K738

PDF page 49 / GP35

Definition/Required elements of service:
An e-assessment is a service performed by a specialist when a primary care physician or nurse
practitioner requests an opinion and/or recommendations from the specialist for management of a
specific patient by providing information electronically through a secure server (e.g. secure
messaging, EMR). The specialist is required to review all relevant data provided by the primary care
physician or nurse practitioner, including the review of any additional information that may be
submitted subsequent to the initial request. For the purpose of this service, “relevant data” may
include family/patient history, history of the presenting complaint, laboratory and diagnostic tests, and
visual images where indicated.
In addition to the Common Elements, E-assessments include the specific elements of assessments,
as listed in the General Preamble, except for paragraphs A and B.
          Payment rules:
          1.E-assessments are only eligible for payment if the specialist has provided an opinion and/or
            recommendations for patient management to the primary care physician or nurse practitioner
            within 30 days from the date of the request. Where a service is requested by a nurse
            practitioner the consultant shall provide the report to the nurse practitioner and the patient’s
            primary care provider, if applicable.
          2.E-assessments are not eligible for payment to the specialist in the following circumstances
              a.when the purpose of the electronic communication is to arrange for transfer of the
                patient’s care to any physician; or
              b.when rendered in whole or in part to arrange for a consultation, a different assessment,
                visit, or K-prefix time-based services, procedure(s), or diagnostic investigation(s); or
              c.when the specialist renders a K-prefix time-based service for the same patient within 30
                days following the request for the specialist e-assessment; or
              d.in circumstances where the primary care physician or specialist receives compensation,
                other than by fee-for service under this Schedule, for participation in the e-assessment.
          3.A consultation, a different assessment or visit rendered by the specialist for the same patient
            for the same diagnosis within 60 days following the request for the specialist e-assessment is
            only payable as a specific or partial assessment, as appropriate to the service rendered.
          4.K738 is eligible for payment to the primary care physician when this physician is required to
            collect additional data (for example dermatology or ophthalmology images not present in the
            primary care physician’s records) to support the specialist’s e-assessment. K738 is not
            eligible for payment where existing data is already available in the primary care physician’s
            records for submission to the specialist.
          [Commentary:
          1.Following the primary care physician’s request, the specialist decides whether an e-
            assessment is the most appropriate service in the circumstances. In some cases, direct
            patient contact or a consultation by videoconference may be more appropriate.
          2.Payment, other than by fee-for-service, includes compensation where the physician receives
            remuneration under a salary, primary care, stipend, APP or AFP model.
          3.Physicians who receive compensation other than by fee-for-service under this Schedule
            should consult their contract for guidance on shadow-billing.]

PDF page 176 / A48

CONSULTATIONS AND VISITS
FAMILY PRACTICE & PRACTICE IN GENERAL (00)
    PHYSICIAN/NURSE PRACTITIONER TO PHYSICIAN E-CONSULTATION
     Physician/nurse practitioner to physician e-consultation is a service where the referring
     physician or nurse practitioner, in light of his/her professional knowledge of the patient,
     requests the opinion of a physician (the “consultant physician”) who is competent to give
     advice in the particular field because of the complexity, seriousness, or obscurity of the case
     and where both the request and opinion are sent by electronic means through a secure server.
     This service is only eligible for payment if the consultant physician has provided an opinion
     and/or recommendations for patient treatment and/or management within thirty (30) days from
     the date of the e-consultation request.
     For the purpose of this service, “relevant data” includes family/patient history, history of the
     presenting complaint, laboratory and diagnostic tests, where indicated.
     Note:
     The Definition/Required elements of service and payment rules for consultations in the General
     Preamble are not applicable to physician/nurse practitioner to physician e-consultations.
    Definition/Required elements of service – Referring physician
     The referring physician or nurse practitioner initiates the e-consultation with the intention of
     continuing the care, treatment and management of the patient.
     In addition to the Constituent and Common Elements of Insured Services described in the
     General Preamble of this Schedule, this service includes the transmission of relevant data to
     the consultant physician and all other services rendered by the referring physician or nurse
     practitioner to obtain the advice of the consultant physician.
     Note:
     This service is eligible for payment in addition to visits or other services provided to the same
     patient on the same day by the same referring physician.
   Definition/Required elements of service – Consultant physician
     This service includes all services rendered by the consultant physician to provide opinion/
     advice/recommendations on patient care, treatment and management to the referring
     physician or nurse practitioner. The consultant physician is required to review all relevant data
     provided by the referring physician or nurse practitioner. Where a service is requested by a
     nurse practitioner, the consultant physician shall provide the report to the nurse practitioner
     and the patient’s primary care provider, if applicable.
 K738 Physician to physician e-consultation – Referring physician ..                  16.45
 K739 Physician to physician e-consultation – Consultant physician                    20.50
     Payment rules:
     1.K738 and K739 are each limited to a maximum of one (1) service per patient per day.
     2.K738 and K739 are each limited to a maximum of six (6) services per patient, any physician,
       per 12 month period.
     3.K738 and K739 are each limited to a maximum of four hundred (400) services per physician,
       per 12 month period.
     4.This service is not eligible for payment to the referring or consultant physicians in the
       following circumstances:
         a.when the purpose of the electronic communication is to arrange for transfer of the
           patient’s care to any physician;

PDF page 177 / A49

CONSULTATIONS AND VISITS
 FAMILY PRACTICE & PRACTICE IN GENERAL (00)
          b.when rendered in whole or in part to arrange for a consultation, assessment, visit, or K-
            prefix time-based services, procedure(s), or diagnostic investigation(s);
          c.when rendered primarily to discuss results of diagnostic investigation(s); or
          d.when a consultant physician renders a consultation, assessment, visit, or K-prefix time-
            based service, on the same day or next day following the physician/nurse practitioner to
            physician e-consultation for the same patient.
      5.In circumstances where a physician receives compensation, other than by fee-for service
        under this Schedule, for participation in the e-consultation, this service is not eligible for
        payment to that physician.
      6.K739 is not eligible for payment to specialists in Dermatology(02) or Ophthalmology(23).
      7.K738 is eligible for payment to the primary care physician when this physician is required to
        collect additional data (for example dermatology or ophthalmology images not present in the
        primary care physician’s records) to support a specialist’s initial, repeat, follow-up or minor e-
        assessment (see page GP37). K738 is not eligible for payment where existing data is already
        available in the primary care physician’s records for submission to the specialist.
      Medical record requirements:
      Physician/nurse practitioner to physician e-consultation is only eligible for payment if all of the
      following elements are included in the medical record of the patient for a physician who submits
      a claim for the service:
          1.patient’s name and health number;
          2.name of the referring physician or nurse practitioner and consultant physicians;
          3.reason for the consultation; and
          4.the opinion and recommendations of the consultant physician.

Master, record 3051. Record Layout PDF, page 1.

K73820260401999999990000016450000000000000000000000000000000000000000000000

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.