In British Columbia, the most common types of visits are basic office, counselling, and complete physical examinations. In this blog, we will break down how to correctly bill each of these types of visits to make sure you get paid for the care you are providing.
Basic Office Visits
Th basic office visit is the most common type of visit. It is billed for evaluating a patient’s medical condition through a history examination and a focused physical examination (if required).
Some examples include:
- Chest pain
- Abdominal pain
The basic office visit can be conducted in-person as well as through telehealth.
Basic In-Office Fee Codes (0100 series)
In-person basic office visits are billed using the age differential 0100 codes shown below.
|12100||Visit – in office (age 0-1)||$34.79|
|00100||Visit – in office (age 2-49)||$31.62|
|15300||Visit – in office (age 50-59)||$34.79|
|16100||Visit – in office (age 60-69)||$36.36|
|17100||Visit – in office (age 70-79)||$41.10|
|18100||Visit – in office (age 80+)||$47.44|
Note: The 0100 basic visit fee codes are subject to the daily volume payment rules which we will discuss later in this blog.
Telemedicine Office Fee Codes (13X37 series)
Telemedicine office visits that are performed via phone or video are billed using the age differential 13×37 codes shown below. A family physician can bill a telemedicine office visit even if they are working from home.
|T13237||Telehealth FP Visit (age 0-1)||$34.79|
|T13437||Telehealth FP Visit (age 2-49)||$31.62|
|T13537||Telehealth FP Visit (age 50-59)||$34.79|
|T13637||Telehealth FP Visit (age 60-69)||$41.10|
|T13837||Telehealth FP Visit (age 80+)||$47.44|
Payment Rules for Basic Office Visit
Family physicians may only bill the basic office visit once per patient per visit per day. This means that even if several medical conditions are addressed during one visit, you may only bill the basic office visit once. Most of the time, a patient only comes to see their doctors once on any given day. However, if a patient comes twice on the same day, there are some circumstances where you can bill two fee codes for the same patient on the same day.
Let’s look at a few scenarios:
- Patient comes in a second time with unrelated conditions to the first visit.
If the patient’s first visit is a cold and the same patient comes in for a second time later in the day with a broken arm, you can bill the basic office visit twice. Please note, if you submit a duplicate billing claim for a second office visit with the same patient on the same day, you are required to use submission code D for the second office visit. For each of your billing claims, include the time of visit, and a short claim note to explain the reason for each visit.
- Patient comes a second time because their condition has worsened and requires a new assessment.
If a patient comes in the morning with a viral upper respiratory tract infection but comes back in the afternoon because they are feeling significantly worse and the physician suspects that the infection has intensified their underlying asthma, you can bill a second visit.
- Patient comes in a second time about the same condition.
If the patient visits in the morning about a urinary tract infection but returns in the afternoon for additional information regarding the infection during their second visit, you may not bill for another basic office visit. Their condition has not worsened and does not require a new assessment; thus, it does not count as a second basic office visit.
Counselling is defined as the discussion about a medical condition which is recognized as difficult by the medical profession or over which the patient is having significant emotional distress.
Some examples include:
- A psychiatric diagnosis such as anxiety or depression where your patient is not coping, making it difficult for them to function, affecting their work, relationships, sleep, mood, or energy.
- A life changing diagnosis such as cancer or type 1 diabetes in a child, where you must take the time to help the patient understand, accept, and cope with the implications and emotional problems related to their difficult diagnosis.
- A significant grief reaction over the loss of a loved one or a miscarriage.
In-Person Counselling Fee Codes (0120 series)
The in-person counselling visits are billed using the age differential 0120 codes shown below.
|12120||Individual counselling – in office (age 0-1)||$62.05|
|00120||Individual counselling – in office (age 2-49)||$56.41|
|15320||Individual counselling – in office (age 50-59)||$62.05|
|16120||Individual counselling – in office (age 60-69)||$64.86|
|17120||Individual counselling – in office (age 70-79)||$73.32|
|18120||Individual counselling – in office (age 80+)||$84.60|
Note: The 0120 basic visit fee codes are subject to the daily volume payment rules which we will discuss later in this blog.
Counselling Telemedicine Fee Codes
Telemedicine counselling visits that are performed via phone or video are billed using the age differential 13×38 codes shown below.
|T13238||Telehealth FP Individual Counselling for a prolonged visit for counselling (age 0-1)||$62.05|
|T13438||Telehealth FP Individual Counselling for a prolonged visit for counselling (age 2-49)||$56.41|
|T13538||Telehealth FP Individual Counselling for a prolonged visit for counselling (age 50-59)||$62.05|
|T13638||Telehealth FP Individual Counselling for a prolonged visit for counselling (age 60-69)||$64.86|
|T13738||Telehealth FP Individual Counselling for a prolonged visit for counselling (age 70-79)||$73.32|
|T13838||Telehealth FP Individual Counselling for a prolonged visit for counselling (age 80+)||$84.60|
Payment Rules for Counselling Visits
Counselling visits require the two following criteria:
- The patient is experiencing emotional distress OR receiving a difficult medical diagnosis.
- The visit was a minimum of 20 minutes.
Note: You may not bill counselling for persuading patients to change their lifestyle habits or explaining diagnostic tests. You also may not bill counselling just because your visit with the patient took longer than 20 minutes.
The following documentation in the progress note is required:
- The patient’s emotional distress.
- The effects the condition is having on the patient.
- The advice you gave to the patient.
- Document the start and end time of the visit in two places:
- In your billing submission to MSP.
- In your progress note.
Complete Physical Examination
A complete physical examination is a detailed physical examination of all body parts and systems with special attention to local examination where clinically indicated. The examination can only be conducted through in-office visits.
Complete Physical Examinations In-Office (0101 series)
The in-person counselling visits are billed using the age differential 0101 codes shown below.
|12101||Complete examination – in office (age 0-1)||$76.83|
|00101||Complete examination – in office (age 2 –49)||$69.95|
|15301||Complete examination – in office (age 50-59)||$76.83|
|16101||Complete examination – in office (age 60-69)||$80.32|
|17101||Complete examination – in office (age 70-79)||$90.80|
|18101||Complete examination – in office (age 80+)||$104.79|
Note: The 0101 basic visit fee codes are subject to the daily volume payment rules which we will discuss later in this blog.
Payment Rules for Complete Physical Examinations
Complete physical examinations require the following criteria:
- Babies 6, 12, 18-month growth and development checks.
- Red flag symptoms – unexplained weight loss, night sweats, and fever where an examination of all body parts and systems may help identify a source of infection or malignancy.
- Chronic medical conditions – patients who would benefit from a full exam to screen for complication or new co-morbidities (ex. in uncontrolled diabetes or frailty).
You cannot bill the physical examination for anyone two years of age and older as a routine annual checkup. When doing an adult female patient’s complete physical examination, include a pap test when it is due. The pap test cannot be billed separately as it is included in the complete physical examination billing code.
Documentation required in the progress note:
- Patient’s current complaints
- Past medical history
- Family history
- Functional inquiry
- Examination findings
- Treatment plan
Daily Volume Payment Rules
The Ministry has implemented daily volume payment rules for the individual physician’s office visits, office counselling, and office complete examinations. For example, if the family physician has a range of 0 to 50 visits of any of the in-person visits (basic office, counselling, or complete physical examinations) on a given day, the physicians will be paid 100% of his or her daily billings to MSP. If the physician’s visits fall within the 51 to 65 range of visits on any given day, they will be paid at 50% of the usual billing value. If physicians go beyond the limit of 66 visits, they will not be paid by MSP.
|Daily Ranges (for an individual practitioner for any single day)||Discounted Rate||Payment Rate|
|0 to 50||0%||100%|
|51 to 65||50%||50%|
|66 and greater||100%||0%|
- The daily volume payment rules only apply to in-office visits. Telehealth fees are not included.
- 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 WCB.
We have created a Quick Reference Guide of all the visit fee codes, you can download it here.
Need help with billing your visits? We can help!