Governing Rules:

• 4.1 COMPLETE EXAMINATION - DEFINITION:

  In the context of GR 4, complete physical examination shall include examination of each organ system of the body, except in psychiatry, dermatology and the surgical specialties. "Complete physical examination" shall encompass all those organ systems which customarily and usually are the standard complete examination prevailing within the practice of the respective specialty. What is customary and usual may be judged by peer review.

• 4.3.1

  Comprehensive Consultation: An in-depth evaluation of a patient with a written report to the referring physician, audiologist, Alberta registered midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner. This service includes the recording of a complete history, performing a complete physical examination appropriate to the physician's specialty, an appropriate record and advice to the patient. It may include the ordering of appropriate diagnostic tests and procedures as well as discussion with the patient and/or the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner.

• 4.4.1

  In this Schedule "consultation" means that situation where a physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner after an appropriate examination of the patient, requests the opinion of a consultant physician, and the consultant does a history, an examination and a review of the diagnostic data and provides a written opinion with recommendations as to the treatment, to the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner. Consultations may not be claimed for the transfer of care alone.

• 4.4.2

  The need for a consultation can arise as a result of the following:

  1. some unusual or serious clinical problem,
  2. a physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner requires further advice regarding diagnosis or management or both, or
  3. the patient, parent or guardian requests another opinion.
• 4.4.3

  A referral may be accepted from any person; however, to receive reimbursement as a consultation, a request must be made by the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner to the consultant in the form of:

  1. verbal or written communication (fax, email, letter);
  2. verbal or written communication between an agent representing the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner and the consultant;
  3. verbal or written communication between the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner and an agent representing the consultant;
  4. verbal or written communication between agents representing the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner and the consultant.

  Agent means any of the following individuals who are acting under the direction of the referring physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner and the consultant, as appropriate:

  1. an employee of a physician, audiologist, midwife, chiropractor, podiatrist, dentist, optometrist, physical therapist or nurse practitioner; or
  2. a hospital or long term care facility staff member; or
  3. a supervised physician in training acting under the direction of a physician.

  Payment for a consultation to an Alberta physician may also be made when an Out of Province physician refers the patient and the criteria stated herein are met.

• 4.4.4

  If a consultation is followed by a procedure performed by the consultant, a benefit may be claimed for the consultation as well as a major procedure up to and including the day of surgery.

• 4.4.7

  When a physician sends a member of his family to another physician, a consultation benefit may not be claimed.

• 4.6.1

  Comprehensive visits and/or comprehensive/major consultations may only be claimed once every 365 days per patient by the same physician. Comprehensive visit and consultation services are defined as HSCs 03.04A, 03.04AZ, 03.08A, 03.08AZ, 03.08B, 03.08BZ, 03.08C, 03.08CV, 03.08F, 03.08H, 03.08K, 08.11A, 08.11C, 08.19A, 08.19AZ, 08.19AA, and 08.19CX.

  HSC 03.09B is defined as comprehensive and may not be billed more frequently than once every 180 days by the same physician.

  HSCs 03.04O and 03.04P are defined as comprehensive services and may not be billed more frequently than four times per year as indicated or within 180 days of a comprehensive service or consultation by the same physician.

• 15.9

  The unscheduled service benefit (modifier SURC) may be claimed for the services outlined in GRs 15.9.1 through 15.9.3.

• 15.9.1

  selected "V" category code services:

  1. consultations, including telehealth (except those provided using store and forward videotechnology);
  2. intensive care unit visits (HSC 03.05A);
  3. psychiatric mental status determination requiring complete mental health status examination and investigation (HSC 08.11A);
  4. for complex patient, requiring complete mental status examination and investigation (HSC 08.11C);
  5. certification under the Mental Health Act (HSC 08.12A);
  6. trauma assessment, multiple trauma, severely injured patient (HSC 13.99GA);
  7. hyperbaric oxygen therapy detention time (HSC 13.99I);
  8. medical emergency detention (HSC 13.99J);
  9. management of complex labor, per 15 minutes (HSC 13.99JA);
  10. donor maintenance prior to cadaveric harvesting of organs (HSC 13.99L);
  11. examination and crisis counseling for sexual/physical abuse (HSC 13.99V);
  12. attendance at delivery (HSC 87.98E).