A004

PDF page 42 / GP28

FIRST VISIT BY PRIMARY CARE PHYSICIAN AFTER HOSPITAL DISCHARGE
  E080 First visit after hospital discharge premium, to other service
          listed in payment rule 5 below ..................................... add        25.90
      Payment rules:
      1.Subject to payment rules 2 through 5, E080 is only eligible for payment for a visit with the
        patient's primary care physician in the physician’s office or the patient’s home within two
        weeks of discharge following in-patient admission to an acute care hospital.
      [Commentary:
      This premium is not payable for visits rendered to patients in locations other than the
      physician's office or patient's home. As such, the premium is not payable for services rendered
      in places such as Nursing Homes, Homes for the Aged, chronic care hospitals, etc.]
      2.E080 is not eligible for payment if the admission to hospital was for the purpose of obstetrical
        delivery unless the mother required admission to an ICU during the hospital stay.
      3.E080 is not eligible for payment if the admission to hospital was for the purpose of newborn
        care unless the infant required admission to a NICU during the hospital stay.
      4.E080 is not eligible for payment if the admission to hospital was for the purpose of performing
        day surgery.
      5.E080 is only eligible for payment when rendered with the following services:
        A001, A003, A004, A007, A008, A261, A262, A263, A264, A888, A900, K004–K008, K013,
        K014, K022, K023, K028-K030, K032, K033, K037, K623, P003, P004, P008.

PDF page 78 / GP64

2. Despite any other provision in this Schedule, the amount payable for the following services to
     an insured person who is at least 65 years of age, as those services are defined in this
     Schedule, is increased by 15 per cent:
     a. A general assessment (A003, C003, W102, or W109);
     b. A general re-assessment (A004, C004, W004);
     c. An intermediate assessment (A007);
     d. A focused practice assessment (A917, A927, A937, A947, A957 or A967);
     e. A periodic health visit (K132).
     f. Comprehensive assessment and care (H102, H122, H132, H152)
     g. A multiple systems assessment (H103, H123, H133, H153)

PDF page 132 / A4

A003 General assessment...............................................................           95.60
                   Note:
                   A003 is not eligible for payment for an assessment provided in the patient’s home.
               A004 General re-assessment ..........................................................            39.35
                   Note:
                   The collection of cervical cancer screening specimen(s) is included in the consultation, repeat
                   consultation, general or specific assessment (or re-assessment), or routine postnatal visit when
                   pelvic examination is normal part of the foregoing services. However, the add-on codes E430
                   or E431 can be billed in addition to these services when collection of cervical cancer screening
                   specimen(s) is performed outside of a hospital or ICHSC.
               A001 Minor assessment...................................................................         26.80
               A007 Intermediate assessment or well baby care ...........................                       44.55
               E432     - when pelvic exam including speculum is performed
                          outside of hospital or ICHSC, to A001 and A007 ....... add                             5.00
               A002 Enhanced 18 month well baby visit (see General Preamble
                        GP34) ................................................................................. 73.95
                   Payment rules:
                   1.Special visit premiums listed in Table VI on page GP75 of this Schedule are not eligible for
                     payment with A007 or A001 when rendered in a patient’s home.
                                          2.For A007 or A001 rendered in a patient’s home, travelling to and from the home is included
                                            as a common element of the insured service. See page GP13 of this Schedule.
                                          3.See the Definitions section of this Schedule for the definition of home.
                                          4.E432 is limited to one service per patient per day.
                                          5.E432 is only eligible for payment when the procedure is personally rendered by the
                                            physician.
                                          6.E432 is not eligible for payment with E430, E431, or E542.
                 Mini assessment
                   A mini assessment is rendered when an assessment of a patient for an unrelated non-WSIB
                   problem is performed during the same visit as an assessment of a WSIB related problem for
                   which only a minor assessment was rendered.
               A008 Mini assessment ..................................................................... 13.40
                   [Commentary:
                   A008 is only payable when the WSIB component of the visit is the service described as A001.
                   In circumstances where a different service or a higher level of assessment is claimed, A008 is
                   not payable in addition.]

PDF page 184 / A56

CONSULTATIONS AND VISITS
FAMILY PRACTICE & PRACTICE IN GENERAL (00)
   Initial discussion with patient re: smoking cessation
     Initial discussion with patient re: smoking cessation is the service rendered to a patient who
     currently smokes tobacco by the primary care physician most responsible for their patient’s
     ongoing care, in accordance with the guidelines and subject to the conditions below.
 E079 Initial discussion with patient, to eligible services ............. add         15.95
     Payment rules:
     1.E079 is only eligible for payment when rendered in conjunction with one of the following
        services: A001, A003, A004, A005, A006, A007, A008, A905, K005, K007, K013, K017,
        K130, K131, K132, K133, P003, P004, P005, P008, W001, W002, W003, W004, W008,
        W010, W102, W104, W107, W109 or W121.
     2.E079 is limited to a maximum of one service per patient per 12 month period.
     Medical record requirements:
     The medical record for this service must document that an initial smoking cessation discussion
     has taken place, by either completion of a flow sheet or other documentation consistent with
     the most current guidelines of the “Clinical Tobacco Intervention” (CTI) program, or the service
     is not eligible for payment.
     [Commentary:
     1.Physicians may complete a flow sheet or alternatively document that an initial discussion
       consistent with the 5A's model of the CTI program has taken place.
     2.E079 is not eligible for payment for discussions related to cannabis smoking or discussions
       related to vaping, including vaping tobacco.]
   Smoking cessation follow-up visit
     Smoking cessation follow-up visit is the service rendered by a primary care physician in the 12
     months following E079 that is dedicated to a discussion of tobacco smoking cessation, in
     accordance with the guidelines and subject to the conditions below.
 K039 Smoking cessation follow-up visit ........................................... 39.25
     Payment rules:
     1.K039 is only eligible for payment when E079 is payable to the same physician in the
       preceding 12 month period.
     2.K039 is limited to a maximum of two services in the 12 months following E079.
     Medical record requirements:
     The medical record for this service must document that a follow-up visit regarding smoking
     cessation has taken place, by either completion of a flow sheet or other documentation
     consistent with the most current guidelines of the “Clinical Tobacco Intervention” (CTI)
     program, or the service is not eligible for payment.
     [Commentary:
     1.Physicians may complete a flow sheet or alternatively document that an initial discussion
       consistent with the 5A's model of the CTI program has taken place.
     2.K039 is not eligible for payment for discussions related to cannabis smoking or discussions
       related to vaping, including vaping tobacco.]

Master, record 4. Record Layout PDF, page 1.

A00420260401999999990000039350000000000000000000000000000000000000000000000

Auxiliary master fields are preserved as raw scaled values. The linked layout calls them zero-filled, but this edition contains non-zero values. They are not presented as final dollar fees or PDF units.