K004

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 70 / GP56

Definitions:
  "Qualifying services" means K004A, K006A, K007A, K010A, K012A, K019A, K020A, K024A K025A,
  K122A and K123A.
  "Fiscal year" means April 1 - March 31st.
  "Qualifying year" means the fiscal year preceding the date of determination of eligibility.
  "Date of determination of eligibility" means the date upon which the General Manager determines that
  the conditions for payment in (1) or (2) below, have been met.
  "All payments" means all payments made to the physician for insured services listed in this Schedule
  other than payments made for insured services listed in this Schedule for which a technical fee is
  payable.

PDF page 71 / GP57

GENERAL PREAMBLE
 PSYCHOTHERAPY, PSYCHIATRIC AND COUNSELLING SERVICES
Payment rules:
For the 12 month period following the date of determination of eligibility for the premium, the amount
payable to a physician shall be automatically increased by 17% for each of the following services
rendered by the physician: K004, K006, K007, K010, K012, K019, K020, K024, and K025, in the
following circumstances:
    1. when the sum of all payments made to the physician for the qualifying services rendered in the
       qualifying year exceeds 50% of the sum of all payments made to the physician in the qualifying
       year; or
    2. when the sum of all payments made to the physician for the qualifying services rendered in the
       qualifying year is at least 40% but not more than 49% of the sum of all payments made to the
       physician in the qualifying year and the requirements set out in (1.) were met by the physician in
       respect of the fiscal year preceding the qualifying year.
          [Commentary:
          While K122 and K123 are qualifying services for the purpose of determining eligibility for the
          focused practice psychotherapy premium, the premium is not payable for K122 and K123.]

PDF page 152 / A24

CONSULTATIONS AND VISITS
FAMILY PRACTICE & PRACTICE IN GENERAL (00)
   Psychotherapy
     Includes narcoanalysis or psychoanalysis or treatment of sexual dysfunction - see General
     Preamble GP54.
     Note:
     Psychotherapy outside hospital and hypnotherapy may not be claimed as such when provided
     in conjunction with a consultation or other assessments rendered by a physician during the
     same patient visit unless there are clearly defined different diagnoses for the two services. Unit
     means ½ hour or major part thereof - see General Preamble GP7, GP54 to GP61 for definitions
     and time-keeping requirements.
 K007 Individual care ............................................................ per unit 80.00
     Group - per member - first 12 units per day
 K019 - 2 people.................................................................. per unit                        40.05
 K020 - 3 people.................................................................. per unit                        26.65
 K012 - 4 people.................................................................. per unit                        20.15
 K024 - 5 people.................................................................. per unit                        16.60
 K025 - 6 to 12 people......................................................... per unit                           14.10
 K010 - additional units per member (maximum 6 units per patient
         per day) .................................................................. per unit                      12.80
     Family
 K004 - 2 or more family members in attendance at the same time
          ............................................................................... per unit                 86.85
   Hypnotherapy
     Unit means ½ hour or major part thereof - see General Preamble GP7, GP54 to GP61 for
     definitions and time-keeping requirements.
 K006 Individual care* ........................................................... per unit 80.00
     Note:
     * May not be claimed in conjunction with delivery as the service is included in the obstetrical
     fees.

PDF page 300 / A172

CONSULTATIONS AND VISITS
PAEDIATRICS (26)
   Developmental and/or behavioural care
     Developmental and/or behavioural care are services encompassing any combination or form of
     assessment and treatment by a paediatrician for mental illness, behavioural maladaptations,
     developmental disorders, and/or other problems that are assumed to be of a developmental or
     emotional nature where there is consideration of the patient's biological and psychosocial
     functioning. Unit means ½ hour or major part thereof - see General Preamble GP7, GP54 to
     GP61 for definitions and time-keeping requirements.
 K122 - individual developmental and/or behavioural care . per unit                 102.35
 K123 - family developmental and/or behavioural care ...... per unit                116.15
     Payment rules:
     These services are only payable to paediatricians who satisfy one of the following criteria:
        a.35% or more of the dollar value of the annual fee-for-service claims in any 12 month
          period consist of K122 and/or K123;
        b.35% or more of the dollar value of the annual fee-for-service claims in any 12 month
          period consist of any combination of K005, K007, K019, K020, K012, K024, K025, K010,
          K004, K006, or K008; or
        c.additional residency or fellowship training in paediatrics or psychiatry. Residency or
          fellowship training includes either completion of training in paediatric or adolescent
          developmental and/or behavioural medicine within a recognized paediatric residency
          training programme of at least one-year duration following completion of the first three
          years of residency, or a post residency fellowship or other equivalent programme in
          paediatrics, adolescent medicine or psychiatry. Documentation of additional residency or
          fellowship training must be provided if requested by the ministry.
     [Commentary:
     Paediatricians who do not meet the criteria listed above but believe they have appropriate
     training and/or experience to permit them to provide paediatric or adolescent developmental
     and/or behavioural care may contact the ministry to determine whether their training and/or
     experience constitute an equivalent residency, training or programme.
     Services rendered by physicians who do not meet these requirements are still insured but
     eligible for payment under another fee schedule code e.g. primary mental health care (K005),
     counselling (K013/K033) or group counselling (K040/K041).]

Master, record 2883. Record Layout PDF, page 1.

K00420260401999999990000086850000000000000000000000000000000000000000000000

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.