The Alberta Medical Association has highlighted ten key changes to the Schedule of Medical Benefits that were rolled out across the province this year:
1. BCP payments will be limited and the rates will be equalized across the province.
• BCP payments will pay a maximum of 50 units per day per physician regardless
of how many eligible claims are submitted from any location in a given day.
• BCP payments will be equalized so that there is one rate payable for the entire
province. Currently Airdrie, DeWinton and Calgary receive a higher rate than
anywhere else in the province. The rate for these areas will be reduced to the
lower rate.
2. Limits on the team and family conference codes
• 03.05JB
o Will no longer be billable in addition to a visit at the same encounter
o Will only be billable to a maximum of 3 hours (12 calls) per patient, per
physician, per year.
• 03.05JA and 03.05JC
o Will only be billable to a maximum of 3 hours (12 calls) per patient, per
physician, per year.
• 08.19K
o Will only be billable to a maximum of 2 calls (30 minutes) per patient,
per physician, per week.
3. Pre Op’s for cataract procedures are no longer payable:
• The pre op for cataract procedures performed under local and or topical
anesthetic is still required but will have to be completed by the operating
surgeon. The only time the pre op medical (03.04M) will be paid in relation to
cataract procedures, is if the patient is having their cataract performed under a
general anesthetic. In those rare cases that require a general anesthetic, the
operating surgeon will have to communicate the unique situation to the
physician completing the pre op medical so that the information can be included
in the text on the claim for the 03.04M pre op medical. If text is not submitted on
the 03.04M for cataracts requiring a general anesthetic, the 03.04M will not be
paid.
4. Transfer of Care is not billable as a consult
• When transferring care of a patient to another physician either a visit code or a
transfer of care code (for those specialties that have transfer of care codes) may
be claimed. Claims for 03.08A where the service is for a transfer of care are not
permitted.
5. Changes to Medical emergency detention time, Resuscitation, MET team
• 13.99J
o A maximum has been placed on the code
o In the physician’s office, a maximum of 8 calls or 2 hours may be
claimed per day, per physician.
o In any other location, a maximum of 16 calls or 4 hours may be
claimed per physician per day.
• 13.99E and 13.99EB
o Both of these codes are now billed in 15 minute units. See Governing
Rule 2.3.5 for more information on submitting claims for services that are
described as “major portion thereof”.
6. Second Qualified Surgeon (SAQS) and Active Practice
• The SAQS modifier may be claimed when all of the criteria are met:
o The complexities of a particular case require the specific skills of a second
qualified surgeon assisting AND
o The physician is considered to be in Active Practice (GR 1.31) meaning
that they have acted as the primary surgeon for at least 5 procedures in
the previous 12 months (and submitted claims as such) AND they have
provided at least 10 or more of any of the following: 03.03A, 03.07A,
03.07B or 03.08A.
7. Physician to Physician phone calls for consulting physicians
• In order to be paid for physician to physician phone calls 03.01LJ, 03.01LK,
03.01LL) you MUST enter in the referring physicians PRACID into the referring
provider field. Claims submitted without a referring PRACID will not pay. This
is meant to bring submissions for phone consultations in line with the process for
billing all other consultations.
8. Bone Mineral Densitometry and Inguinal Hernia ultrasounds
• BMD X128 ORDERING PHYSICIANS
o A BMD may only be ordered for patients 50 years of age or older
UNLESS the request for the exam is made by endocrinology,
Gastroenterology, General Surgery, Internal Medicine, Nephrology,
Orthopedics, Pediatrics (including sub specialties), Physical Medicine or
Rheumatology.
o BMD’s may only be performed once every two years, UNLESS the patient
has a condition, medication regime or illness that requires more frequent
BMDs. In those rare instances, please include this extra information in
the request for the exam. Please see the Fee Navigator for more
information.
• INGUINAL HERNIA ULTRASOUNDS
o May only be ordered when the request for the exam is made by a
Urologist or a General Surgeon. In the case of pediatric patients, the
request may be made by a General Practitioner, Pediatrician, Urologist or
Pediatric General Surgeon.
9. BMI Change to 40
• This change was made January 1, 2017. In order to submit a BMI claim for a
patient, the patients BMI must be 40 or greater.
10. Comprehensive visits limited to once every 365 days and pap code changes
• HSCs 03.04A, 03.08A, 03.08B, 03.08C, 03.08F, 03.08H, 03.08K, 08.11A, 08.11C,
08.19A and 08.19AA – may only be claimed once every 365 days, per patient per
physician. AH has programmed a length of 345 days between services to
accommodate for scheduling. If you claimed a 03.04A last June (2016) you may
not claim another 03.04A (or other comprehensive) for another 365 days (keep in
mind 345 day allowances).
• 13.99BC pap smear/speculum exam code was DELETED January 1, 2016 and
replaced with 13.99BA. The speculum exam code is 13.99BE
o Pap smear code has been amended to be consistent with the TOP
guidelines for pap screening. Patients aged 21-69 are eligible for paps,
once per year. For those instances where age requirements are not met or
more frequent paps are required, text on the claim describing the
patient’s condition must be submitted.
This article offers general information only and is not intended as legal, financial or other professional advice. A professional advisor should be consulted regarding your specific situation. While information presented is believed to be factual and current, its accuracy is not guaranteed and it should not be regarded as a complete analysis of the subjects discussed. All expressions of opinion reflect the judgment of the author(s) as of the date of publication and are subject to change. No endorsement of any third parties or their advice, opinions, information, products or services is expressly given or implied by RBC Ventures Inc. or its affiliates.
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