The following definitions must be adhered to when preparing MSP billings for consultation, complete examination, office visit and individual counselling services (both in and out-of-office listing).
OUT-OF-OFFICE FEE ITEMS: 12210, 13210, 15210, 16210, 17210, 18210, 12200, 13200, 15200, 16200, 17200, 18200, 12201, 13201, 15201, 16201, 17201, 18201, 12220, 13220, 15220, 16220, 17220, and 18220 apply to consultation, visit, complete examination and counselling services provided in either a patient’s home, at the scene of an illness or accident, in a hospital in-patient area, palliative care facility, long term care institution or in a hospital emergency department, unless the circumstance of the service is specifically covered by the definition of either fee item 00103, 00108, 00109, 00127, 00128, 13028, 00111, 00112, 00114, 00115, 00113, 00105, 00123, 13228 or one of the 01800 series.
For any condition seen requiring a complete physical examination and detailed history (to include tonometry and biomicroscopy when performed).
i) A complete physical examination shall include a complete detailed history and detailed physical examination of all parts and systems with special attention to local examination where clinically indicated, adequate recording of findings and if necessary, discussion with patient. The above should include complaints, history of present and past illness, family history, personal history, functional inquiry, physical examination, differential diagnosis, and provisional diagnosis.
ii) Routine or periodic physical examination (check-up) is not a benefit under MSP. This includes any associated diagnostic or laboratory procedures unless significant pathology is found. Advise laboratory of patient’s responsibility for payment.
iii) Complete examination fee codes are not to be charged for in-hospital admission examinations. Fee code 00109 may apply in this circumstance. See Preamble and listing restrictions.
Please reference the billing pre-amble for these relevant interpretations of this billing code:See Pre-Amble Notes