NUMERIC INDEX CHAPTER 1: GENERAL MEDICARE INFORMATION...

Transcription

1 B March 3, 2015

2 TABLE OF CONTENTS NUMERIC INDEX CHAPTER 1: GENERAL MEDICARE INFORMATION Section 1: Conditions of Participation Definition of a Practitioner Participating Practitioner Procedure to become a non-participating practitioner Opted Out Practitioners Conditions Regarding Submission and Payment of Claims Opted-in practitioners Information to patients regarding opted-out status Participating Physician s Agreement Claims Submission and Payment Procedure *Required Information Electronically Submitted Claims *Required Information Paper Claims Submitted Time Limit for Submission of Claims Submission of Claim Form Submission of claims opted-out services Residents of other countries Residents of other provinces Non-resident claim form Services Excluded Under the *Interprovincial Agreements for Processing Payment of Claims Payment to practitioners Adjustment to claims Patient identification Procedure if patient is not registered Prior Approval Section 2: Appeal Procedures Appeals by Physician Appeals by beneficiaries Section 3: Excluded Services Section 4: Supplies and Materials Included Excluded Section 5: Patient Eligibility and Registration Section 6: Forms Section 7: Practitioner Audit General Information Records standards Interval On-site Visits Verification Letters Findings Professional Review Committee... 43

3 CHAPTER 2: ASSESSMENT RULES Section 1: Basis of Payment Assessment Rules General Assessment Rules Details CHAPTER 3: GENERAL PREAMBLE Section 1: Introduction Principles of Billing Terms and Definitions Specialist Visit Examination Consultations Obstetrical Services Paediatric services Surgical services Referred and transferred patients Anaesthetic Services Independent Consideration New Services *Iatrogenic Injuries Detention Fees Laboratory Services Disputed Fees Revision of Schedule Unit Values Sessional Rates Legend Abbreviations CHAPTER 4: ITEMS COMMON TO ALL PRACTITIONERS Section 1: Uninsured Services Industrial and public health medicine or other services at the request of a public body Blood alcohol samples and documentation at the request of the Department of Public Safety Visit and Examination Blood samples and documentation Detention Section 2: Miscellaneous Services Nursing Homes Emergency Visits Visits to hospital emergency or outpatient departments Detention Fee Surgical Assistance fee Role Explaining the need for a second assistant Collaborating Surgery Role Concurrent Care... 69

4 2.7.1 Directive Care Continuing Care Supportive Care Transfer of Care Sessional fees Special Care Units Miscellaneous Services Total Parenteral Nutrition (hyperalimentation) *After Hours Emergency Premium Information Table Re: Claiming IC / Cancer / Emergency Premium Service Codes Eligibile for AHEP Under Conscious Sedation Cancer Premium *Surgical Obesity Premium Miscellaneous Visit Fees Extramural Program Counseling Home Visits Extended care/restorative care Reassessment for Chemotherapy Initial Management of multiple systems trauma Attendance During Transport Attendance Fees Victims of Alleged Sexual Assault Organ Donor Maintenance Fee Injections Immunizations Surgical Prioritization Tool Completion Telemedicine *Rural Health Care *Travel Stipend New Brunswick Medicare On-Call Programs Mandated On Call / Second Call Program *Mandated On-Call Rotations CHAPTER 5: SPECIALITIES Section 1: General Practice Consultations Office Visits Hospital Care Initial management of multiple systems trauma Home Visits Visit to vessel Post-mortem examination Obstetrical care Newborn Care Psychotherapy Anaesthesia fees *Telemedicine Section 2: Services in Anaesthesia Anaesthetic Services Preamble

5 2.2 Modifying Units Special Procedures Consultations and Visits Hospital Care Intensive Care Section 3: Specialists in Cardiac Surgery Consultations Hospital Care Directive Care Other Visit Fees Section 4: Specialists in Dermatology Consultations Office Visits Hospital Care Home Visits MOHS Micrographic Surgery Section 5: Specialists in General Surgery Consultations Office Visits Hospital Care Home Visits Initial Management of Multiple Systems Trauma Section 6: Specialists in Internal Medicine Consultations Office Visits Hospital Care Home Visits Intensive Care Pacemaker Section 7: Specialists in Laboratory Medicine Miscellaneous Section 8: Specialists in Neurology Consultations Office Visits Hospital Care Home Visits Intensive Care Special Procedures *Botulinium Oculin Toxin Injection Section 9: Specialists in Neurosurgery Consultations Office Visits Hospital Care Intensive Care Section 10: Specialists in Obstetrics and Gynaecology Consultations Office Visits

6 10.3 Home Visits Obstetrical Care *Gynecology Procedures Add-on fee Section 11: Specialists in Ophthalmology Consultations Other Referrals Office Visits Procedures Hospital Care Home Visits Visual Fields Computerized Visual Fields Ultrasound - Eye Contact Lens Fitting Heidelbert Retinal Tomography (HRT) Section 12: Specialists in Orthopaedic Surgery Consultations Office Visits Hospital Care Home Visits Section 13: Specialists in Otolaryngology Consultations Office Visits Hospital Care Home Visits Intra Lympanic Injection of Medication Special Examination Electronystagmography Tonsillectomy +/- adenoidectomy *Botoulinium Oculin Toxin Injection Section 14: Specialists in Paediatrics Consultations Office Visits Injections Hospital Care Premature Care Home Visit IntensiveCare Special Procedures Section 15: Specialists in Physical Medicine and Rehabilitation Consultations Office Visits Hospital Care Home Visits Special Procedures *Botulinium Oculin Toxin Injection Section 16: Specialists in Plastic Surgery Consultations

7 16.2 Office Visits Hospital Care Home Visits Team Procedures Major Complex Reconstruction Surgery Section 17: Specialists in Psychiatry Consultations Office Visits Hospital Care Home Visits Other Procedures Section 18: Specialists in Respirology Consultations Office Visits Hospital Care Directive Care Other Visit Fees Section 19: Specialists in Rheumatology Consultations Office Visits Hospital Care Directive Care Other Visit Fees Section 20: Specialists in Urology Consultations Office Visits Hospital Care Home Visits Scaral Afferent Nerve Stimulation CHAPTER 6: SURGICAL PROCEDURES Section 1: Preamble CHAPTER 7: INTEGUMENTARY SYSTEM Section 1: Skin and Subcutaneous Tissue Incision Skin Lesions Tendons, Tendon Sheaths, Fascia Operations on the Breast CHAPTER 8: MUSCULOSKELETAL SYSTEM Section 1: Preamble Section 2: Classification Section 3: Casts and Splints Section 4: Bones Section 5: Joints Section 6: Tendons, Fascia, Ligaments Section 7: Bursae

8 Section 8: Muscles Section 9: *Botulinium Oculin Toxin Injection Section 10: Amputations CHAPTER 9: RESPIRATORY SYSTEM Section 1: Nose Section 2: Nose Accessory Sinuses Section 3: Larynx Section 4: Trachea and Bronchi Section 5: Chest Wall and Mediastinum Section 6: Lungs and Pleura CHAPTER 10: CARDIOVASCULAR SYSTEM Section 1: Veins Section 2: Arteries Section 3: Heart and Pericardium Preamble - Catheterization Diagnostic Procedures Electrophysiology and Pacemakers Therapeutic Procedures Section 4: Cardiac Surgery General Incision and/or Excision Repair Valves CHAPTER 11: HAEMIC AND LYMPHATIC SYSTEMS Section 1: Spleen and Marrow Section 2: Lymph Channels CHAPTER 12: DIGESTIVE SYSTEM Section 1: Mouth Section 2: Lips Section 3: Tongue Section 4: Teeth and Gums Section 5: Palate and Uvula Section 6: Salivary Glands and Ducts Section 7: Pharynx, Adenoids and Tonsils Section 8: Oesophagus Section 9: Stomach Section 10: Intestines (Except Rectum) Section 11: Meckel s Diverticumum and the Mesentery Section 12: Appendix Section 13: Rectum

9 Section 14: Anus Section 15: Liver Section 16: Biliary Tract Section 17: Pancreas Section 18: Abdomen, Peritoneum and Omentum CHAPTER 13: ENDOCRINE SYSTEM Section 1: Thyroid Gland Section 2: Parathyroid, Thymus and Adrenal Glands CHAPTER 14: UROLOGICAL PROCEDURES Section 1: Kidney and Perinephrium Section 2: Ureter Section 3: Bladder Section 4: Urethra CHAPTER 15: MALE REPRODUCTIVE SYSTEM Section 1: Penis Section 2: Testes Section 3: Epididymis Section 4: Tunica Vaginalis Section 5: Scrotum Section 6: Vas Deferens Section 7: Spermatic Cord Section 8: Seminal Vesicles Section 9: Prostate Section 10: Endoscopy CHAPTER 16: FEMALE REPRODUCTIVE SYSTEM Section 1: Abortion Section 2: Operative Delivery Section 3: Vulva Section 4: Vagina Section 5: Fallopian Tubes Section 6: Ovary Section 7: Uterus and Cervix Uteri CHAPTER 17: NEUROSURGICAL PROCEDURES Section 1: Preamble Section 2: Peripheral Nerves Section 3: Neurovegetative System Section 4: Diagnostic and Minor Treatment Procedures Section 5: Cranial Trauma

10 Section 6: Spinal Trauma Section 7: Skull Lesions Section 8: Brain Section 9: Vascular Procedures Section 10: Spinal Cord Section 11: Cranial Nerves Section 12: Discs CHAPTER 18: OPERATIONS OF THE EYE Section 1: Surgical Removal of the Eye Section 2: Exenteration of Orbit +/- Skin Graft Section 3: Operations on Extraocular Muscles Section 4: Other Operations on Orbit Section 5: Eyelids Section 6: Nasolacrimal System Section 7: Conjunctiva Section 8: Sclera Section 9: Cornea Section 10: Operations for Glaucoma Section 11: Intraocular Section 12: Cataract Operations Section 13: Other Operations on Anterior Segment Section 14: Retina Section 15: Vitreous CHAPTER 19: OPERATIONS OF THE EAR Section 1: External Ear Section 2: Middle Ear Section 3: Internal Ear CHAPTER 20: PLASTIC SURGICAL PROCEDURE Section 1: Preamble Section 2: Skin Grafts and Tissue Shifts Local Tissue Shifts Flaps from a Distance Head and Neck Reconstruction Section 3 Skin Grafts Tissue Expanders Section 4 Skin Lesions, Superficial Tumors, Etc Section 5 Laser Destruction of Skin Lesions Section 6 Carcinoma Section 7 Wounds Section 8 Burns

11 Section 9 Keloids Section 10 Cheeks Section 11 Nose Section 12 Orbit Section 13 Ears Section 14 Mouth Section 15 Lips Section 16 Palate and Uvula Section 17 Breast Section 18 Trunk Section 19 Genitalia Section 20 Limbs Section 21 Hand Section 22 Microsurgical Repair Section 23 Miscellaneous Section 24 Tattooing Surgery CHAPTER 21: DIAGNOSTIC AND THERAPEUTIC PROCEDURES Section 1 Allergy Section 2 Nerve Blocks, Diagnostic and Therapeutic Section 3 Ultrasound - Heart Section 4 Ultrasound - Carotid Section 5 *Endoscopic Ultrasound Section 6 Ultrasound Obstetrical Section 7 Ultrasound Peripheral Vascular (including Doppler) Section 8 Non-Invasive Vascular Tests (Ultrasound, Duplex Only) Section 9 Venous Cannulation CHAPTER 22: CLINICAL PROCEDURES ASSOCIATED WITH DIAGNOSTIC IMAGING (LIST B) Section 1 Special Procedural Fees CHAPTER 23: (SECTION A) SPECIALISTS IN DIAGNOSTIC RADIOLOGY Section 1 Fee Schedule Interpretation Section 2 Chest and Thoracic Viscera Section 3 Abdomen and Gastrointestinal Tract Section 4 Genitourinary System Section 5 Head and Neck Section 6 Upper Extremity Section 7 Lower Extremity Section 8 Spine and Pelvis Section 9 Miscellaneous

12 Section 10 Special Procedures Interpretation Only Section 11 Cardiac Angiography and angioplasty Section 12 Computerized Tomography Section 13 Ultrasound Section 14 Magnetic Resonance Images Section 15 Clinical and Diagnostic Procedures Liver Biliary System Urinary Other Body Procedures CHAPTER 24: SPECIALISTS IN THERAPEUTIC RADIOLOGY AND NUCLEAR MEDICINE Section 1 Radioisotope Therapy Section 2 Radioisotope Diagnostic Procedures Thyroid Blood Renal Urinary System Gastrointestinal Tract Cardiovascular System Respiratory System Central Nervous System Skeletal System Other Systems CHAPTER 25: SITE CODES