K008

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 72 / GP58

COUNSELLING
  Definition/Required elements of service:
  Counselling is a patient visit dedicated solely to an educational dialogue with a physician. This service
  is rendered for the purpose of developing awareness of the patient’s problems or situation and of
  modalities for prevention and/or treatment, and to provide advice and information in respect of
  diagnosis, treatment, health maintenance and prevention.
                                          [Commentary:
                                          1.Advice given to a patient that would ordinarily constitute part of a consultation, assessment,
                                            or other treatment, is included as a common or constituent element of the other service, and
                                            does not constitute counselling.
       2.Detention time may be payable following a consultation or assessment when a physician is
         required to spend considerable extra time in treatment or monitoring of the patient. See
         GP29 for further information.]
  Payment rules:
    1. With the exception of the codes listed in the below, no other services are eligible for payment
       when rendered by the same physician the same day as any type of counselling service:
       E080, G010, G039, G040, G041, G042, G043, G202, G205, G365, G372, G384, G385, G394,
       G462, G480, G489, G482, G538, G590, G593, G840, G841, G842, G843, G844, G845, G846,
       G847, G848, G849, H313, K002, K003, K008, K014, K015, K031, K035, K036, K038, K682,
       K683, K684, K730
                    2. Individual and group counselling services are limited to 3 units per patient per physician per
                       year at the higher fee (K013 or K040 respectively); the amount payable for services rendered in
                       excess of this limit will be adjusted to a lesser fee (K033 or K041 respectively).
                    3. If the patient does not have a pre-booked appointment, the amount payable for this service will
                       be adjusted to a lesser assessment fee.
  A. Individual Counselling
  Definition:
  Individual counselling is counselling rendered to a single patient.
  B. Group Counselling
  Definition:
  Group Counselling is counselling rendered to two or more patients with a similar medical condition or
  situation.
  Payment rules:
     1. Group counselling is only eligible for payment when all of the following conditions are fulfilled:

PDF page 156 / A28

CONSULTATIONS AND VISITS
FAMILY PRACTICE & PRACTICE IN GENERAL (00)
   Interviews
     Interviews are not eligible for payment when the information being obtained is part of the
     history normally included in the consultation or assessment of the patient. The interview must
     be a booked, separate appointment lasting at least 20 minutes. Unit means ½ hour or major
     part thereof - see General Preamble GP7, GP54 to GP61 for definitions and time-keeping
     requirements.
 K002 Interviews with relatives or a person who is authorized to make
          a treatment decision on behalf of the patient in accordance
          with the Health Care Consent Act .......................... per unit       80.00
     Payment rules:
     K002 is only eligible for payment if the physician can demonstrate that the purpose of the
     interview is not for the sole purpose of obtaining consent.
 K003 Interviews with Children’s Aid Society (CAS) or legal guardian
           on be half of the patient in accordance with the Health Care
           Consent Act conducted for a purpose other than to obtain
           consent................................................................... per unit       80.00
     Note:
     K002, K003 are claimed using the patient’s health number and diagnosis. These listings apply
     to situations where medically necessary information cannot be obtained from or given to the
     patient or guardian, e.g. because of illness, incompetence, etc.
 K008 Diagnostic interview and/or counselling with child and/or
           parent for psychological problem or learning disabilities
            ............................................................................... per unit 80.00
     Note:
     K008 is claimed using the child’s health number. Psychological testing is not an insured
     service.

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 2887. Record Layout PDF, page 1.

K00820260401999999990000080000000000000000000000000000000000000000000000000

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.