LFP Payment Model Key Concepts

Services at a Facility are Excluded Services unless a physician has registered to bill for LFP Facility based Services provided in an applicable Facility setting:

• Long-term Care and Palliative Care Facilities
• Inpatient Care
• Facility-based Pregnancy & Newborn Facility Services

LFP Facility-based Services for which the physician has not registered are excluded from the LFP Payment Model. In addition, all other types facility-based services are excluded from the LFP Payment Model (e.g. surgery, surgical assists unrelated to pregnancy).

The term “Facility” is defined in Appendix A [Definitions]. For reference, it means an acute care,hospice, palliative care, or long-term care facility. This includes but is not limited to hospitals, nursing homes, intermediate care facilities, extended care units, rehabilitation facilities, chronic care facilities, convalescent care facilities, and personal care facilities.

Services provided under an Alternative Payments Subsidiary Agreement (APSA) contract (e.g., service contract, sessional contract, salary agreement) between a physician and a health authority (including Provincial Health Services Authority, Providence Health Care Society and First Nations Health Authority) are excluded from the LFP Payment Model.

The following medical assistance in dying services in all settings are excluded from the LFP Payment Model. They can be billed using an alternative payment model or applicable Fee-for-Service codes:

• MAiD Assessment (Prescriber) (13501)
• MAiD Assessment (Assessor) (13502)
• Physician witness to video conference MAiD Assessment – Patient Encounter (13503)
• MAiD Event Preparation and Procedure (13504)
• MAiD Medication Pick-up and Return (13505)
• MAiD Expert Case Review (13506)
• MAiD Waiver of Final Consent (13507)
• Oral MAiD extension (13508)

Other palliative care (e.g. care planning, end of life visits) can be billed under the LFP Payment Model for applicable services and settings.

Hospital at Home allows eligible patients to receive hospital-level care in their homes rather than in a hospital. Patients receive care at home from an interdisciplinary team led by a physician with hospital admitting privileges.

Services provided to patients admitted to a Hospital at Home program are excluded from the LFP Payment Model. They can be billed using an alternative payment model or applicable Fee-for-Service codes when billed by physicians working in a health authority-operated Hospital at Home program. This includes the following fee-for-service codes:

• Hospital at Home Virtual Visit (13010)
• Hospital at Home In-Person Visit (13011)
• Hospital at Home FP Conference with Allied Care Provider and/or Physician (13012)
• Emergency visit (call placed between hours of 0800 and 1800 hours) – weekdays (00112)
• Visit – out of office (12200, 13200, 15200, 16200, 17200, 18200)
• Call-Out Charges (01200, 01201, 01202)
• Continuing Care Surcharges (01205, 01206, 01207)
• Fee-for-service codes for procedures noted in Appendix D

For physicians who have registered to bill LFP Inpatient Care Services: Services provided to the patient while the physician and patient are on site at the hospital should be billed under the LFP Payment Model using Inpatient Care time and interaction codes.

Surgical procedures not listed in Appendix D are excluded from the LFP Payment Model. Physicians must claim for surgical procedures not listed in Appendix D under a different compensation model, including fees contained in Fee-for-Service or an alternative payment model, as applicable. If Fee-for-Service or the applicable alternative payment model includes follow-up services associated with the surgical procedure, that follow-up service is excluded for payment under the LFP Payment Model.

When a physician provides a consultation and a surgical procedure not listed in Appendix D to the same patient on the same day:

• Direct Patient Care time is payable for the time spent on the consultation, but not the surgical procedure.
• An LFP consultation interaction code is payable in addition to the surgical procedure.
• No other interaction codes are payable for the same patient on the same day.

Services related to motor vehicle accidents (ICBC-related services) are excluded from the LFP Payment Model. These services must be billed under Fee-for-Service, in accordance with the Fee-for-Service Payment Schedule (General Preamble C. 17 Motor Vehicle Accident Billing Guidelines).

Services related to WorkSafeBC services are excluded from the LFP Payment Model. These services must be billed using Fee-for-Service codes with WorkSafeBC identified as the payor. A detailed description of WorkSafeBC fees, preamble, and policies is contained in the Physicians and Surgeons’ WorkSafeBC Services Agreement.

Services to residents of other provinces and territories are excluded from the LFP Payment Model.

• MSP-insured services for out-of-province patients are billed under Fee-for-Service, except for
  residents of Quebec.
• Physicians can charge services for Quebec residents directly to the patient.

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 card.

There are some services that are excluded from these interprovincial agreements, as identified in the Fee-for-Service Payment Schedule (General Preamble C. 11 Reciprocal Claims). Physicians can charge these services directly to the patient.

Services provided to patients who are not beneficiaries under the Medicare Protection Act are excluded from the LFP Payment Model. This includes out-of-country patients and patients who do not meet minimum residency requirements (with the exception of residents of other provinces and territories with a valid provincial health card).

Physicians can charge these services to the third party or directly to the patient as appropriate.

Services that are not insured by MSP are not payable under the LFP Payment Model:

• Services that are not benefits under the Medicare Protection Act.
• Services requested or required by a third party for reasons other than medical
  requirements.
• Services requested or required by provincial government ministries other than the
  Ministry of Health for reasons other than medical requirements, including
  RoadSafetyBC forms and Ministry of Social Development and Poverty Reduction forms
  (e.g. Persons with Disabilities (PWD) Designation Application).
• Services provided solely in association with other services not insured under MSP,
  including patient consultations, pre-operative examinations, and laboratory
  investigations.
• Medical services which are provided solely for the purposes of research or
  experimentation.
• Cosmetic procedures solely to alter or restore appearance.
• Charges for missed appointments.
• Services provided by a physician to their family and household members as follows:
  • spouse,
  • child or stepchild,
  • parent or stepparent,
  • parent of a spouse,
  • grandparent,
  • grandchild,
  • sibling,
  • person living in their household, or
  • spouse of a person referred to in the above list.

Physicians can charge these services to the third party or directly to the patient as appropriate.

Services are not payable under the LFP Payment Model if the patient is eligible for and entitled to them under the following legislation:

• the Aeronautics Act (Canada),
• the Civilian War-related Benefits Act,
• the Government Employees Compensation Act (Canada),
• the Merchant Seaman Compensation Act (Canada),
• the National Defence Act (Canada),
• the Pension Act (Canada),
• the Royal Canadian Mounted Police Pension Continuation Act (Canada),
• the Royal Canadian Mounted Police Superannuation Act (Canada),
• the Canadian Forces Members and Veterans Re-establishment and Compensation Act,
• the Department of Veterans Affairs Act,
• the Corrections and Conditional Release Act (Canada),
• the Workers Compensation Act, or
• the Hospital Insurance Act.

Physicians are responsible for ensuring they do not exceed the following limits:

• The maximum of 14 hours of clinic-based time codes (98010/98040, 98011/98041, 98012/98042) is payable in a single calendar day.
• The maximum of 120 hours of clinic-based time codes (98010/98040, 98011/98041, 98012/98042) is payable in any 14-day period.
• The maximum amount of Clinical Administration time (98012 or 98042) payable is 10% of the total amount of clinic-based time codes (98010/98040 98011/98041, 98012/98042) paid to a physician in a calendar year. It is anticipated that Clinical Administration time for most physicians will be in the range of 5% of the time claimed under the clinic-based time codes.

Claims for time codes that exceed typical hours by peer family physicians are more likely to result in a review and/or audit

50 clinic-based interaction codes are payable in one day.

• This applies to all codes, except 98022 and 98052.
• This does not apply to services provided in communities that were receiving NIA premiums as of December 15, 2002.

A physician may choose to provide services for patients who are not on the panel of the longitudinal physicians or nurse practitioners who work at the same LFP Clinic.

• Services for these patients cannot be more than 30% of interaction codes for LFP Clinic-based Services in one year.
• Please review additional details about the 30% limit on clinic non-panel services.

Physicians are responsible for ensuring they do not exceed the following limits:

• Maximum Daily Time – The maximum amount payable for the following time codes is 14 hours in a single calendar day:
  • Long-term Care and Palliative Care Facility Direct Patient Care Time (98120/98220, 98121/98221, 98122/98222, 98123/98223)
• Maximum Two-Week Time – The maximum amount payable for the following time codes is 120 hours in any 14-day period:
  • Long-term Care and Palliative Care Facility Direct Patient Care Time (98120/98220, 98121/98221, 98122/98222, 98123/98223).
• Maximum Clinical Administration Time – The maximum amount of Clinical Administration time (98012/98042) payable for the Long-term Care and Palliative Care Facility setting is 10% of the total amount of the following time codes paid to a physician in a calendar year:
  • Long-term Care and Palliative Care Facility Direct Patient Care Time (98120/98220, 98121/98221, 98122/98222, 98123/98223);
  • Indirect Patient Care Time (98011/98041); and
  • Clinical Administration Time (98012/98042).

50 interaction codes for long-term care and palliative care facilities are payable in one day.

• This applies to all codes, except Team Communication 98035 and 98235.
• This does not apply to services provided in communities that were receiving NIA premiums as of December 15, 2002.

Physicians are responsible for ensuring they do not exceed the following limits:

• Maximum Daily Time – The maximum amount payable for the following time codes is 24 hours in a single calendar day:
  • Inpatient Direct Patient Care Time (98124/98224, 98125/98225, 98126/98226, 98127/98227);
  • Indirect Patient Care Time (98011 or 98041); and
  • Clinical Administration Time (98012 or 98042).
• Maximum Clinical Administration Time – The maximum amount of Clinical Administration time (98012/98042) payable for Inpatient Care setting is 10% of the total amount of the following time codes paid to a physician in a calendar year:
  • Inpatient Direct Patient Care Time (98124/98224, 98125/98225, 98126/98226, 98127/98227);
  • Indirect Patient Care Time (98011/98041); and
  • Clinical Administration Time (98012/98041).

Inpatient Care interaction codes are structured to enable family physicians to provide accessible, high-quality, comprehensive, and continuous inpatient care. As such, a daily limit does not apply in recognition of the varying needs of patients and communities.

Physicians are responsible for ensuring they do not exceed the following limits:

• Maximum Daily Time – The maximum amount payable for the following time codes is 24 hours in a single calendar day:
  • Facility-based Pregnancy & Newborn Services Direct Patient Care Time (98128/98228, 98129/98229, 98130/98230, 98131/98231);
  • Indirect Patient Care Time (98011/98041); and
  • Clinical Administration Time (98012/98042).
• Maximum Clinical Administration Time – The maximum amount of Clinical Administration time (98012/98042) payable for Pregnancy & Newborn Services setting is 10% of the total amount of the following time codes paid to a physician in a calendar year:
  • Facility-based Pregnancy & Newborn Services Direct Patient Care Time (98128/98228, 98129/98229, 98130/98230, 98131/98231);
  • Indirect Patient Care Time (98011/98041); and
  • Clinical Administration Time (98012/98042).

Facility-based Pregnancy & Newborn Services interaction codes are structured to enable family physicians to provide accessible, high-quality, comprehensive, and continuous care for pregnant people and newborns. As such, a daily limit does not apply in recognition of the varying needs of patients and communities.