Consultations & Assessments
A consultation is an assessment rendered following a written request from a referring physician or nurse practitioner who, in light of his/ her professional knowledge of the patient, requests the opinion of a physician (the “consultant physician”) competent to give advice in this field because of the complexity, seriousness, or obscurity of the case, or because another opinion is requested by the patient or patient’s representative.
A copy of the written request for the consultation, signed by the referring physician or nurse practitioner must be kept in the consulting physician’s medical record, except in the case of a consultation which occurs in a hospital, long-term care institution or multi-specialty clinic where common medical records are maintained. In such cases, the written request may be contained on the common medical record.
- 1. The referring physician or nurse practitioner must determine if multiple requests by a patient or the patient’s representative to different physicians in the same specialty for the same condition are medically necessary. Services that are not medically necessary are uninsured.
- 2. If the physician rendering the service requests a referring physician or nurse practitioner to submit a consultation request for that service after the service has been provided, a consultation is not payable. The visit fee appropriate to the service rendered may be claimed.
- 3. Where a physician who has been paid for a consultation for the patient for the same diagnosis makes a request for a referral for ongoing management of the patient, the service rendered following the referral is not payable as a consultation.
A repeat consultation is an additional consultation rendered by the same consultant, in respect of the same presenting problem, following care rendered to the patient by another physician in the interval following the initial consultation but preceding the repeat consultation. A repeat consultation has the same requirements as a consultation including the requirement for a new written request by the referring physician or nurse practitioner.
A limited consultation is a consultation which is less demanding and, in terms of time, normally requires substantially less of the physician’s time than the full consultation. Otherwise, a limited consultation has the same requirements as a full consultation. Under the heading of “Family Practice & Practice in General”, a limited consultation is the service rendered by any physician who is not a specialist, where the service meets all the requirements for a consultation but, because of the nature of the referral, only those services which constitute a specific assessment are rendered.
A general assessment is a service, rendered at a place other than in a patient’s home that requires a full history (the elements of which must include a history of the presenting complaint, family medical history, past medical history, social history, and a functional inquiry into all body parts and systems), and, except for breast, genital or rectal examination where not medically indicated or refused, an examination of all body parts and systems, and may include a detailed examination of one or more parts or systems.
Any combination of Medical Specific Assessments and Complex Medical Specific Re-assessments (see below) are limited to 4 per patient per physician per 12-month period.
General assessments are limited to one per patient per physician per 12-month period unless either of the following circumstances is met in which case the limit is increased to two per 12- month period:
- • The patient presents a second time with a complaint for which the diagnosis is clearly different and unrelated to the diagnosis made at the time of the first general assessment; or
- • At least 90 days have elapsed since the date of the last general assessment and the second assessment is a hospital admission assessment. The amount payable for general assessments in excess of these limits will be adjusted to a lesser assessment fee.
A general re-assessment includes all the services listed for a general assessment, with the exception of the patient’s history, which need not include all the details already obtained in the original assessment.
Payment rules: With the exception of general re-assessments rendered for hospital admissions, general re-assessments are limited to two per 12-month period, per patient per physician.
Specific Assessment & Medical Specific Assessment
Limited to 1 per 12 months (or 2 for different dx)
Specific assessment and medical specific assessment are services rendered by specialists, in a place other than a patient’s home, and require a full history of the presenting complaint and detailed examination of the affected part(s), region(s), or system(s) needed to make a diagnosis, and/or exclude disease, and/or assess function.
Payment rules: Specific assessments or medical specific assessments are limited to one per patient per physician per 12-month period unless either of the following circumstances are met in which case the limit is increased to two per patient per physician per 12-month period:
- • The patient presents a second time with a complaint for which a clearly different diagnosis is made,
unrelated to the diagnosis made at the time of the first specific assessment in that 12-month
- • In the case of a medical specific assessment, at least 90 days have elapsed since the date of the last specific assessment and the second assessment is a hospital admission assessment. Any
combination of medical specific assessments and complex medical specific re-assessments (see below) are limited to 4 per patient per physician per 12-month period. The amount payable for these services in excess of this limit will be adjusted to a lesser assessment fee.
Specific Re-assessment & Medical Specific Re-assessment
Limited to 2 per 12 months
Specific re-assessment and medical specific re-assessment are services rendered by specialists and require a full, relevant history and physical examination of one or more systems. Admission assessments are deemed to be a specific re-assessment or medical specific reassessment under either of the following circumstances:
- • For those procedures prefixed with a “Z” or noted as an IOP, by a surgical specialist who has assessed
the patient prior to admission in respect of the same illness; or
- • For those patients who have been assessed by a physician and subsequently admitted to the hospital
for the same illness by the same physician.
Complex Medical Specific Re-assessment
Limited to 4 per 12 months
A complex medical specific re-assessment is a re-assessment of a patient because of the complexity, obscurity, or seriousness of the patient’s condition and includes all the requirements of a medical specific re-assessment. The physician must report his/her findings, opinions, or recommendations in writing to the patient’s primary care physician or the amount payable for the service will be adjusted to a lesser assessment fee.
A partial assessment is the limited service that constitutes a history of the presenting complaint, the necessary physical examination, advice to the patient and appropriate record.