K013

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 149 / A21

CONSULTATIONS AND VISITS
 FAMILY PRACTICE & PRACTICE IN GENERAL (00)
     Primary mental health care
       Primary mental health care is not to be billed in conjunction with other consultations and visits
       rendered by a physician during the same patient visit unless there are clearly 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.
   K005 Individual care............................................................. per unit 80.00
        Counselling
         Unit means ½ hour or major part thereof - see General Preamble GP7, GP54 to GP61 for
         definitions and time-keeping requirements.
       Individual care
   K013 - first three units of K013 and K040 combined per patient per
            provider per 12 month period ................................. per unit                     80.00
   K033 - additional units per patient per provider per 12 month period
             ............................................................................... per unit   56.30
       Group counselling - 2 or more persons
   K040 - where no group members have received more than 3 units
           of any counselling paid under codes K013 and K040
           combined per provider per 12 month period .......... per unit                                80.00
   K041        - additional units where any group member has received 3 or
                 more units of any counselling paid under codes K013 and
                 K040 combined per provider per 12 month period . per unit                              57.30
   K014 Counselling for transplant recipients, donors or families of
          recipients and donors
           - 1 or more persons ............................................... per unit                 80.00
   K015 Counselling of relatives - on behalf of catastrophically or
          terminally ill patient
           - 1 or more persons ............................................... per unit                 80.00

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 227 / A99

Definition/Required elements of service:
         Diabetes Management by a specialist is a service rendered by a specialist in Endocrinology,
         Internal Medicine or Paediatrics who is most responsible for providing ongoing management of
         a diabetic patient. This service includes all services related to the coordination, provision and
         documentation of ongoing management using a planned care approach consistent with the
         required elements of the current Canadian Diabetes Association (CDA) Clinical Practice
         Guidelines. The medical record must document that all of the CDA required elements have
         been provided for the previous 12 month period and include, at a minimum, the following:
             a.Lipids, cholesterol, HbA1C, blood pressure, weight and body mass index (BMI), and
                medication dosage;
             b.Discussion and offer of preventive measures including vascular protection, influenza and
                pneumococcal vaccination;
             c.Health promotion counselling and patient self-management support;
             d.Albumin to creatinine ratio (ACR);
             e.Discussion and offer of referral for dilated eye examination; and
             f. Foot examination and neurologic examination.
   K045 Diabetes management by a specialist ....................................    80.25
       Payment rules:
       1.K045 is limited to a maximum of one service per patient per 12 month period.
          2.K045 is only eligible for payment if the physician has rendered a minimum of 4 of any of the
            following: consultations/assessments, K013, K033, K029, K002, K003 to the same patient in
            the 12 month period for which K045 is claimed.
          3.K045 is only eligible for payment when the physician has greater than 100 patients per year
            with diabetes.
          4.K045 is eligible for payment to a physician from one of the following specialties: Internal
            Medicine (13), Endocrinology (15) or Paediatrics (26).
          Medical record requirements:
          K045 is only eligible for payment if the flow sheet and/or a diabetic registry record has been
          completed for the previous 12 month period including the above listed requirements and is
          maintained in the patient’s permanent medical record.
          Claims submission instructions:
          Claims for K045 may only be submitted when the required elements of the service have been
          completed for the previous 12 month period.
          [Commentary:
          A copy of a flow sheet meeting the medical record requirements and CDA Clinical Practice
          Guidelines may be found at https://guidelines.diabetes.ca/GuideLines/media/Docs/cpg/
          Appendix-3.pdf ]

PDF page 228 / A100

Definition/Required elements of service:
    This is an annual fee payable to a specialist in internal medicine or endocrinology for the
    comprehensive team-based care of a patient with diabetes.
     The diabetes management team must include the specialist most responsible for the diabetes
     management of the patient and at least one or more Certified Diabetes Educators (CDE). DTM
     includes all services related to the coordination, provision and documentation of all required
     elements of ongoing care, as necessary, by the physician and/or the CDE.
 K046 Diabetes team management...................................................  127.20
     Payment rules:
     1.A maximum of one K046 is eligible for payment per patient per 12 month period.
     2.K046 is only eligible for payment if all of the following requirements are fulfilled:
         a.the physician has rendered a minimum of 4 of any combination of consultations/
           assessments or K013, K033, K029, K002, K003 to the same patient in the 12 month
           period for which K046 is claimed;
         b.the CDE is an employee of the physician;
         c.when the physician has treated more than 100 patients with diabetes during the period for
           which K046 is claimed; and
         d.the physician is from one of the following specialities: Internal Medicine (13) or
           Endocrinology (15).
     3.K046 is not eligible for payment unless the physician documents the services rendered by
       the CDE. The physician must provide such documentation to the ministry, if requested.
     4.The CDE must have current certification by the Canadian Diabetes Educator Certification
       Board at the time the CDE renders services to the patient.

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 2891. Record Layout PDF, page 1.

K01320260401999999990000080000000000000000000000000000000000000000000000000

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.