Items 12101, 00101, 15301, 16101, 17101 and 18101 are subject to the daily volume payment rules described earlier in this section.
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).
IN-OFFICE FEE ITEMS: 12110, 00110, 15310, 16110, 17110, 18110, 12100, 00100, 15300, 16100, 17100, 18100, 12101, 00101, 15301, 16101, 17101, 18101, 12120, 00120, 15320,16120, 17120, and 18120 apply to consultation, visit, complete examination and counselling services provided in offices, clinics, outpatient areas of hospitals, diagnostic treatment centers and similar locations.
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.
Daily Volume Payment Rules Applying to Designated Office Codes
(i) The codes to which these rules apply are as follows:
Office visits: 12100, 00100, 15300, 16100, 17100, 18100
Office counselling: 12120, 00120, 15320, 16120, 17120, 18120
Office complete examinations: 12101, 00101, 15301, 16101, 17101, 18101
(ii) The total of all billings under the codes listed in i) that are accepted for payment by MSP will be calculated for each practitioner for each calendar day. When such a daily total exceeds 50 the practitioner’s payment on these codes for that day will be discounted. Moreover, when a daily total exceeds 65, a further payment discount will be made.
“0-50 daily claims = 100% payout, 51-65 daily claims = 50% payout, 66 and great claims = 0% payout.”
(iii) Payment discounts will not be applied to services rendered in communities that are/were receiving NIA premiums as of December 15, 2002.
(iv) Payment discounts will not be applied to services designated by the physician as being the responsibility of ICBC, (designate by checking the MVA indicator on the claim), or services that are the responsibility of Worksafe BC.
(v) Services will be assessed and payment/discounts will be applied to services in the order in which they are received and accepted for payment by MSP.
Please reference the billing pre-amble for these relevant interpretations of this billing code:See Pre-Amble Notes