K007

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 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.]

PDF page 198 / A70

CONSULTATIONS AND VISITS
VIRTUAL CARE SERVICES
     Claims submission instructions:
     Comprehensive Virtual Care Services rendered within an Existing/Ongoing Patient-Physician
     Relationship must be claimed using the fee codes listed in Appendix J – Section 1.
     Claims submitted for Comprehensive Virtual Care Services must include the modality indicator
     that identifies the technology used to deliver the service:
        K300A – identifies Video technology used during the service
        K301A – identifies Telephone technology (audio only) used during the service
     Submit claims for Comprehensive Virtual Care Services using the in-person fee value
     regardless of whether the service is rendered by Video or Telephone. Payments for Telephone
     services will be automatically reduced as set out below.
     Limited Virtual Care Services rendered outside of an Existing/Ongoing Patient-Physician
     Relationship must be claimed using the fee codes listed in Appendix J – Section 2.
     Payment rules:
     Comprehensive Virtual Care Services rendered by Video are payable at fees that are
     equivalent to the corresponding in-person fees for those services; or for Limited Virtual Care
     Services, the fees listed in Appendix J – Section 2 that correspond to those services.
     The amount payable for Comprehensive Virtual Care Services rendered by Telephone is 85%
     of the corresponding in-person fee except for K007, K005, K197 and K198 which will be
     payable at 95% of the corresponding in-person fee.

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 2886. Record Layout PDF, page 1.

K00720260401999999990000080000000000000000000000000000000000000000000000000

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.