Preamble to Fees

All benefits listed in the Schedule, except where specific exceptions are identified, must include the following as part of the service being claimed; payment for these inherent components is included in the listed fees:

i) Direct face-to-face encounter with the patient by the medical practitioner, appropriate physical examination when pertinent to the service and on-going monitoring of the patient’s condition during the encounter, where indicated.

ii) Any inquiry of the patient or other source, including review of medical records, necessary to arrive at an opinion as to the nature and/or history of the patient’s condition.

iii) Appropriate care for the patient’s condition, as specifically listed in the Schedule for the service and as traditionally and/or historically expected for the service rendered.

iv) Arranging for any related assessments, procedures and/or therapy as may be appropriate, and interpreting the results, except where separate listings are applicable to these adjunctive services. (Note: This does not preclude medical practitioners rendering referred “diagnostic and approved laboratory facility” services from billing for interpretation of diagnostic or laboratory test results).

v) Arranging for any follow-up care which may be appropriate.

vi) Discussion with and providing advice and information to the patient or the patient’s representative(s) regarding the patient’s condition and recommended therapy, including advice as to the results of any related assessments, procedures and/or therapy which may have been arranged. No additional claims may be made to the Plan for such advice and discussion, nor for the provision of prescriptions and/or diagnostic and laboratory requisitions, unless the patient’s medical condition indicates that the patient should be seen and assessed again by the medical practitioner in order to receive such advice.

vii) Making and maintaining an adequate medical record of the encounter that appropriately supports the service being claimed. A service for which an adequate medical record has not been recorded and retained is considered not to be complete and is not a benefit under the Plan.

A Payment Schedule for medical practitioners is established under Section 26 of the Medicare Protection Act and is referred to in the Master Agreement between the Government of the Province of British Columbia and the Medical Services Commission (MSC) and Doctors of BC. The fees listed are the amounts payable by the Medical Services Plan (MSP) of British Columbia for listed benefits. “Benefits” under the Act are limited to services which are medically required for the diagnosis and/or treatment of a patient, which are not excluded by legislation or regulation, and which are rendered personally by medical practitioners or by others delegated to perform them in accordance with the Commission’s policies on delegated services.

Services requested or required by a “third party” for other than medical requirements are not insured under MSP. Services such as consultations, laboratory investigations, anesthesiology, surgical assistance, etc., rendered solely in association with other services which are not benefits also are not considered benefits under MSP, except in special circumstances as approved by the Medical Services Commission (e.g.: Dental Anesthesia Policy).

The tri-partite Medical Services Commission (MSC) manages the Medical Services Plan (MSP) on behalf of the Government of British Columbia in accordance with the Medicare Protection Act and Regulations. The MSC is the body that has the statutory authority to set the fees that are payable for insured medical services provided to beneficiaries enroled with the Medical Services Plan (MSP).

The MSC Payment Schedule is the official list of fees for which insured services are paid by MSP. Doctors of BC maintains and publishes the Fee Guide. The Guide mirrors the MSC Payment Schedule, with some exceptions including recommended private fees for uninsured services.

The process for additions, deletions or other changes to the MSC Payment Schedule, are made in accordance with the Master Agreement. Medical practitioners who wish to have modifications to the MSC Payment Schedule considered should submit their proposals to the Doctors of BC Tariff Committee through the appropriate Section. The Government and Doctors of BC have agreed to consult with each other prior to submitting a recommendation to the MSC. If both parties agree, in writing, to a revision, MSC will adopt the recommendation as part of the MSC Payment Schedule as long as the service is medically necessary and consistent with the requirements of the Medicare Protection Act and Regulations and it agrees with the estimated projected cost that will result from the revision. In the case where there is no agreement between Government and Doctors of BC, both parties may make a separate recommendation to the MSC and the MSC will determine the changes, if any, to the MSC Payment Schedule.

Usually, the earliest retroactive effective date that may be established for a new or interim fee code, is April 1st of the current fiscal year. For services not listed in the MSC Payment Schedule, please refer to the following sections C. 3. & C. 4.

This section relates to services not listed in the MSC Payment Schedule that are:
• new medically necessary services generally considered to be accepted standards of care in the medical community currently and not considered experimental in nature;
• unusually complex procedures, for established but infrequently performed procedures;
• for unlisted “team” procedures, or
• for any medically required service for which the medical practitioner desires independent consideration to be given by MSP

Claims under a miscellaneous fee code will be accepted for adjudication only if the following criteria are fulfilled:
• An estimate of an appropriate fee, with rationale for the level of that fee
• Sufficient documentation of the services (such as the operative report) to substantiate the claim.

The Medical Services Plan will review the fee estimate proposed and the supporting documentation and by comparing with the service provided with comparable services listed in the MSC Payment Schedule, determine the level of compensation. While an application for a new fee item is in process (as per Section C. 2.), MSP will pay for the service at a percentage of a comparable fee until the new fee item is effective. Should it be determined that a new listing will not be established due to the infrequency of the unlisted service, payments will be made at 100% of the comparable service.

Miscellaneous Fee Item
00199 Family Medicine

If a medical practitioner wishes to dispute the adjudication of a claim submitted under a miscellaneous fee, please refer to section C. 12. on Disputed Payments.

If it is not medically necessary for a patient to be personally reassessed prior to prescription renewal, specialty referral, release of diagnostic or laboratory results, etc., claims for these services must not be made to MSP regardless of whether or not a medical practitioner chooses to see his/her patients personally or speak with them via the telephone.

The completion of Pharmacare required Special Authority requests or Pharmacare Plan G forms is part of a visit, consultation, or service and as a consequence, no charge will be made for its completion.

Some services listed in the MSC Payment Schedule have fees which are specifically intended to cover multiple services over extended time periods. Examples are most surgical procedures, the critical care per diem listings and some obstetrical listings. The preambles and Schedule are explicit where these intentions occur.

When, because of serious complications or coincidental non-related illness, additional care is required beyond that which would normally be recognized as included in the listed service, MSP will give independent consideration to claims for this additional care, if adequate explanation is submitted with the claim.

Except for referred “diagnostic facility” services and approved laboratory facility services, a medical record is not considered adequate unless it contains all information which may be designated or implied in the MSC Payment Schedule for the service. Another medical practitioner of the same specialty, who is unfamiliar with both the patient and the attending medical practitioner, would be able to readily determine the following from that record at hand:

a. Date and location of the service.
b. Identification of the patient and the attending medical practitioner.
c. Presenting complaint(s) and presenting symptoms and signs, including their history.
d. All pertinent previous history including pertinent family history.
e. The relevant results, both negative and positive, of a systematic enquiry pertinent to the patient’s problem(s).
f. Identification of the extent of the physical examination including pertinent positive and negative findings.
g. Results of any investigations carried out during the encounter.
h. Summation of the problem and plan of management.

….

All Provinces, and Territories, except Quebec, have entered an agreement to pay for insured services provided to residents of other provinces when a patient presents with a valid Provincial Health Registration Card. Claims can be submitted electronically and details of this process may be obtained by contacting MSP. However, the services listed below are exempt from this agreement and should be billed directly to the non-resident patient.

Medical Practitioner Services Excluded under the Inter-Provincial Agreements for the Reciprocal Processing of Out-of-Province Medical Claims
1. Surgery for alteration of appearance (cosmetic surgery)
2. Gender-reassignment surgery
3. Surgery for reversal of sterilization
4. Routine periodic health examinations including routine eye examinations (including PAP tests for screening only)
5. In-vitro fertilization, artificial insemination
6. Acupuncture, acupressure, transcutaneous electro-nerve stimulation (TENS), moxibustion, biofeedback, hypnotherapy
7. Services to persons covered by other agencies; Armed Forces, WorkSafe BC, Department of Veterans Affairs, Correctional Services of Canada (Federal Penitentiaries)
8. Services requested by a “Third Party”
9. Team conference(s)
10. Genetic screening and other genetic investigation, including DNA probes
11. Procedures still in the experimental/developmental phase
12. Anesthetic services and surgical assistant services associated with all of the foregoing.

The services on this list may or may not be reimbursed by the home province. The patient should make enquires of that home province after direct payment to the BC medical practitioner.

1. All cases directly relating to an MVA which ICBC Insurance coverage applies should be identified as such by a “yes” code in the Teleplan MVA field.

2. All such cases should be coded “MVA” regardless of whether seen in an office visit, emergency, diagnostic, lab or x-ray facility. Surgery or procedures performed in regard to these cases should also be identified.

3. Where possible, please attach an ICBC claim number to each coded MVA in your Teleplan billing.

4. In cases where a visit or procedure was occasioned by more than one condition, the dominant purpose must be related to an MVA to code it as such.

5. If the patient is from another province, use the normal out-of-province billing process.

6. In those instances in which the patient has no MSP coverage, the medical practitioner should bill the patient or ICBC directly. Medical practitioners have the choice of either billing the uninsured patient directly at the BCMA recommended rate and having the patient recover the costs from ICBC (see BCMA Guide to Fees), or billing ICBC for the MSP amount.

7. If the MVA is work-related, WorkSafeBC (WSBC) should be billed under their procedures.

8. Medical Practitioners are accountable for proper MVA identification and are subject to audit.

When patient care is rendered in a clinical teaching unit or other setting for clinical teaching by a health care team, the supervising medical practitioner shall be identified to the patient at the earliest possible moment. No fees may be charged in the name of the supervising staff physician for services rendered by a trainee, resident or fellow prior to the identification taking place. Moreover, the supervising staff physician must be available in person, by telephone or videoconferencing in a timely manner appropriate to the acuity of the service being supervised.

For a medical practitioner who supervises two or more procedures or other services concurrently through the use of trainees, residents, fellows or other members of the team, the total billings must not exceed the amount that a medical practitioner could bill in the same time period in the absence of the other team members. For example:

a) If an anesthesiologist is supervising two rooms simultaneously, the anesthetic intensity/complexity units should only be billed for one of the two cases.

b) If a surgeon is operating in one room while his/her resident is operating in a second room, charges should only be made for the case the surgeon performs.

c) In psychotherapy where direct supervision by the staff physician may distort the psychotherapeutic milieu, the staff physician may claim for psychotherapy when a record of the psychotherapeutic interview is carefully reviewed with the resident and the procedure thus supervised. However, the time charged by the staff physician should not exceed the lesser of the time spent by the resident in the psychotherapeutic interview or the staff physician in the supervision of that interview.

d) For hospital visits and consultations rendered by the resident in the name of the staff physician, the staff physician should only charge for services on the days when actual supervision of that patient’s care takes place through a physical visit to the patient by the staff physician and/or a chart review is conducted with detailed discussion with the other members of the health team within the next weekday workday.

e) The supervising physician may not bill for out-of-office hours premiums or continuing care surcharges unless he/she complies with the explanatory notes for out-of-office hours premiums in the Payment Schedule/Guide to Fees and personally attends the patient.

f) In order to bill for a supervised service the physician must review in person, by telephone or videoconferencing the service being billed with the trainee, resident or fellow and have signed off within the next weekday workday on the ER record, hospital chart, office chart or some other auditable document.

1. Services are not benefits of MSP if a medical practitioner provides them to the following members of the medical practitioner’s family:

a) a spouse,
b) a son or daughter,
c) a step-son or step-daughter,
d) a parent or step-parent,
e) a parent of a spouse,
f) a grandparent,
g) a grandchild,
h) a brother or sister, or
i) a spouse of a person referred to in paragraph (b) to (h).

2. Services are not benefits of MSP if a medical practitioner provides them to a member of the same household as the medical practitioner.

Procedures which are generally and traditionally accepted as those which may be carried out by a nurse, nurse practitioner or a medical assistant in the employ of a medical practitioner may, when so performed, only be billed to MSP by the medical practitioner when the performance of the procedure is under the “direct supervision” of the medical practitioner or a designated alternate medical practitioner with equivalent qualifications. Direct supervision requires that during the procedure, the medical practitioner be physically present in the office or clinic at which the service is rendered. While this does not preclude the medical practitioner from being otherwise occupied, s/he must be in personal attendance to ensure that procedures are being performed competently and s/he must at all times be available immediately to improve, modify or otherwise intervene in a procedure as required in the best interest of the patient. Billing for these procedures also implies that the medical practitioner is taking full responsibility for their medical necessity and for their quality. Any exceptions to this rule are subject to the written approval of MSP.

“Procedures” in this context do not include such “visit” type services as examinations/ assessments, consultations, psycho-therapy, counselling, telehealth services, etc., which may not be delegated.

The foregoing limitations do not apply to approved procedures rendered in approved “diagnostic facilities”, as defined under the Medicare Protection Act and Regulations, or to services rendered in approved laboratory facilities, as defined under the Laboratory Services Act and Regulation and which are subject to accreditation under the Diagnostic Accreditation Program.

A detailed description of WorkSafeBC (WSBC) fees, preamble, and policies is contained in the WorkSafeBC section of the Doctors of BC Guide to Fees. The fees listed under “MSP and WSBC Fee” have been accepted by the WorkSafeBC through negotiated agreements as the basis for their Guide to Fees. WorkSafeBC supplies its own reporting and billing forms. To facilitate payment, WorkSafeBC requires the practitioner to include their MSP payment number on all forms.

MSP is currently processing claims on behalf of WorkSafeBC as its agent. Doctors of BC and WorkSafeBC agree that MSP Teleplan is the only acceptable manner of billing WorkSafeBC for services billable through MSP.

The Business Cost Premium (BCP) is to provide improved compensation for physicians who are responsible for some or all of the rent, lease, or ownership costs (either directly or indirectly) of a community-based office. The BCP is a percentage premium paid on all fees to compensate physicians for the work they do with patients regardless of the location at which the services are delivered. Physicians must be entitled to receive and retain payment for the eligible fees directly from MSP (i.e. payments assigned to Health Authorities are not eligible for the premium).

The BCP does not apply to Alternative Payments Program (APP) or Longitudinal Family Payment (LFP) payment models, form fees, or to primary health program payments such as the Provincial Attachment System (PAS) and Community Longitudinal Family Physician (CLFP) payments.

BCP does not apply to radiology, anesthesiology, pathology and nuclear medicine fees for services delivered in or for Agency facilities.

The percentage values and the daily maximum amounts of the BCP are based on the location the eligible service is rendered:

1. City of Vancouver: 5% of eligible fees up to a maximum BCP payment of $60 per day per physician.
2. Metro Vancouver (excluding the City of Vancouver) and Greater Victoria: 4% of eligible fees up to a maximum BCP payment of $48 per day per physician.
3. Other communities (outside Greater Vancouver and Greater Victoria) not eligible for the Rural Retention Premiums: 3% of eligible fees up to a maximum BCP payment of $36 per day per physician.

To receive the BCP:

1. The physician is responsible for some or all of the lease, rental, or ownership costs of that community-based office, and
2. The community-based facility in which the eligible services are provided must be in an eligible location and have a unique Facility Number registered with MSP, and
3. The physician must be registered with MSP as a physician practicing at that Facility, and
4. The correct Facility Number must be entered on each claim where the eligible service is rendered.
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See the General Preamble for the list of eligible BCP fee items.

A consultation applies when a medical practitioner, or a health care practitioner*, in the light of his/her professional knowledge of the patient and because of the complexity, obscurity or seriousness of the case, requests the opinion of a medical practitioner competent to give advice in this field.

* “Health care practitioner” in this context is limited to the following:
• chiropractor, for orthopaedic consultations;
• midwife, for obstetric or neonatal consultations;
• nurse practitioner;
• optometrist, for ophthalmology consultations;
• optometrist, for neurology consultations for suspected optic neuritis or
amaurosis fugax or anterior ischemic optic neuropathy (AION) or stroke or
diplopia;
• oral/dental surgeon, for diseases of mastication;
• registered nurse or registered psychiatric nurse, for addiction medicine or
psychiatry consultations for substance use conditions.

The referring practitioner is expected to provide the consulting physician with a letter of referral that includes the reason for the request and the relevant background information on the patient. The referring practitioner is also required to notify MSP of the referral by including the practitioner number of the specialist to who the patient is being referred on their associated FFS claim. If no FFS claim is being submitted, a “no charge referral” claim under fee item 03333 is to be sent to MSP.

The service includes the initial services of a consultant necessary to enable him/her to prepare and render a written report, including his/her findings, opinions and recommendations, to the referring practitioner. A consultation must not be claimed unless the attending practitioner specifically requested it, and unless the written report is rendered. It is expected that a written report will be generated by the medical practitioner providing the consultation within 2 weeks of the date-of-service. In exceptional circumstances, when beyond the consultant’s control, a delay of up to 4 weeks is acceptable.

Additional criteria apply to certain types of specialty specific consultations. These are described in the Sectional Preambles and/or the notes to the specific fee codes.

i) A consultation for the same diagnosis is not normally payable as a full consultation unless an interval of at least six months has passed since the consultant has last billed a visit or service for the patient. A limited consultation may be payable within the six month interval, if medically necessary and a consultation has been specifically requested.

ii) For consultations and/or other specialty limited services to be paid by MSP, the medical practitioner rendering the service must be certified by or be a Fellow of the Royal College of Physicians and Surgeons of Canada, and be so recognized by the College of Physicians and Surgeons of British Columbia. No other specialist qualifications will be recognized by MSP and payments for visits and examinations rendered by licensed physicians not so qualified will be made on the basis of fees listed in the Family Medicine Section of this MSC Payment Schedule.

Exceptions to this limitation will only be made in cases of geographic need, as recommended by the College of Physicians and Surgeons of BC.

Note: This information reflects the July 1, 2023 changes to the MSC Payment Schedule

A subsequent consultation for the same diagnosis may be payable as the applicable full consultation when an interval of at least six months has passed since the consultant has last provided an insured service for the patient. All referrals include a potential implicit rereferral for the same problem unless a re-referral is specifically excluded. A subsequent consultation must comply with MSC Payment Schedule D. 2. in all respects with the exception that it does not have to be specifically requested via an explicit (new) re-referral.

The potential implicit re-referral may be activated, if medically appropriate, to allow the patient and consultant to schedule and conduct one or more subsequent consultations for the same problem, unless explicitly excluded by either of the following:

1. 1. The referring practitioner’s referral letter specifically disallows an implicit rereferral by stating: “This referral is for one consultation only and does not include a re-referral” or similar language, OR
   2. The referring practitioner disallows the implicit re-referral via written response to the consultant within 14 days of receiving notification by the consultant of the scheduled date for a subsequent consultation.

Notification by the consultant of the scheduling of any subsequent consultation must be provided to the referring practitioner at least 30 days before the scheduled date and must conform to all other College of Physicians and Surgeons of BC Guidelines and Standards.

Any additional subsequent consultations must follow the same rules. Another implicit rereferral potentially exists following any subsequent consultation unless the referring practitioner has explicitly excluded it as described above. A subsequent consultation may not be billed if the implicit re-referral has been disallowed.

If the referring practitioner is no longer in practice a subsequent consultation may be performed if medically appropriate, but the consultant must document the unavailability of the original referring practitioner and their advice to the patient to obtain a new referring and/or primary care provider.

A limited consultation requires all of the components expected of a full consultation for that
specialty but is less demanding and normally requires substantially less of the medical practitioner’s time than a full consultation.

It is expected that the limited consultation, when medically necessary and specifically requested, will be billed as part of continuing care, and that a full consultation is not billed simply because of the passage of time.

A new and unrelated diagnosis can be billed as a full consultation without regard to the passage of time since the consultant has last billed any visit or service for the patient.

Specific additional conditions may apply to specific types of consultation, as designated in the Preamble to the pertinent section of the MSC Payment Schedule and/or the notes to the specific listings.

Once a consultation has been rendered and the written report submitted to the referring practitioner, this aspect of the care of the patient normally is returned to the referring practitioner. However, if by mutual agreement between the consultant and the referring practitioner, the complexities of the case are felt to be such that its management should remain for a time in the hands of the consultant, the consultant should claim for continuing care according to the MSC Payment Schedule pertaining to the pertinent specialty.

Where the care of this aspect of the case has been transferred, except for a patient in hospital, the referring practitioner generally should not charge for this aspect of the patient’s care unless and until the full responsibility is returned to him/her. For hospitalized patients, supportive care may apply.

Continuing care by a specialist (following consultation) normally is paid at the pertinent specialist rates. However, continuing care requires that a written update of the patient’s condition and care be appropriately reported to the referring practitioner at least every six months, until the responsibility for this aspect of the patient’s care is returned to the Primary Care practitioner.

i) A complete physical examination shall include a complete detailed history and physical examination of all parts and systems with special attention to local examination where clinically indicated, adequate record of findings and, if necessary, discussion with patient. The above should include complaints, history of present and past illness, family history, personal history, functional inquiry physical examination, differential diagnosis and provisional diagnosis.

ii) Routine or periodic complete physical examination (check up) is not a benefit under MSP. This includes any associated diagnostic procedures or approved laboratory facility services unless significant pathology is found. The physician should advise the diagnostic or approved laboratory facility of the patient’s responsibility for payment.

Counselling is defined as the discussion with the patient, caregiver, spouse or relative about a medical condition which is recognized as difficult by the medical profession or over which the patient is having significant emotional distress, including the management of malignant disease. Counselling, to be claimed as such, must not be delegated and must last at least 20 minutes.

Counselling is not to be claimed for advice that is a normal component of any visit or as a substitute for the usual patient examination fee, whether or not the visit is prolonged. For example, the counselling codes must not be used simply because the assessment and/or treatment may take 20 minutes or longer, such as in the case of multiple complaints. The counselling codes are also not intended for activities related to attempting to persuade a patient to alter diet or other lifestyle behavioural patterns. Nor are the counselling codes generally applicable to the explanation of the results of diagnostic tests or approved laboratory facility services.

Not only must the condition be recognized as difficult by the medical profession, but the medical practitioner’s intervention must of necessity be over and above the advice which would normally be appropriate for that condition. For example, a medical practitioner may have to use considerable professional skill counselling a patient (or a patient’s parent) who has been newly diagnosed as having juvenile diabetes, in order for the family to understand, accept and cope with the implications and emotional problems of this disease and its treatment. In contrast, if simple education alone including group educational sessions (e.g.: asthma, cardiac rehabilitation and diabetic education) is required, such service could not appropriately be claimed under the counselling listings even though the duration of the service was 20 minutes or longer. It would be appropriate to apply for sessional payments for group educational sessions. Unless the patient is having significant difficulty coping, the counselling listings normally would not be applicable to subsequent visits in the treatment of this disease.

Other examples of appropriate claims under the counselling listings are Psychiatric Care, the counselling that may be necessary to treat a significant grief reaction, and conjoint therapy and/or family therapy for significant behavioural problems.

MSP payment of counselling under the counselling listings is limited to four sessions per year per patient unless otherwise specified. Subsequent counselling is payable under the other visit listings. Counselling by telephone is not a benefit under MSP.

The group counselling fee items found in the Family Medicine and various specialty sections of the Schedule apply only when two or more patients are provided counselling in a group session lasting 60 minutes or more. The group counselling fee items are not applicable when there is a discussion with the patient in the presence of a caregiver, spouse, or relative when the patient is the only person requiring medical care. In those situations, only the applicable individual counselling fee item could be billed, using the patient’s MSP personal health number.

Group counselling fee items are not billable for each person in the group. Claims should be submitted under the Personal Health Number of only one of the beneficiaries, with the names of the other patients attending the session listed in the note record. Only patients with valid MSP coverage should be included. Times should be included with billings for group counselling fee items.

An in-hospital admission examination (fee item 00109 or 13109) may be claimed when a patient is admitted to an acute care hospital for medical care rendered by a family physician. The service also may be applicable when a medical practitioner is required to perform an admission examination prior to a hospital service being delivered by a health care practitioner (e.g.: a dental surgeon). The hospital admission examination listing is not applicable when a patient has been admitted for surgery or when a patient is admitted for care (other than directive care) rendered by a specialist. This service is applicable only once per patient per hospitalization and is in lieu of a “hospital visit” on the day it is rendered. This item is intended to apply in lieu of fee items 00108 or 13008 on the first in-patient day. However, if extra visits are medically required because of the nature of the problem, 00108 or 13008 may be billed in addition. An explanation of the reasons for the additional charges should accompany the claim.

This service includes all of the components of a complete examination and may not be claimed if either of these two services has been claimed by this medical practitioner, within the week preceding the patient’s admission to hospital. If the MSC Payment Schedule listing for a hospital admission examination is not applicable, the service may be billed under the appropriate “hospital visit” listings.

A subsequent hospital visit is the routine monitoring and/or examination(s) that are medically required following a patient’s admission to an acute care hospital. Payments for subsequent hospital visits are usually limited to one per patient per day for a period up to 30 days. However, it is not the intent of the Schedule that subsequent visit fees be claimed for every day a patient is in hospital unless the visits are medically required and unless a medical practitioner visits the patient each day.

If it is medically required for a patient to be visited more than once per day at any time, or daily beyond the initial 30 day period (e.g.: if the patient is in one of the Intensive Care wards), an explanation should be submitted with the claim and independent consideration will be given.

For long stays in an acute care hospital including discharge planning and holding units because of serious illness extending beyond 30 days, claims for subsequent hospital visits greater than two visits per patient per week should include an explanation, and will be given independent consideration.

Newborn care in hospital is the routine care of a well baby up to 10 days of age and includes an initial complete assessment and examination and all subsequent visits as may be appropriate, including instructions to the parent(s) and/or the patient’s representative(s) regarding health care. Newborn well baby care in hospital normally is not payable to more than one medical practitioner for the same patient. However, when a well baby is transferred to another hospital (because of the mother’s state of health), separate claims for newborn care when rendered by a different medical practitioner at each hospital may be made.

When visits are required to patients in long-term-care institutions (such as nursing homes, intermediate care facilities, extended care units, rehabilitation facilities, chronic care facilities, convalescent care facilities and personal care facilities, whether or not any of these facilities are situated on the campus of an acute care facility) claims may be made to a maximum of one visit every two weeks. It is not sufficient, however, for the medical practitioner simply to review the patient’s chart. A face-to-face patient/medical practitioner encounter must be made. For acute concurrent illnesses or exacerbation of original illness requiring institutional visits beyond the foregoing limitations, additional institutional visits may be claimed with accompanying written explanation.

The Palliative Care listings are applicable to the visits for palliative care delivered to patients with any life-limiting illness with life expectancy of up to 6 months, when the focus of care is palliative rather than treatment aimed at cure. These listings only apply where aggressive treatment of the underlying disease process is no longer taking place and care is directed instead to maintaining the comfort of the patient until death occurs.

Claims for these listings should be billed continuously from time of determination of patient’s palliative status, for a period not to exceed 180 days prior to death. Under extenuating circumstances palliative listings billed beyond 180 days will be given independent consideration upon receipt of an explanatory note record.

The listings are applicable to patients in acute care hospitals, hospice facilities or other institutions whether or not the patient is in a designated palliative care unit. The palliative care listings do not apply when unexpected death occurs after long hospitalization for a diagnosis unrelated to the cause of death.

Emergency Medicine Preamble

i) A house call is considered necessary and may be billed only when the patient cannot practically attend a physician’s office due to a significant medical or physical disability or debility and the patient’s complaint indicates a serious or potentially serious medical problem that requires a medical practitioner’s attendance in order to determine appropriate management;

ii) A house call may be initiated by the patient, the patient’s advocate, or the physician when planned proactive care is determined to be medically necessary to manage the patient’s condition;

iii) If a house call is determined to be necessary and is rendered any day of the week between 0800 and 2300 hours, the house call should be billed as a home visit (use 00103);

iv) If the house call is initiated and rendered between 2300 and 0800 hours, the visit may be billed as an out-of-office visit with the night call-out charge (01201).

v) A house call provided for patient convenience should be billed as an out-of-office visit (12200, 13200, 15200, 16200, 17200 or 18200) without a service charge;

vi) The above also applies to house calls rendered by medical practitioners taking call for other medical practitioners;

vii) As practicality dictates, the necessity and detail and the time of the call should be documented in the patient’s clinical record.

The fees for surgery, unless otherwise specifically indicated, include the surgical procedure itself and in-hospital post-operative follow-up, including removal of sutures and care of the operative wound by the surgeon or associate. Unless otherwise specifically indicated, the normal post-operative period included in the surgical fee is 14 days and the surgery fees include all concomitant services necessary to perform the listed service (including preparation of the operative site, incision, exploration, review of the results of diagnostic tests and approved laboratory facility services rendered during the surgery, closure, and pre and post-operative discussion with the patient and/or patient’s family).

When unusual circumstances require that additional medical services are provided in the in-hospital 14 days following a surgical procedure over and above the concomitant services necessary to perform the operative procedure, the additional services performed are not part of the inclusive fee for the
surgical procedure and may be billed separately. A note record is required.

For listings designated “operation only” the in-hospital, 14 day post-operative visits may be claimed in addition to the surgical procedure, with the exception of the visit(s) made on the day of the procedure.

i) Time, for the purposes of fee codes 00193, 00198, 07920, 70019 and 70020 is calculated at the earliest time of medical practitioner/patient contact in the operating suite.

ii) Where a medical practitioner renders surgical assistance at two operations under the same anesthetic but for which repositioning or redraping of the patient or more than one separately draped surgical operating field is medically/surgically required, separate assistants’ fees may be claimed for each operation, except for bilateral procedures, procedures within the same body cavity, or procedures on the same limb.

iii) If, in the interest of the patient, the referring medical practitioner is requested by the patient or the surgeon to attend but does not assist at the procedure, attendance at surgery may be claimed as a subsequent hospital visit.

iv) The specialist’s assistant listings apply only to surgical procedures having unusual technical difficulties identified and documented by the primary surgeon in a detailed note record as necessitating the services of a certified surgical assistant. The general assistant listings are applicable to all other situations where surgical assistance is necessary. (Also see General Preamble B Definitions, Prefixes to Fee Codes).

v) Where surgery is abandoned, independent consideration will be given to the fee applicable to the assistant, to a maximum of 50 percent of the listed assistant fee for the intended procedure.

vi) Surgical fee modifiers are excluded from the calculation for total operative fee(s) for which surgical assist fees are based.

a. The listings under the “Diagnostic Procedures and Selected Therapeutic Procedures” section of the MSC Payment Schedule may be claimed in addition to a consultation or other assessment/visit, when performed during that visit.

If, however, the procedure takes place on a subsequent visit arranged to perform the procedure, then that visit may not be claimed in addition to the procedure unless the fee code for the latter is prefixed by the letter “Y”.

A subsequent visit fee will be paid in addition to the procedure if more than thirty (30) days has elapsed between the initial visit or service and the diagnostic procedure.

b. Diagnostic procedures may be claimed in addition to surgical procedures, when applicable.

c. For multiple diagnostic procedures performed at the same sitting, the procedure having the largest fee may be claimed in full and the remaining procedure(s) at 50 percent of the listed fee(s), unless otherwise specifically indicated in the Payment Schedule.

d. When two diagnostic/therapeutic procedures are performed by separate medical practitioners at the same sitting and both procedures are or should be within the competence of either medical practitioner, the total fee claimed should be no greater than that which would be payable if both procedures had been performed by one medical practitioner, plus one assistant’s fee (if applicable).

e. When a medical practitioner performs a diagnostic procedure, s/he must be allowed to appropriately perform a full or limited consultation for which s/he charges and is paid, regardless of what consultations and procedures have been performed by other specialists or sub-specialists. The consultation would require a written report in addition to the report of the diagnostic procedure.
If the diagnostic procedure is done on an initial visit, and the initial visit is for the specific purpose of performing the diagnostic procedure, and this visit occurs on an out-patient basis in a procedure facility (including endoscopy suites and cardiac catheterization suites), then a limited consultation would normally be billed rather than a full consultation.

f. Procedures designated as “extra” will be paid at 100 percent for the first “extra” and 50 percent for any additional procedures designated as “extra”. Should all procedures be designated as “extra” then the first procedure will be deemed a regular procedure and payment for the first subsequent “extra” will be at 100 percent and all others at 50 percent.

a. Minor Diagnostic and Therapeutic Procedures are defined as procedures which have a fee value that is less than that of the office visit.

Note: To determine the service with the greatest value when a tray fee is applicable, the amount of the tray fee will be added to the value of the procedure fee in the calculation process.

b. When minor diagnostic or therapeutic procedures are performed in conjunction with an assessment/visit (not a consultation) either the visit or the procedure may be claimed, but not both. Includes fee items identified as “isolated procedures”.

c. When the performance of a minor diagnostic or therapeutic procedure is the primary purpose of the visit (excluding home visits), the fee listed for the procedure includes the associated assessment.

d. If in the course of a visit for a specific complaint, one or more procedures are performed which are unrelated to the purpose of the visit (e.g.: URI and laceration repair), the service having the largest fee may be claimed in full and the remaining service(s) at 50 percent of the listed fee(s), unless otherwise specifically indicated in the MSC Payment Schedule.

e. For two or more minor diagnostic or therapeutic procedures listed in the “General Services” section of the Payment Schedule and performed together at the same sitting, each applicable fee may be claimed in full.

a. Surgery to alleviate significant physical symptoms or to restore or improve function to any area altered by disease, trauma or congenital deformity normally is a benefit under MSP. Surgery solely to alter or restore appearance is not a benefit of MSP except under the circumstances listed in the following policy.

b. In establishing this policy, it has been recognized that:
• peer acceptance in our society often is influenced disproportionately by the face,
• children are especially susceptible to emotional trauma caused by physical appearances,
• some procedures traditionally have been accepted as benefits of Health Insurance Plans in spite of the obvious cosmetic nature of these procedures.

c. Emotional, psychological or psychiatric grounds are not considered sufficient reason for MSP coverage of surgery for alteration of appearance except in children and under exceptional circumstances in adults.
On request of the attending medical practitioner, exceptions may be made on an independent consideration basis if the proposed surgery is to alter a significant defect in appearance caused by disease, trauma or congenital deformity, and if the surgery is essential to obtain employment as documented by the attending physician and by an employer with regard to a specific job.

d. Surgery to revise or remove features of physical appearance which are familial in nature is not a benefit of MSP.

e. Within the context of this policy, the word “disease” does not include the normal sequelae of aging. Surgery to alter changes in appearance caused by aging is not a benefit of MSP.

f. Within the context of this policy, the word “trauma” includes trauma due to treatment such as surgery, radiation, etc.

g. As the phrase “reasonable period of convalescence” is imprecise, independent consideration will be given to more complex cases or extenuating circumstances.

h. Authorization from MSP is not required for all surgery to alter appearance. It is required only for those categories of procedures for which some cases may not be a benefit under MSP policy.

Authorization required and obtained remains valid for a period of up to two years, after which a new authorization will be required.

Where authorization has been denied or has not been obtained when required for a surgical procedure, the associated consultations, anesthesiology and surgical assistance also are not covered by MSP. Hospitalization costs also will remain the patient’s responsibility.

a. Head or Neck
• The repair of all significant and unsightly scars, such as keloids, is a benefit of MSP.
• Repair procedures may include excision and/or injection.

b. Excision of keloids in other areas
• Not a benefit of MSP unless significantly symptomatic or there is functional impairment.

Surgical, physical or chemical removal of benign lesions of the skin, including that done by dermabrasion or chemical peel, unless the diagnosis is specifically defined as an approved indication, in article D. 9. 2. 4. a. is not a benefit of MSP.

Examples of benign lesions that are not insured include but are not limited to the following: benign naevi, seborrhoeic keratosis, common warts (verrucae), lipomata, uncomplicated benign dermal and/or epidermal cysts, telangiectasias and angiomata of the skin, skin tags, acrochordons, fibroepithelial polyps, papillomata, neurofibromata, dermatofibromata.

a. Exceptions
Destructive therapies of benign skin lesions are insured services when the treatment is medically necessary. Examples of medical necessity include but are not limited to the following indications:
• genital warts (condylomata acuminate)
• plantar warts
• viral induced cutaneous tumours in the immune compromised patient
• inflamed dermal and epidermal cyst
• dysplastic naevi
• lentigo maligna
• congenital naevi
• actinic (solar) keratosis
• atypical pigmented naevi
• lesions which cause significant pathophysiologic dysfunction

b. When a patient presents with a surface pathology, the initial visit and or consultation and/or pathologic examination of a tissue specimen, when one is submitted, is regarded as medically necessary to establish the diagnosis, and therefore, is an insured service. Any use of dermoscopy and/or any other diagnostic technology (e.g.: use of Artificial Intelligence) is included within the visit and/or consultation.

a. Scalp or Neck
(i) Post-traumatic:
• Repair to the area of traumatic hair loss is a benefit of MSP only if carried out within a reasonable period of convalescence.
• MSP authorization is required.

(ii) Other Etiology:
• Not a benefit of MSP

(iii) Usual repair procedures may include skin shifts or flaps, skin grafts, or hair plugs.

b. Other Anatomical Areas
• Not a benefit of MSP