will be paid through MSI; if the physician negotiates a different
amount then they must invoice the entire service directly to WCB.

DEFT WCB18 Special Assessment Service (WCB Authorization Only).

Special assessment service requiring WCB approval prior to use ............................ $61.70

DEFT WCB19 Special Reporting Service (WCB Authorization Only).

Special reporting service requiring WCB approval prior to use ................................. $61.70

DEFT WCB98 Second opinion consultation specifically requested by WCB regarding

back surgery .............................................................................................................. 64.2 units

The following are applicable to the specialty of Orthopaedics only:
DEFT WCB9 W CB completion of Form 9 in conjunction with an expedited non-emergency

Orthopaedic Consultation

RF=REFD, SP=ORTH ............................................................................................... 30.43 units

DEFT WCB10 WCB completion of Form 10 in conjunction with an expedited non-emergency

Orthopaedic Major Surgical Procedure

SP=ORTH ................................................................................................................. IC

May 2011

MISCELLANEOUS - 3

PROLONGED CONSULTATIONS
A Prolonged Consultation may be applied to cases where the consultation extends beyond one hour for Comprehensive
Consultations and a half-hour for Repeat Consultations. A Prolonged Consultation cannot be claimed with a Limited
Consultation and is not to be confused with active treatment associated with detention. Prolonged Consultations are paid
in 15-minute time intervals or portions thereof. This information is entered on your service encounter using the Multiples
indicator. For further details refer to the Billing Instructions Manual Chapter 5.

A Prolonged Consultation may be claimed by the following specialities only:

Anaesthesia .....................15 units per 15 minutes

Internal Medicine .............13.5 units per 15 minutes

Neurology ........................13.5 units per 15 minutes

Physical Medicine ............13.5 units per 15 minutes

Paediatrics .......................16.3 units per 15 minutes

Psychiatry ........................18.22 units per 15 minutes

MULTIPLES
The Multiples indicator (MU) indicates the number of services performed (e.g., number of lesions), the length of time
(e.g., 15 minute time intervals, detention, counselling, etc.) or the percentage of body (burns) or surface area (e.g.,
square inches). For further details refer to the Billing Instructions Manual Chapter 4.

DETENTION
Medical detention occurs when a service provider’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 is not payable when provided in the office.
Detention commences 30 minutes after the provider is first in attendance and may be claimed in 15 minute increments
thereafter. The first 30 minutes is the appropriate visit fee. When claimed with a Comprehensive or a Limited
Consultation, detention time commences after 1 hour. The fee for detention is 12.5 units per 15 minutes. The detention
modifier RO=DETE must be indicated on the service encounter. For further details refer to the Preamble.

PREMIUM FEES
Premium fees may be claimed for certain services provided on an emergency basis during designated time periods. An

emergency basis is defined as a service which must be performed without delay because of the medical
condition of the patient.

Premium Fees are paid at 35% (US=PREM) or 50% (US=PR50) of the appropriate service code but at not less than 18
units for patient specific services and not less than 9 units for non-patient specific services. For further details refer to the
Preamble.

OUTDATED SERVICE ENCOUNTERS
Service encounters submitted beyond 90 days from date of service shall not be payable 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 extenuating circumstances by writing to the Manager of
MSI Programs.

Note: WCB and facility based non patient specific service encounters follow the same ruling.

OUTDATED RECIPROCAL SERVICE ENCOUNTERS
Service encounters submitted beyond one year from date of service shall not be payable.

TERMINATION DATE
The expiry date of a Health Service Code tariff temporarily assigned to a new procedure during the process of adding it
to the Schedule of Benefits. For further details refer to the Preamble under item Interim Fees.

May 2011

MISCELLANEOUS - 4

SPECIALTY ABBREVIATIONS
ANAE - Anaesthesia

ANPA - Anatomical Pathology
CARD - Cardiology
CASG - Cardiovascular/Thoracic Surgery
CLIA - Clinical Immunology & Allergy
COMD - Community Medicine
DENT - Dental Practitioner
DERM - Dermatology
DIRD - Diagnostic Radiology
EMMD - Emergency Medicine
ENDO - Endodontics
ENME - Endocrinology & Metabolism
GAST - Gastroenterology
GEMD - Geriatric Medicine
GENP - General Practitioner
GNSG - General Surgery
HAGY - Haematology
HAPA - Haematological Pathology
HUGE - Human Genetics
INDI - Infectious Diseases
INMD - Internal Medicine
MDON - Medical Oncology
MEBI - Medical Biochemistry
MEGE - Medical Genetics
MEMI - Medical Microbiology
NCMD - Nuclear Medicine
NEPA - Neuropathology

CATEGORY ABBREVIATIONS
ADON - Add On

ALPM - Alternate Payments
ANAE - Anaesthesia
BOGR - Bone Graft
CASP - Casts and Splints
COCR - Complete Care
CONS - Consultation
CRCR - Intensive Care / Critical Care
DEFT - Default
DISL - Dislocation
MAAS - Manual Assess

NEPE - Neurology Paediatric
NEPH - Nephrology
NEUR - Neurology
NUSG - Neurosurgery
OBGY - Obstetrics & Gynaecology
ODON - Orthodontics
OPHT - Ophthalmology
OPTO - Optometry
ORAL - Oral Surgery
ORTH - Orthopaedic Surgery
OTOL - Otolaryngology
PATH - General Pathology
PEDI - Paediatrics
PEDO - Pedodontics
PERI - Periodontics
PHMD - Physical Medicine & Rehabiltation
PLAS - Plastic Surgery
PROS - Prosthodontics
PSYC - Psychiatry
RADI - Diagnosti c & Therapeutic Radiology
RDON - Radiation Oncology
RHEU - Rheumatology
RSMD - Respiratory Medicine
THSG - Thoracic Surgery
UROL - Urology
VASG - Vascular Surgery

MAFR - Major Fracture
MASG - Major Surg ery
MIFR - Minor Fracture
MISG - Minor Surgery
OBST - Obstetrical
OPTO - Optometry
PMNO - Pain Management (non obstetrical)
PSYC - Psychiatric Care
VADT - Visit Allowed Diagnostic & Therapeutic Procedure
VEDT - Visit Excluded Diagnostic & Therapeutic Procedure
VIST - Visit

MISCELLANEOUS -5

TYPE

VALUE

DESCRIPTION

AG

ADUT

Person 16 years and older

AG

CH04

Child up to four years

AG

CH07

Child up to seven years

AG

CH12

Child up to twelve years

AG

CH16

Child up to sixteen years

AG

NWBN

Newborn (infant up to and including ten days)

AG

OV65

Person 65 years and older

AG

PR07

Person 7 years and older

AN

DFED

Delivery following epidural introduction

AN

EPID

Epidural anaesthetic

AN

GENL

General anaesthetic

AN

LABR

Labor

AN

LOCL

Local anaesthetic

AN

PNCT

Pain control

AN

REGL

Regional

AP

ABDO

Abdominal

AP

ANTE

Anterior

AP

CERV

Cervical

AP

CLSD

Closed procedure

AP

DRSL

Dorsal

AP

EXTR

External

AP

INPR

Intra peritoneal

AP

LMBR

Lumbar

AP

OPEN

Open procedure

AP

PERC

Percutaneous approach

AP

PERI

Perineal

AP

POST

Posterior

AP

SUBC

Subcutaneous

AP

THOR

Thoracic

AP

TRUR

Transurethral

AP

VAGN

Vaginal

AP

WPLO

With pleura open

CO

BPU5

By-pass pump - patient under 5000 grams

CO

CHYO

Controlled hypotension

MODIFIER DESCRIPTIONS
The following is a list of all available modifiers. In order to be paid the correct value for the service rendered, the

appropriate modifiers and/or modifier combinations must be submitted. This Physician’s Manual provides a list of the
base unit values for the Health Service Codes. The complete list of all unit values and modifiers or modifier combinations
is also available on your computer system.

AP WPLC With pleura closed

May 2011

MISCELLANEOUS -6

T

V

D

CO

CRBY

Cardiac by-pass with pump

CO

HPTH

Hypothermia

CO

INFE

Infant resuscitation after delivery

CO

PACM

Pacemaker monitoring

CO

UN5K

Patient under 5000 grams

CT

PROF

Professional component

CT

TECH

Technical component

DA

DALY

Daily rate applies

DA

RGE1

Date range defining Saturday, Sunday and Holidays

DA

RGE2

Sundays and Holidays

DA

WKLY

Weekly rate applies

FN

DTOX

Detox Centre

FN

EMCC

Emergency Care Centre

FN

INCU

Intensive care

FN

INPT

Inpatient

FN

NICU

Neonatal Intensive Care

FN

OTPT

Outpatient

IN

CC01

Critical care first day

IN

CC10

Critical care day 2 to 10 inclusive

IN

CC11

Critical care 11th day onward

IN

CP01

Comprehensive care 1st day

IN

CP10

Comprehensive care day 2 to 10 inclusive

IN

CP11

Comprehensive care 11th day onward

IN

INCR

Intensive care per day

IN

INHD

Intensive care per half day

IN

INPH

Intensive care per hour

IN

NIC1

Neonatal intensive care day 1

IN

NIC4

Neonatal intensive care day 2 to 4 inclusive

IN

NIC5

Neonatal intensive care day 5 onward

IN

VC01

Ventilatory care first day

IN

VC10

Ventilatory care day 2 to 10 inclusive

IN

VC11

Ventilatory care 11th day onward

LO

CCNT

Correctional Centre

LO

HMHC

Acute Home Care

LO

HOME

Home

LO

HOSP

Hospital

LO

NRHM

Nursing Home

LO

OFFC

Office

LO

OTHR

Other

YPE

ALUE

ESCRIPTION

May 2011

MISCELLANEOUS -7

T

V

D

LV

LV50

The second or subsequent procedure done through the same approach

LV

LV65

Indicates a procedure done through separate approach

ME

ABDM

Abdominal

ME

CMST

Composite procedure

ME

COMP

Complicated procedure

ME

CRYO

Cryotherapy treatment by freezing

ME

CURT

Curettage scraping

ME

ELEC

Electrocautery removal by burning

ME

EXRM

Removal by excision

ME

EXTN

External

ME

FTSG

First stage

ME

INTN

Internal

ME

INTR

Intrauterine

ME

LAPA

Procedure performed by laparotomy

ME

LASR

Procedure performed using laser technique

ME

MAJO

Extensive complication

ME

MINO

Complexity minor or limited

ME

RADI

Radical extensive procedure

ME

SCOP

Procedure performed through scope

ME

SDSG

Second stage

ME

SIMP

Simple procedure

ME

TELE

Telemedicine Conference

ME

VAGN

Vaginal

OL

HMHC

OPD visit from Acute Home Care

OL

HOME

Admission from home to Acute Home Care

OL

INPT

Admission from inpatient to Acute Home Care

OL

OFFC

Admission from office to Acute Home Care

OL

OTPT

Admission from OPD to Acute Home Care

OL

USEM

Admission from unscheduled emergency call to Acute Home Care

PO

COML

Entire procedure performed

PO

ONTW

One to twenty percent of body

PO

PART

Partial procedure performed

PO

RADI

Procedure to the fullest extent

PO

SBTL

Subtotal (less than complete)

PO

SEGM

Segmental part of the body

PO

TOTF

Twenty-one to thirty-five percent of body

PO

TSOV

Thirty-six percent of body and over

PO

WEGE

Wedge part of the segment

PT

CDDR

Cadaver donor

PT

DONR

Donor

YPE

ALUE

ESCRIPTION

May 2011

MISCELLANEOUS -8

T

V

D

PT

EXPT

Additional patient seen at same location

PT

FTPT

First patient seen

PT

LIDR

Live donor

PT

PRBK

Patient referred back

PT

PRTO

Patient referred to Ophthalmologist

PT

RECP

Recipient

RF

REFD

Referring doctor

RG

BOTH

Bilateral procedure

RG

FEMR

Femur head and neck

RG

LEFT

Procedure performed on the left side of the body

RG

RIGT

Procedure performed on the right side of the body

RO

ABAS

Abdominal assistant

RO

ABDM

Abdominal surgeon two team approach

RO

ABDO

Abdominal surgeon

RO

ADAC

Adacel (diphtheria, pertussis and tetanus)

RO

ANAE

Anaesthetist

RO

ANCO

Anticoagulant supervision per month

RO

ANTL

Antenatal

RO

BOTR

Boostrix (diphtheria, pertussis and tetanus)

RO

CAPT

Comprehensive reassessment of a cancer patient

RO

CCDT

Continuing care and detention

RO

CCDX

Continuing care in conjunction with attending and describing a differential diagnosis

RO

CHDT

Closed head injury with detention

RO

CLHD

Closed head injury

RO

CNTC

Continuing care

RO

CRTC

Palliative care medicine chart review (and/or telephone call, fax or email initiated by a
health care professional)

RO

DBSU

Double set up

RO

DETE

Detention

RO

DIRC

Directive care

RO

DRDT

Directive care and detention

RO

DTAS

Dental assistant

RO

DUTY

Duty doctor

RO

DYDT

Duty doctor and detention

RO

EXEM

Injection when potential for allergic reaction to ingredient exists

RO

FPHN

First physician

RO

HMDY

Home dialysis

RO

HMTE

Acute or chronic home care, medical chart review, telephone calls, fax or email

RO

HPVV

HPV Vaccine

RO

INCH

Physician in hyperbaric chamber

YPE

ALUE

ESCRIPTION

May 2011

MISCELLANEOUS -9

T

V

D

RO

INFL

Injection for various strains of influenza

RO

INPR

Interpretation and procedure

RO

INTP

Interpretation

RO

MENC

Meningococcal type C conjugate vaccine

RO

MMAR

Injection for measles, mumps and rubella

RO

NBCR

Newborn care

RO

OBDA

Obstetrical delivery assist

RO

OTCH

Physician out of hyperbaric chamber

RO

PAMO

Pathology materials only

RO

PAND

Injection for pandemic vaccination

RO

PCSV

Palliative care support visit

RO

PEAS

Perineal assistant

RO

PENT

Injection for diphtheria, pertussis, tetanus, poliomyelitis and haemophilus influenza type B

RO

PNEC

Pneumococcal conjugate vaccine (Prevnar)

RO

PNEU

Injection for pneumococcal pneumonia, bacteraemia and meningitis

RO

PRIN

Perineal surgeon two team approach

RO

PROC

Procedure

RO

PTNT

Post natal

RO

PTPP

Post partum

RO

QUAD

Injection for diphtheria, pertussis, tetanus and poliomyelitis

RO

RESC

Resuscitation

RO

RNDT

Resuscitation of newborn with detention

RO

SNAS

Second assistant

RO

SPCR

Supportive care

RO

SPHN

Second physician

RO

SPIN

Supervision and interpretation

RO

SRAS

Surgical assistant

RO

SSAN

Second simultaneous anaesthetist

RO

STBY

Standby

RO

SUPV

Supervision

RO

TALR

Telephone advice and medical chart review of liver transplant recipient

RO

TCCP

Telephone advice and medical chart review of a cancer patient by the Oncologist

RO

TEDI

Injection for tetanus and diphtheria (adults)

RO

TRPL

Treatment planning

RO

TRTL

Trauma team leader

RO

UPCK

Visit pacemaker check

RO

VARI

Injection for varicella

RO

VGSG

Vaginal surgeon

RO

WBCR

Well baby care

YPE

ALUE

ESCRIPTION

May 2011

MISCELLANEOUS -10

T

V

D

RP

CON2

Second chronic disease managed

RP

INTL

Initial

RP

REPT

A repeat of a service

RP

REVS

Revision

RP

SUBS

Subsequent similar service

SE

FEML

Female

SE

MALE

Male

SP

ANAE

Anaesthetist

SP

ANPA

Anatomical Pathology

SP

CARD

Cardiology

SP

CASG

Cardiovascular/Thoracic surgery

SP

CLIA

Clinical Immunology and Allergy

SP

COMD

Community Medicine

SP

DENT

Dental General Practitioner

SP

DERM

Dermatology

SP

DIRD

Diagnostic Radiology

SP

EMMD

Emergency Medicine

SP

ENDO

Endodontics

SP

ENME

Endocrinology and Metabolism

SP

GAST

Gastroenterology

SP

GEMD

Geriatric Medicine

SP

GENP

General Practitioner

SP

GNSG

General Surgery

SP

HAGY

Haematology

SP

HAPA

Haematological Pathology

SP

HUGE

Human Genetics

SP

INDI

Infectious Diseases

SP

INMD

Internal Medicine

SP

MDON

Medical Oncology

SP

MEBI

Medical Biochemistry

SP

MEGE

Medical Genetics

SP

MEMI

Medical Microbiology

SP

NCMD

Nuclear Medicine

SP

NEPA

Neuropathology

SP

NEPE

Neurology Paediatric

SP

NEPH

Nephrology

SP

NEUR

Neurology

SP

NUSG

Neurosurgery

SP

OBGY

Obstetrics and Gynaecology

YPE

ALUE

ESCRIPTION

May 2011

MISCELLANEOUS -11

T

V

D

SP

ODON

Orthodontics

SP

OPHT

Ophthalmology

SP

OPTO

Optometry

SP

ORAL

Oral Surgery

SP

ORTH

Orthopaedic Surgery

SP

OTOL

Otolaryngology

SP

PATH

General Pathology

SP

PEDI

Paediatrics

SP

PEDO

Pedodontics

SP

PERI

Periodontics

SP

PHMD

Physical Medicine and Rehabilitation

SP

PLAS

Plastic Surgery

SP

PROS

Prosthodontics

SP

PRPR

Prosthetic Provider

SP

PSYC

Psychiatry

SP

RADI

Diagnostic and Therapeutic Radiology

SP

RDON

Radiation Oncology

SP

RHEU

Rheumatology

SP

RSMD

Respiratory Medicine

SP

THSG

Thoracic Surgery

SP

UROL

Urology

SP

VASG

Vascular Surgery

TI

AMNN

0801-1200

TI

ETMD

2001-2359

TI

EVNT

1701-2000

TI

GPEW

GP Evening & Weekend Office Visit Incentive (M-F 1800-2200 or S/S 0900-1700)

TI

MDNT

0000-0800

TI

NNEV

1201-1700

US

PREM

Premium fee of 35 percent

US

PR50

Premiu m fee of 50 percent

US

SCHD

Planned / Scheduled outpatient visit (0800-2000)

US

UCHH

Urgent call back by acute home care staff

US

UIOH

Urgent visit interrupting normal office hours

US

UNOF

Urgent visit not interrupting office hours

YPE

ALUE

ESCRIPTION

May 2011

MISCELLANEOUS -12

SERVICE CODE

DESCRIPTION

22.5C

Plastic repair (without skin graft) eyelid - no prior appro val required if condition is
trauma related

30.4

Surgical correction of prominent ear - congenital (18 years and older)

30.61A

External ear otoplasty, exclusive of simple lacerations (minor)

30.61A

External ear otoplasty, exclusive of simple lacerations (major)

30.61B

Total reconstruction of ear (Pinna) (18 years and older)

33.74

Rhinoplasty with bone or cartilage graft (entire)

33.74

Rhinoplasty with bone or cartilage graft (partial)

33.76B

Complete rhinoplasty with submucous resection without skin grafting

33.76D

Rhinoplasty - removal of hump

33.76E

Scalping rhinoplasty - two stages

33.79B

Reconstruction of nasal tip, ala and columella

56.93

Gastroplasty or gastric bypass for morbid obesity

97.31A*

Unilateral mammoplasty with nipple transplantation

97.31C

Unilateral functional pedicled breast reduction (unilateral)

97.32*

Bilateral reduction mammoplasty

97.32B

Bilateral functional pedicled breast reduction

97.43*

Unilateral augmentation mammoplasty by implant or graft

97.44*

Bilateral augmentation mammoplasty by implant or graft

97.6B*

Breast reconstruction by myocutaneous flap and breast prosthesis

97.6C*

Breast reconstruction using rectus abdominis flap, including reconstruction of the
rectus sheath as required.

97.6D*

Deep inferior epigastric perforator (DIEP) free flap breast reconstruction

97.75A*

Breast reconstruction by myocutaneous flap and prosthesis

97.77*

Other repair or reconstruction of nipple

97.94A*

Removal of breast prosthesis

97.94B*

Removal of breast prosthesis with capsulectomy

98.93A

Dermabrasion - full face

98.93B

Dermabrasion - less than 1/4 of face

98.93C

Dermabrasion of single area face (e.g., trauma scar)

98.93D

Dermabrasion between 1/4 and 1/2 of face

EC

Lipectomy (single reduction - plastic operation)

PREAUTHORIZATION SERVICE ENCOUNTE RS
Service encounters submitted for the following procedures must have prior approval and a valid referral in order to be

paid. Refer to the Billing Instructions Manual, Chapter 5 for information on submitting prior approval codes.
* prior approval unless procedure is post-mastectomy for malignant or pre-malignant condition

HEALTH

May 2011

CODE

GROUP

DESCRIPTION

VALUE

1

Other

Interpretation of submitted films

6.25

2

Other

Fluoroscopy in O.R.

3.13

3

Other

Conventional tomography

9.38

5

H&N

Skull - routine views

4.40

6

H&N

Temporomandibular joints

4.34

7

H&N

Internal auditory meati

4.34

8

H&N

Sella turcica

4.34

9

H&N

Optic foramina

4.34

11

H&N

Mastoids - added view

4.34

12

H&N

Eye for foreign body

4.34

15

H&N

Facial bones

4.40

20

H&N

Mandible

3.31

25

H&N

Nasal bones

3.31

30

H&N

Sinuses - paranasal

3.88

35

H&N

Salivary gland region

3.31

45

H&N

Panorex (teeth - full set)

4.97

50

H&N

Arthrogram

20.76

55

H&N

Dacrocystogram

5.53

60

H&N

Sialogram

9.38

70

H&N

Speech study

44.24

105

Bone

Cervical spine

5.19

110

Bone

Thoracic spine

3.31

115

Bone

Lumbar spine

5.19

120

Bone

Sacrum / coccyx

3.31

125

Bone

Scoliosis series

8.85

126

Bone

Scoliosis with stress

11.07

129

Bone

Metastatic series (5)

9.12

130

Bone

Metabolic bone survey

9.12

131

Bone

All long bones added to 129

2.28

140

Mylo

Discogram

11.07

150

Mylo

Lumbar myelogram

18.75

151

Mylo

Complete myelogram

28.14

152

Mylo

Cervical injection myelogram

18.75

185

Other

Fetal Study

3.31

205

Bone

Shoulder

3.41

210

Bone

Scapula

3.41

215

Bone

A.C. joints with and without weights

3.41

RADIOLOGY NON-PATIENT - SPECIFIC BULK BILLING FEES

UNIT

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LING FEES Page 1

CODE

GROUP

DESCRIPTION

UNIT

VALUE

220

Bone

Clavicle

3.41

221

Bone

Bone age determination

4.53

223

Bone

Scaphoid

3.41

224

Bone

Humerus

3.41

225

Bone

Elbow

3.41

226

Bone

Wrist

3.41

227

Bone

Forearm

3.41

228

Bone

Hand

3.41

229

Bone

Finger

1.71

230

Bone

Arthrogram shoulder

20.76

305

Bone

Hip

3.41

310

Bone

Pelvis

3.31

315

Bone

Pelvis and hips

3.99

320

Bone

Sacroiliac joints

3.31

321

Bone

Patella

3.41

322

Bone

Foot

3.41

323

Bone

Ankle

3.41

324

Bone

Knee

3.41

325

Bone

Calcaneus

3.41

326

Bone

Tibia and fibula

3.41

327

Bone

Toe

1.71

328

Bone

Feet - weight bearing

6.64

335

Bone

Femur

3.41

340

Bone

Orthoroentgenogram (leg length measurement)

2.58

350

Bone

Arthrogram hip

20.76

351

Bone

Arthrogram knee

20.76

403

Other

Fluoroscopy 10 minutes

12.50

404

Chest

Single view

3.13

405

Chest

Multiple views

5.13

425

Chest

Ribs - each side

2.90

435

Chest

Sternum

3.31

439

Bone

Dual photon densitometry

11.73

440

Bone

Sternoclavicular joints

3.41

445

H&N

Neck - for soft tissue

3.31

470

Chest

Bronchogram unilateral

11.07

484

Mammo

Mammography screening bilateral

5.09

485

Mammo

Mammography unilateral

7.19

486

Mammo

Breast cystography

6.63

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LING FEES Page 2

CODE

GROUP

DESCRIPTION

UNIT

VALUE

490

Mammo

Mammography diagnostic bilateral

14.07

495

Mammo

Needle localization

34.39

500

Mammo

Galactography

6.63

505

Mammo

Stereotactic localization

19.29

510

Mammo

Surgical specimen radiography

3.82

605

Abdomen

Survey film

3.13

610

Abdomen

Multiple films

3.88

620

G.I.

Esophagus

14.62

625

G.I.

Upper G.I. series

18.69

630

G.I.

Upper G.I. paediatric

28.05

635

G.I.

Small bowel study

9.67

640

G.I.

Enteroclysis

26.57

650

G.I.

Colon - barium only

14.91

655

G.I.

Colon paediatric - single

22.37

660

G.I.

Colon - double contrast

19.92

666

G.I.

Defaecography

26.57

670

G.I.

Cholecystogram

4.97

690

G.I.

T-tube cholangiogram

6.63

691

G.I.

Operative cholangiogram

4.66

695

G.I.

ERCP

6.63

709

G.I.

Herniography

9.38

710

G.I.

Fistula/sinus with contrast

4.40

745

G.I.

Percutaneous transhepatic cholangiogram

6.63

815

G.I.

Intravenous urogram (IVP)

14.53

823

G.U.

Retrograde pyelogram

4.53

830

G.U.

Voiding cystourethrogram

11.07

835

G.U.

Cystogram paediatric

18.75

840

G.U.

Loopogram

4.40

845

G.U.

Retrograde urethrogram

4.53

846

G.U.

Cavernosogram

4.40

850

G.U.

Antegrade (t-tube) pyelogram

4.53

865

G.U.

Renal cystogram

6.63

885

G.U.

Vasogram

4.40

895

G.U.

Hysterosalpingogram

5.53

910

G.U.

Pelvimetry

6.63

1001

Vascular

Venous DSA - abnormal or renal

35.52

1002

Vascular

Venous DSA - aortic arch

39.58

1003

Vascular

Pulmonary angiogram bilateral

93.79

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LING FEES Page 3

CODE

GROUP

DESCRIPTION

UNIT

VALUE

1004

Vascular

Pulmonary angiogram unilateral

62.53

1006

Vascular

Unilateral peripheral arteriogram

22.14

1007

Vascular

Bilateral peripheral arteriogram

33.21

1008

Vascular

Aortography (abdominal)

44.21

1009

Vascular

Visceral selective arteriogram

44.21

1010

Vascular

Venogram extremity

25.01

1011

Vascular

Venocavogram selective

22.14

1012

Vascular

Visceral venogram

22.14

1013

Vascular

Spinal artery selective

22.14

1014

Vascular

Bronchial artery selective

44.21

1015

Vascular

Lymphangiogram

44.21

1016

Vascular

Arch aortogram

44.21

1017

Vascular

Spleenoportogram

53.90

1018

Vascular

Intraoperative angiogram

43.77

1021

Vascular

Common carotid bilateral

55.83

1022

Vascular

Internal carotid bilateral

55.83

1023

Vascular

External carotid bilateral

55.83

1024

Vascular

Vertebral bilateral

55.83

1026

Vascular

Common carotid unilateral

30.45

1027

Vascular

Internal carotid unilateral

30.45

1028

Vascular

External carotid unilateral

30.45

1029

Vascular

Vertebral unilateral

30.45

1056

Cardiac

Coronary arteries

50.75

1057

Cardiac

Coronary arteries with ergot

25.38

1058

Cardiac

Coronary artery grafts

50.75

1059

Cardiac

P.T.C.A.

50.75

1061

Cardiac

Right ventriculogram

25.38

1062

Cardiac

Left ventriculogram

25.38

1063

Cardiac

Cardiac panning < 45 min.

60.90

1064

Cardiac

Cardiac panning > 45min.

121.81

1071

Cardiac

Aortic root (cardiac)

25.38

1105

C.T.

CT head without contrast

42.33

1111

C.T.

CT head with contrast

42.33

1115

C.T.

CT head without and with contrast

53.27

1121

C.T.

CT neck without contrast

42.33

1125

C.T.

CT neck with contrast

42.33

1130

C.T.

CT neck without and with contrast

53.27

1135

C.T.

CT thorax without contrast

42.33

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LING FEES Page 4

CODE

GROUP

DESCRIPTION

UNIT

VALUE

1141

C.T.

CT thorax with contrast

42.33

1145

C.T.

CT thorax without and with contrast

53.27

1150

C.T.

CT abdomen without contrast

42.33

1155

C.T.

CT abdomen with contrast

42.33

1160

C.T.

CT abdomen without and with contrast

53.27

1162

C.T.

CT extremities without contrast

42.33

1163

C.T.

CT extremities with contrast

42.33

1164

C.T.

CT extremities without and with contrast

53.27

1165

C.T.

CT pelvis without contrast

42.33

1166

C.T.

CT pelvis with contrast

42.33

1167

C.T.

CT pelvis without and with contrast

53.27

1169

C.T.

CT spine without contrast

42.33

1170

C.T.

CT spine with contrast

42.33

1172

C.T.

CT spine without and with contrast

53.27

1173

C.T.

Densitometry CT

9.07

1180

C.T.

3D reconstruction

12.16

1186

C.T.

CT head special without contrast

42.33

1187

C.T.

CT head special with contrast

42.33

1188

C.T.

CT head special without and with contrast

53.27

1205

Ultrasound

Abdomen general

25.39

1206

Ultrasound

Spine

25.39

1211

Ultrasound

Aorta

12.50

1212

Ultrasound

Appendix

18.75

1213

Ultrasound

Kidneys

18.75

1214

Ultrasound

Pylorus

18.75

1220

Ultrasound

Pelvis, male or female (GYN)

18.75

1225

Ultrasound

Endovaginal

26.95

1226

Ultrasound

Endovaginal with pelvic

38.70

1231

Ultrasound

Endorectal

25.39

1245

Ultrasound

Obstetrical

27.51

1246

Ultrasound

Obstetrical, recheck

12.50

1250

Ultrasound

Biophysical profile

4.84

1255

Ultrasound

Obs. Multiple - (add on)

20.04

1256

Ultrasound

Obs. Multiple - recheck (add on)

6.25

1264

Ultrasound

Cerebral

33.49

1265

Ultrasound

Thyroid/parathyroid (neck)

18.75

1270

Ultrasound

Real time (eye)

38.70

1271

Ultrasound

Axial length measurement

25.44

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LING FEES Page 5

CODE

GROUP

DESCRIPTION

UNIT

VALUE

1275

Ultrasound

Scrotum

25.45

1280

Ultrasound

Shoulder

18.75

1285

Ultrasound

Hip

18.75

1295

Ultrasound

Breast, single

12.50

1296

Ultrasound

Chest

18.75

1297

Ultrasound

Popliteal fossa

12.50

1298

Ultrasound

Subcutaneous mass

12.50

1306

Ultrasound

Intraoperative U/S

47.56

1307

Ultrasound

Portable - M.D. in attendance

18.75

1309

Ultrasound

Fetal echo

78.16

1310

Ultrasound

Two dimensional cardiac

47.56

1311

Ultrasound

M-Mode cardiac

25.44

1312

Ultrasound

Doppler - quantitative, cardiac

30.45

1313

Ultrasound

Doppler - qualitative, cardiac

15.23

1335

Ultrasound

Doppler abdominal blood vessels

33.49

1340

Ultrasound

Carotid doppler

33.49

1345

Ultrasound

Doppler - extremities

18.75

1405

M.R.I.

Cranial multisection SE

40.97

1406

M.R.I.

Cranial multisection IR

25.76

1407

M.R.I.

Cranial repeat, sequence

19.91

1409

M.R.I.

Ent multisection SE

40.97

1411

M.R.I.

Ent multisection IR

25.76

1412

M.R.I.

Ent repeat, sequence

19.91

1415

M.R.I.

Thorax multisection SE

46.83

1416

M.R.I.

Thorax multisection IR

40.97

1417

M.R.I.

Thorax repeat, sequence

23.42

1420

M.R.I.

Abdomen multisection SE

46.83

1421

M.R.I.

Abdomen multisection IR

40.97

1422

M.R.I.

Abdomen repeat, sequence

23.42

1425

M.R.I.

Pelvis multisection SE

46.83

1426

M.R.I.

Pelvis multisection IR

40.97

1427

M.R.I.

Pelvis repeat sequence

23.42

1430

M.R.I.

Extremities multisection SE

40.97

1431

M.R.I.

Extremities multisection IR

25.76

1432

M.R.I.

Extremities repeat, sequence

19.91

1440

M.R.I.

Spine (one seq.) multisection SE

37.47

1441

M.R.I.

Spine (one seq.) multisection IR

24.58

1442

M.R.I.

Spine (one seq.) repeat, sequence

18.73

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LING FEES Page 6

CODE

GROUP

DESCRIPTION

UNIT

VALUE

1445

M.R.I.

Spine (two adjoining) multisection SE

44.50

1446

M.R.I.

Spine (two adjoining) multisection IR

37.47

1447

M.R.I.

Spine (two adjoining) repeat sequence

22.25

1450

M.R.I.

Spine (two not add.) multisection SE

66.74

1451

M.R.I.

Spine (two not add.) multisection IR

37.47

1452

M.R.I.

Spine (two not add.) repeat sequence

32.78

1453

M.R.I.

Add 30% for gating

14.05

1776

Nuc. Med.

Labelled WBC

41.04

1777

Nuc. Med.

Gallium (one area)

28.14

1778

Nuc. Med.

Gallium (multiple areas)

35.08

1790

Nuc. Med.

Vascular study (flow) add on

11.73

1810

Nuc. Med.

Brain scan

11.73

1811

Nuc. Med.

Brain perfusion

46.89

1812

Nuc. Med.

CSF study (cisternogram)

35.18

1813

Nuc. Med.

Shunt function study

46.89

1814

Nuc. Med.

Radionuclide arthrogram

35.18

1816

Nuc. Med.

Bone scan - one area

23.45

1817

Nuc. Med.

Bone scan - multiple areas

28.14

1818

Nuc. Med.

Bone marrow - one area

23.45

1819

Nuc. Med.

Marrow scan - multiple areas

28.14

1820

Nuc. Med.

Bone density

11.73

1830

Nuc. Med.

Lung ventilation scan

23.45

1835

Nuc. Med.

Lung scan perfusion

23.45

1840

Nuc. Med.

Liver and spleen

18.75

1843

Nuc. Med.

Haemangioma (RBC)

28.14

1845

Nuc. Med.

Spleen scan (RBC)

18.75

1850

Nuc. Med.

Hepatobiliary

23.45

1853

Nuc. Med.

Bile salt study

23.45

1855

Nuc. Med.

Gastric emptying

23.45

1860

Nuc. Med.

Ectopic gastric mucosa

23.45

1865

Nuc. Med.

G.I bleed

46.89

1870

Nuc. Med.

G.E. reflux

18.75

1871

Nuc. Med.

Esophageal motility

46.89

1872

Nuc. Med.

Ciliary motion study

31.27

1873

Nuc. Med.

Peritoneal/venous shunt

23.45

1875

Nuc. Med.

Renal static imaging

11.73

1880

Nuc. Med.

Renal scan and renogram

35.18

1881

Nuc. Med.

A.C.E. renal scan

46.89

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LING FEES Page 7

CODE

GROUP

DESCRIPTION

UNIT

VALUE

1885

Nuc. Med.

Diuretic stimulation (add on)

11.73

1890

Nuc. Med.

Testicular scan

23.45

1899

Nuc. Med.

Residual urine (add on)

11.73

1904

Nuc. Med.

Myocardial rest

23.45

1905

Nuc. Med.

Mycardial stress and rest

37.52

1906

Nuc. Med.

Myocardial rest quantitative (add on)

7.04

1907

Nuc. Med.

Myocardial stress and rest quantitative - add on

11.73

1910

Nuc. Med.

MUGA with quantitative

23.45

1911

Nuc. Med.

Exercise MUGA

58.62

1912

Nuc. Med.

Myocardial Infarction

23.45

1913

Nuc. Med.

Cardiac first pass

28.14

1914

Nuc. Med.

Cardiac shunt

23.45

1915

Nuc. Med.

Venoscintigram

23.45

1920

Nuc. Med.

Thyroid uptake

18.75

1921

Nuc. Med.

Thyroid scan

18.75

1922

Nuc. Med.

Thyroid uptake special

23.45

1925

Nuc. Med.

Adrenal scan

70.34

1930

Nuc. Med.

Parathryoid scan

35.18

1935

Nuc. Med.

Tumor imaging

28.14

1940

Nuc. Med.

Salivary gland scintigraphy

23.45

1945

Nuc. Med.

Dacroscintigraphy

30.48

1946

Nuc. Med.

Lymphoscintigram

23.45

1947

Nuc. Med.

Isolated limb perfusion

11.73

1950

Nuc. Med.

Tomography (add on)

12.50

1951

Nuc. Med.

Hepatobiliary with pharmacologic stimulation

35.18

1955

Nuc. Med.

Hyperthyroidism (therapy)

42.21

1960

Nuc. Med.

Carcinoma of thyroid (therapy)

58.62

1961

Nuc. Med.

Metastatic carcinoma (therapy)

42.21

1962

Nuc. Med.

Ascites or pleural effusion (therapy)

42.21

1963

Nuc. Med.

Synovectomy (therapy)

42.21

1964

Nuc. Med.

Polycythemia (therapy)

42.21

1970

Nuc. Med.

Red cell volume

11.73

1971

Nuc. Med.

Plasma volume

11.73

1972

Nuc. Med.

Red cell survival

23.45

1973

Nuc. Med.

Sequestration study

46.89

1974

Nuc. Med.

Ferrokinetics

23.45

1976

Nuc. Med.

Stool for blood loss

11.73

1977

Nuc. Med.

I-131 Gastrointestinal protein loss study

11.73

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LING FEES Page 8

CODE

GROUP

DESCRIPTION

UNIT

VALUE

1978

Nuc. Med.

C-14 Breath test

11.73

1979

Nuc. Med.

Glomerular filtration rate (with blood samples)

11.73

1981

Nuc. Med.

Schilling test with or without intrinsic factor

11.73

1995

Nuc. Med.

Retrograde nuclide cystogram

18.75

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LING FEES Page 9

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LING FEES Page 10

CODE

GROUP

DESCRIPTION

PREMIUM

VALUE

UNIT

VALUE

3001

Other

Interpretation of submitted films

35%

15.25

5001

Other

Interpretation of submitted films

50%

15.25

3005

H&N

Skull - routine views

35%

13.40

5005

H&N

Skull - routine views

50%

13.40

3012

H&N

Eye for foreign body

35%

13.34

5012

H&N

Eye for foreign body

50%

13.34

3015

H&N

Facial bones

35%

13.40

5015

H&N

Facial bones

50%

13.40

3020

H&N

Mandible

35%

12.31

5020

H&N

Mandible

50%

12.31

3030

H&N

Sinuses - paranasal

35%

12.88

5030

H&N

Sinuses - paranasal

50%

12.88

3105

Bone

Cervical spine

35%

14.19

5105

Bone

Cervical spine

50%

14.19

3110

Bone

Thoracic spine

35%

12.31

5110

Bone

Thoracic spine

50%

12.31

3115

Bone

Lumbar spine

35%

14.19

5115

Bone

Lumbar spine

50%

14.19

3120

Bone

Sacrum / coccyx

35%

12.31

5120

Bone

Sacrum / coccyx

50%

12.31

3150

Mylo

Lumbar myelogram

35%

27.75

5150

Mylo

Lumbar myelogram

50%

28.13

3151

Mylo

Complete myelogram

35%

37.99

5151

Mylo

Complete myelogram

50%

42.21

3205

Bone

Shoulder

35%

12.41

5205

Bone

Shoulder

50%

12.41

3223

Bone

Scaphoid

35%

12.41

5223

Bone

Scaphoid

50%

12.41

3224

Bone

Humerus

35%

12.41

5224

Bone

Humerus

50%

12.41

3225

Bone

Elbow

35%

12.41

5225

Bone

Elbow

50%

12.41

3226

Bone

Wrist

35%

12.41

5226

Bone

Wrist

50%

12.41

3227

Bone

Forearm

35%

12.41

5227

Bone

Forearm

50%

12.41

RADIOLOGY NON-PATIENT SPECIFIC BULK BILLING

– PREMIUM FEES

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LI N G FEES - PREMIUM FEES Page 11

CODE

GROUP

DESCRIPTION

PREMIUM

VALUE

UNIT

VALUE

3228

Bone

Hand

35%

12.41

5228

Bone

Hand

50%

12.41

3305

Bone

Hip

35%

12.41

5305

Bone

Hip

50%

12.41

3310

Bone

Pelvis

35%

12.31

5310

Bone

Pelvis

50%

12.31

3321

Bone

Patella

35%

12.41

5321

Bone

Patella

50%

12.41

3322

Bone

Foot

35%

12.41

5322

Bone

Foot

50%

12.41

3323

Bone

Ankle

35%

12.41

5323

Bone

Ankle

50%

12.41

3324

Bone

Knee

35%

12.41

5324

Bone

Knee

50%

12.41

3325

Bone

Calcaneus

35%

12.41

5325

Bone

Calcaneus

50%

12.41

3326

Bone

Tibia and fibula

35%

12.41

5326

Bone

Tibia and fibula

50%

12.41

3335

Bone

Femur

35%

12.41

5335

Bone

Femur

50%

12.41

3403

Other

Fluoroscopy 10 min.

35%

21.50

5403

Other

Fluoroscopy 10 min.

50%

21.50

3404

Chest

Single view

35%

12.13

5404

Chest

Single view

50%

12.13

3405

Chest

Multiple views

35%

14.13

5405

Chest

Multiple views

50%

14.13

3425

Chest

Ribs - each side

35%

11.90

5425

Chest

Ribs - each side

50%

11.90

3435

Chest

Sternum

35%

12.31

5435

Chest

Sternum

50%

12.31

3445

H&N

Neck - for soft tissue

35%

12.31

5445

H&N

Neck - for soft tissue

50%

12.31

3605

Abdomen

Survey film

35%

12.13

5605

Abdomen

Survey film

50%

12.13

3610

Abdomen

Multiple films

35%

12.88

3625

G.I.

Upper G.I. series

35%

27.69

5625

G.I.

Upper G.I. series

50%

28.04

3650

G.I.

Colon - barium only

35%

23.91

5610 Abdomen Multiple films 50% 12.88

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LI N G FEES - PREMIUM FEES Page 12

CODE

GROUP

DESCRIPTION

PREMIUM

VALUE

UNIT

VALUE

5650

G.I.

Colon - barium only

50%

23.91

3655

G.I.

Colon Paediatric - single contrast

35%

31.37

5655

G.I.

Colon Paediatric - single contrast

50%

33.56

3710

G.I.

Fistula/sinus with contrast

35%

13.40

5710

G.I.

Fistula/sinus with contrast

50%

13.40

3745

G.I.

Percutaneous transhepatic cholangiogram

35%

15.63

5745

G.I.

Percutaneous transhepatic cholangiogram

50%

15.63

3815

G.U.

Intravenous urogram (IVP)

35%

23.53

5815

G.U.

Intravenous urogram (IVP)

50%

23.53

3845

G.U.

Retrograde urethrogram

35%

13.53

5845

G.U.

Retrograde urethrogram

50%

13.53

3850

G.U.

Antegrade (T-tube) Pyelogram

35%

13.53

5850

G.U.

Antegrade (T-tube) Pyelogram

50%

13.53

4001

Vascular

Venous DSA-abdominal or renal

35%

47.95

6001

Vascular

Venous DSA-abdominal or renal

50%

53.28

3002

Vascular

Venous DSA-aortic arch

35%

53.43

5002

Vascular

Venous DSA-aortic arch

50%

59.37

3003

Vascular

Pulmonary angiogram bilateral

35%

126.62

5003

Vascular

Pulmonary angiogram bilateral

50%

140.69

3006

Vascular

Unilateral peripheral arteriogram

35%

31.14

5006

Vascular

Unilateral peripheral arteriogram

50%

33.21

3007

Vascular

Bilateral peripheral arteriogram

35%

44.83

5007

Vascular

Bilateral peripheral arteriogram

50%

49.82

3008

Vascular

Aortography (abdominal)

35%

59.68

5008

Vascular

Aortography (abdominal)

50%

66.32

3009

Vascular

Visceral selective arteriogram

35%

59.68

5009

Vascular

Visceral selective arteriogram

50%

66.32

3010

Vascular

Venogram extremity

35%

34.01

5010

Vascular

Venogram extremity

50%

37.52

3013

Vascular

Spinal artery selective

35%

31.14

5013

Vascular

Spinal artery selective

50%

33.21

3016

Vascular

Arch aortogram

35%

59.68

5016

Vascular

Arch aortogram

50%

66.32

3021

Vascular

Common carotid bilateral

35%

75.37

5021

Vascular

Common carotid bilateral

50%

83.75

3022

Vascular

Internal carotid bilateral

35%

75.37

5022

Vascular

Internal carotid bilateral

50%

83.75

3023

Vascular

External carotid bilateral

35%

75.37

5023

Vascular

External carotid bilateral

50%

83.75

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LI N G FEES - PREMIUM FEES Page 13

CODE

GROUP

DESCRIPTION

PREMIUM

VALUE

UNIT

VALUE

3024

Vascular

Vertebral bilateral

35%

75.37

5024

Vascular

Vertebral bilateral

50%

83.75

3026

Vascular

Common carotid unilateral

35%

41.11

5026

Vascular

Common carotid unilateral

50%

45.68

3027

Vascular

Internal carotid unilateral

35%

41.11

5027

Vascular

Internal carotid unilateral

50%

45.68

3028

Vascular

External carotid unilateral

35%

41.11

5028

Vascular

External carotid unilateral

50%

45.68

3029

Vascular

Vertebral unilateral

35%

41.11

5029

Vascular

Vertebral unilateral

50%

45.68

3056

Cardiac

Coronary arteries

35%

68.51

5056

Cardiac

Coronary arteries

50%

76.13

3058

Cardiac

Coronary artery grafts

35%

68.51

5058

Cardiac

Coronary artery grafts

50%

76.13

3059

Cardiac

P.T.C.A.

35%

68.51

5059

Cardiac

P.T.C.A.

50%

76.13

3061

Cardiac

Right ventriculogram

35%

34.38

5061

Cardiac

Right ventriculogram

50%

38.07

3062

Cardiac

Left ventriculogram

35%

34.38

5062

Cardiac

Left ventriculogram

50%

38.07

3071

Cardiac

Aortic root (cardiac)

35%

34.38

5071

Cardiac

Aortic root (cardiac)

50%

38.07

4105

C.T.

CT head without contrast

35%

57.15

6105

C.T.

CT head without contrast

50%

63.50

3111

C.T.

CT head with contrast

35%

57.15

5111

C.T.

CT head with contrast

50%

63.50

4115

C.T.

CT head without and with contrast

35%

71.91

6115

C.T.

CT head without and with contrast

50%

79.91

3125

C.T.

CT neck with contrast

35%

57.15

5125

C.T.

CT neck with contrast

50%

63.50

3135

C.T.

CT thorax without contrast

35%

57.15

5135

C.T.

CT thorax without contrast

50%

63.50

3141

C.T.

CT thorax with contrast

35%

57.15

5141

C.T.

CT thorax with contrast

50%

63.50

3145

C.T.

CT thorax without and with contrast

35%

71.91

5145

C.T.

CT thorax without and with contrast

50%

79.91

4150

C.T.

CT abdomen without contrast

35%

57.15

6150

C.T.

CT abdomen without contrast

50%

63.50

3155

C.T.

CT abdomen with contrast

35%

57.15

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LI N G FEES - PREMIUM FEES Page 14

CODE

GROUP

DESCRIPTION

PREMIUM

VALUE

UNIT

VALUE

5155

C.T.

CT abdomen with contrast

50%

63.50

3160

C.T.

CT abdomen without and with contrast

35%

71.91

5160

C.T.

CT abdomen without and with contrast

50%

79.91

3162

C.T.

CT extremities without contrast

35%

57.15

5162

C.T.

CT extremities without contrast

50%

63.50

3165

C.T.

CT pelvis without contrast

35%

57.15

5165

C.T.

CT pelvis without contrast

50%

63.50

3166

C.T.

CT pelvis with contrast

35%

57.15

5166

C.T.

CT pelvis with contrast

50%

63.50

3167

C.T.

CT pelvis without and with contrast

35%

71.91

5167

C.T.

CT pelvis without and with contrast

50%

79.91

3169

C.T.

CT spine without contrast

35%

57.15

5169

C.T.

CT spine without contrast

50%

63.50

3180

C.T.

3D reconstruction

35%

21.16

5180

C.T.

3D reconstruction

50%

21.16

3186

C.T.

CT head special without contrast

35%

57.15

5186

C.T.

CT head special without contrast

50%

63.50

3187

C.T.

CT head special with contrast

35%

57.15

5187

C.T.

CT head special with contrast

50%

63.50

3188

C.T.

CT head special without and with contrast

35%

71.91

5188

C.T.

CT head special without and with contrast

50%

79.91

4205

Ultrasound

Abdomen general

35%

34.39

6205

Ultrasound

Abdomen general

50%

38.09

3211

Ultrasound

Aorta

35%

21.50

5211

Ultrasound

Aorta

50%

21.50

3212

Ultrasound

Appendix

35%

27.75

5212

Ultrasound

Appendix

50%

28.13

3213

Ultrasound

Kidneys

35%

27.75

5213

Ultrasound

Kidneys

50%

28.13

3214

Ultrasound

Pylorus

35%

27.75

5214

Ultrasound

Pylorus

50%

28.13

3220

Ultrasound

Pelvis, male or female (GYN)

35%

27.75

5220

Ultrasound

Pelvis, male or female (GYN)

50%

28.13

4225

Ultrasound

Endovaginal

35%

36.38

6225

Ultrasound

Endovaginal

50%

40.43

4226

Ultrasound

Endovaginal with pelvic

35%

52.25

6226

Ultrasound

Endovaginal with pelvic

50%

58.05

3245

Ultrasound

Obstetrical

35%

37.14

5245

Ultrasound

Obstetrical

50%

41.27

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LI N G FEES - PREMIUM FEES Page 15

CODE

GROUP

DESCRIPTION

PREMIUM

VALUE

UNIT

VALUE

3246

Ultrasound

Obstetrical, recheck

35%

21.50

5246

Ultrasound

Obstetrical, recheck

50%

21.50

3250

Ultrasound

Biophysical profile

35%

13.84

5250

Ultrasound

Biophysical profile

50%

13.84

3255

Ultrasound

Obs. multiple - (add on)

35%

29.04

5255

Ultrasound

Obs. multiple - (add on)

50%

30.06

3275

Ultrasound

Scrotum

35%

34.45

5275

Ultrasound

Scrotum

50%

38.18

3285

Ultrasound

Hip

35%

27.75

5285

Ultrasound

Hip

50%

28.13

3298

Ultrasound

Subcutaneous mass

35%

21.50

5298

Ultrasound

Subcutaneous mass

50%

21.50

3307

Ultrasound

Portable - M.D. in attendance

35%

27.75

5307

Ultrasound

Portable - M.D. in attendance

50%

28.13

4335

Ultrasound

Doppler abdominal blood vessels

35%

45.21

6335

Ultrasound

Doppler abdominal blood vessels

50%

50.24

3345

Ultrasound

Doppler - extremities

35%

27.75

5345

Ultrasound

Doppler - extremities

50%

28.13

4405

M.R.I.

Cranial multisection SE

35%

55.31

6405

M.R.I.

Cranial multisection SE

50%

61.46

3407

M.R.I.

Cranial repeat, sequence

35%

28.91

5407

M.R.I

Cranial repeat, sequence

50%

29.87

3409

M.R.I.

Ent multisection SE

35%

55.31

5409

M.R.I.

Ent multisection SE

50%

61.46

3412

M.R.I.

Ent repeat, sequence

35%

28.91

5412

M.R.I.

Ent repeat, sequence

50%

29.87

3415

M.R.I.

Thorax multisection SE

35%

63.22

5415

M.R.I.

Thorax multisection SE

50%

70.25

3416

M.R.I.

Thorax multisection IR

35%

55.31

5416

M.R.I.

Thorax multisection IR

50%

61.46

3417

M.R.I.

Thorax repeat, sequence

35%

32.42

5417

M.R.I.

Thorax repeat, sequence

50%

35.13

3420

M.R.I.

Abdomen multisection SE

35%

63.22

5420

M.R.I.

Abdomen multisection SE

50%

70.25

3421

M.R.I.

Abdomen multisection IR

35%

55.31

5421

M.R.I.

Abdomen multisection IR

50%

61.46

3422

M.R.I.

Abdomen repeat, sequence

35%

32.42

5422

M.R.I.

Abdomen repeat, sequence

50%

35.13

4425

M.R.I.

Pelvis multisection SE

35%

63.22

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LI N G FEES - PREMIUM FEES Page 16

CODE

GROUP

DESCRIPTION

PREMIUM

VALUE

UNIT

VALUE

6425

M.R.I.

Pelvis multisection SE

50%

70.25

3426

M.R.I.

Pelvis multisection IR

35%

55.31

5426

M.R.I.

Pelvis multisection IR

50%

61.46

3427

M.R.I.

Pelvis repeat sequence

35%

32.42

5427

M.R.I.

Pelvis repeat sequence

50%

35.13

3430

M.R.I.

Extremities multisection SE

35%

55.31

5430

M.R.I.

Extremities multisection SE

50%

61.46

3432

M.R.I.

Extremities repeat, sequence

35%

28.91

5432

M.R.I.

Extremities repeat, sequence

50%

29.87

3440

M.R.I.

Spine (one seg.) multisection SE

35%

50.58

5440

M.R.I.

Spine (one seg.) multisection SE

50%

56.21

3442

M.R.I.

Spine (one seg.) repeat, sequence

35%

27.73

5442

M.R.I.

Spine (one seg.) repeat, sequence

50%

28.10

4445

M.R.I.

Spine (two adjoining) multisection SE

35%

60.08

6445

M.R.I.

Spine (two adjoining) multisection SE

50%

66.75

3447

M.R.I.

Spine (two adjoining) repeat sequence

35%

31.25

5447

M.R.I.

Spine (two adjoining) repeat sequence

50%

33.28

3453

M.R.I.

Add 30% for gating

35%

23.05

5453

M.R.I.

Add 30% for gating

50%

23.05

3776

Nuc. Med.

Labelled WBC

35%

55.40

5776

Nuc. Med.

Labelled WBC

50%

61.56

3790

Nuc. Med.

Vascular study (flow) (add on)

35%

20.73

5790

Nuc. Med.

Vascular study (flow) (add on)

50%

20.73

3810

Nuc. Med.

Brain scan

35%

20.73

5810

Nuc. Med.

Brain scan

50%

20.73

3811

Nuc. Med.

Brain perfusion

35%

63.30

5811

Nuc. Med.

Brain perfusion

50%

70.34

3816

Nuc. Med.

Bone scan (one area)

35%

32.45

5816

Nuc. Med.

Bone scan (one area)

50%

35.18

3817

Nuc. Med.

Bone scan (multiple areas)

35%

37.99

5817

Nuc. Med.

Bone scan (multiple areas)

50%

42.21

3830

Nuc. Med.

Lung ventilation scan

35%

32.45

5830

Nuc. Med.

Lung ventilation scan

50%

35.18

3835

Nuc. Med.

Lung scan perfusion

35%

32.45

5835

Nuc. Med.

Lung scan perfusion

50%

35.18

4850

Nuc. Med.

Hepatobiliary

35%

32.45

6850

Nuc. Med.

Hepatobiliary

50%

35.18

3865

Nuc. Med.

G.I. bleed

35%

63.30

5865

Nuc. Med.

G.I. bleed

50%

70.34

May 2011 RADIOLOGY NON-PATIENT-SPECIFIC BULK BIL LI N G FEES - PREMIUM FEES Page 17