Claims for unlisted services will be assessed by comparing the service provided and the fee claimed with similar or comparable services listed in the Schedule. The assessment will be based on the time, complexity, and intensity of the services. Supporting information, such as an operative report, is required with the claim.
Unless otherwise specified, services that may be claimed once per year may be claimed 365 days after the previous service date or 366 days in a leap year.
Cumulative time is calculated by adding the total time spent delivering patient care as identified in the description of the HSC, over the course of the day (GR 1.19) and dividing the total time by the time units specified in the HSC to determine the appropriate number of calls. When the remainder of the time calculation equals less than half of one call, an additional call may not be claimed. Separate encounters may only be claimed when a special call for attendance has been made on the patient's behalf.
Where time is described as a full amount of minutes e.g. a full 5 minutes, the physician must spend the full amount of time stated in the HSC in order to submit a claim for the service.
Where time is described as a portion thereof, the physician may spend any amount of time providing the services described by the HSC in order to submit a claim for the service.
Where time is described as a major portion thereof, the physician must spend a minimum of half of the time described in the HSC providing the service in order to submit a claim for the service. Additional calls for the same HSC may not be claimed until the full time period as described in the HSC for each previous call has elapsed.
For example, when billing for one call of a code that is described as "per 15 minutes or major portion thereof" , the minimum amount of time that MUST be spent is 8 minutes. Two calls can only be claimed when a minimum of 23 minutes is spent (15 minutes for the first call and 8 minutes (minimum) for the second call).
When billing time based services, including modifiers, the physician must document the time spent providing time based services for each day of service (as defined in GR 1.19). The record must be available upon request and should be kept in chronological order, for each day. The total time claimed for time based services in a single day cannot exceed the total time spent delivering patient care activities in relation to an insured service. Claims for services that are described as cumulative time, major portion thereof or portion thereof may continue to be submitted in accordance to GR's 2.3.2, 2.3.4 and 2.3.5.
Concurrent billing for overlapping time for separate patient encounters/ services may not be claimed.
G.R. 2.3.7 indicates that a physician may not submit two claims for services for the same time period.
For example, the physician examines the patient for 15 minutes and provides a minor procedure (wart removal 98.12L) at the same visit, the total time spent with the patient is 35 minutes. The physician may submit a claim for the: visit 03.03A + CMGP01 or CMXV15/20 (as appropriate) for the visit portion and the minor procedure 98.12L
Time spent providing the procedure cannot be submitted using complex modifiers when a claim for BOTH the procedure and the visit are submitted.
