Alberta Health Care Insurance Plan
Number: Med l33 Date: May 15, 2008 Page: 1 of 1
Subject: Schedule of Medical Benefits amendments/Claims for stillborns
Reference: Schedule of Medical Benefits
To: all physicians and hilling staff
Schedule of Medical Benefits amendments
In accordance with the Physician Services Agreement and discussions between the Alberta Medical Association, the regional health authorities and Alberta Health and Wellness, amendments are being made to the Schedule of Medical Benefits (SOMB) effective June 1,2008. Exception: The amendment to health service code 03.04A is retroactive to April 1,2008. Please refer to the attachment for details, where amended text is shown in bold print.
The June 1,2008 SOMB will be posted on the Alberta Health and Well ness website as soon as possible at www.health.alberta.calprofessionalslsomb.html. The Alberta Medical Association website at
www.albertadoctors.org will also contain a link. to the SOMB. Your accredited submitter will receive
details of these changes in order to provide you with required updates.
If you wish to obtain a CD-ROM or hard copy of the revised SOMB from Alberta Health and Wellness, you can fax a request to 780-427-1093. Please include your Practitioner Identifier number (pRAC ID) with your request.
Claims for stillborns
When preparing a claim for examination of a stillborn (health service code 03.7 A), use the same process that applies to regular newborn claims:
• Enter all required data on the Base Claim Segment, but leave the "Service Recipient PHN" field blank. Enter the applicable code in the "Newborn Code" field. The code for a stillborn is STBN. • Attach a Person Data Segment. Enter the mother's name and her Personal Health Number
(PHN), and the birth date and sex of the stillborn.
The stillborn will be registered with Alberta Health and Wellness, but no information will be sent to the mother. Claims for stillborns are not to be submitted with the mother's PHN on the Base Claim
Segment.
Contact: Client Services Branch Approval: Telephone: Local 780-422-1600
Toll free 310-0000 Fax: 780-422-3552
Position: Executive Director Client Services Branch
Schedule of Medical Benefits amendments Page 1 of 5
Schedule of Medical Benefits Amendments
Amendment retroactive to April 1, 2008
03.04A – In the Price List, amend the rate for skill DERM (dermatology) to 40.82.
03.04A billing note: Claims affected by the above amendment will be automatically reassessed to pay the correct amount. The reassessed claims will appear on the Statement of Assessment as soon as possible.
Amendments effective June 1, 2008
General rule amendment
General rule 4.2.6 – Amend to read as shown below. (This rule is redundant as services are defined under health service codes 03.01NG, 03.01NH, 03.01NI, 03.01B, 03.01BA and 03.01BB.)
4.2.6 Deleted
Health service code amendments - Procedure and Price List
01.09 – Amend Note 4 to read as shown below. Also delete VANE modifier L30AT. 01.09 Other nonoperative bronchoscopy
NOTE: 1. No additional benefit for aspiration.
2. May be claimed in addition to HSC 43.96E and 45.88A.
3. For a repeat, during the same hospitalization, benefit will be reduced. Refer to Price List.
4. For patients aged 12 months or younger, the procedural benefit varies. Refer to
Price List; modifier L1.
02.75A – Amend the text and the base rate to read as shown below. Also delete VANE modifier
L30AT.
Schedule of Medical Benefits amendments Page 2 of 5
03.01NI – Amend the notes to read as shown below. (Note 3 is split into Note 3 and 4. Subsequent Notes are renumbered.)
03.01NI Patient care advice to paramedic - pre hospital patch, assisted living/designated assisted living and lodge staff, active treatment facility worker for hospital in-patient, long term care worker for patients in a long term care facility, nurse practitioner or home care worker, any day 2200 to 0700 hours, provided via telephone or other telecommunication methods, in relation to the care and treatment of a patient
NOTE: 1. Active treatment facility worker may include Registered Nurse, Licensed Practical Nurse, Occupational Therapist, Physiotherapist, Speech Language Pathologist, Social Worker, Pharmacist, Psychologist, Recreational Therapist or Respiratory Therapist.
2. Long term care worker may include Registered Nurse, Licensed Practical Nurse, Occupational Therapist, Physiotherapist, Speech Language Pathologist, Social Worker, Pharmacist, Psychologist or Recreational Therapist.
3. Advice to nurse practitioners may only be claimed if the nurse practitioner is in independent practice or working at a nursing station where no
physician is present.
4. In the case of long term care or active treatment facility worker, claims may only be submitted when the physician is outside the facility where the patient is located.
5. May be claimed for advice given to home care worker in person as well as advice by telephone or other telecommunication methods.
6. HSCs 03.01NG, 03.01NH and 03.01NI are to be claimed using the Personal Health Number of the patient.
7. May only be claimed when the call is initiated by the long term care worker, assisted living/designated assisted living or lodge staff member, active treatment facility worker, home care worker, nurse practitioner or paramedic.
8. In the case of a long term care patient the call may be initiated by the physician if it is in response to receipt of diagnostic or other information that would affect the patient's treatment plan.
9. May be claimed in addition to visits or other services provided on the same day, by the same physician.
10. A maximum of two (any combination of HSC 03.01NG, 03.01NH, 03.01NI) claims may be made per patient, per physician, per day.
Schedule of Medical Benefits amendments Page 3 of 5
03.05R – Amend the Notes to read as shown below.
03.05R Special callback to hospital inpatient, Saturday, Sunday, or statutory holiday, (0700-2200 hours)
NOTE: 1. May only be claimed when a special call for attendance is made on the patient's behalf.
2. The physician responds to such a call from outside the hospital, on an unscheduled basis.
3. The patient is attended on a priority basis. 4. There is direct attendance by the physician.
5. Second or subsequent patients seen during the same callback are not eligible for benefits under HSCs 03.05N, 03.05P, 03.05QA, 03.05QB or 03.05R but may be claimed using HSC 03.03AR. Time spent with second and subsequent patients may be claimed using the AFTER HOURS TIME PREMIUM modifier with
HSCs 03.01AA or 03.05BA.
6. May not be claimed in association with any HSC except 03.01AA. Refer to GR 15.8.
13.59M – Add the following modifiers:
TYPE CODE EXPLCT ACTION AMOUNT
BMI BMIANT Y Increase By 25%
ROLE ANEST Y Replace Base 16.00
ANU ANU
1 For Each Call Pay Base At 100%
2-105 For Each Call Increase By 16.00
28.4A – Delete modifier REPT. 28.5A – Delete modifier REPT.
36.99F – Amend the base rate and the rate for CALL modifier 2-20 to read as shown below.
HSC BASE RATE TYPE CODE EXPLCT ACTION AMOUNT CAT
36.99F 122.58 CALL M15
1 For Each Call Pay Base At 100%
2-20 For Each Call Increase by 30.67
Add the following heading before health service code 50.94B:
50.94 Central venous pressure monitoring
71.4A – Add the following Note: 71.4 A Fascia lata sling operation
NOTE: An additional benefit of 50% may be claimed for a repeat by using modifier REPT.
Schedule of Medical Benefits amendments Page 4 of 5
71.7A – Add the following Note: 71.7 A Anterior urethropexy
NOTE: An additional benefit of 50% may be claimed for a repeat by using modifier REPT.
71.8 – Add the following modifier:
TYPE CODE EXPLCT ACTION AMOUNT
BMI BMISRG Y Increase By 25%
82.41A – Add the following Note: 82.41A Repair of cystocele
NOTE: An additional benefit of 50% may be claimed for a repeat by using modifier REPT.
82.42A – Add the following Note: 82.42A Rectocele repair
NOTE: An additional benefit of 50% may be claimed for a repeat by using modifier REPT.
82.69B – Add the following Note: 82.69B Enterocoele repair
NOTE: An additional benefit of 50% may be claimed for a repeat by using modifier REPT.
82.7 A – Add the following Note: 82.7 A Abdominal sacrocolpopexy
NOTE: An additional benefit of 50% may be claimed for a repeat by using modifier REPT.
89.2 – Amend the Note below this heading to read as follows: 89.2 Wedge osteotomy
NOTE: Benefits for HSCs 89.20A to 89.26A include fixation
91.87C – Amend to read as shown below. (This service is per toe.) 91.87C Toe
98.12M – Amend to read as follows:
98.12M Removal of pigmented benign naevus, excluding face
Schedule of Medical Benefits amendments Page 5 of 5
X27E – Amend Note 4 to read as shown below.
X 27E Screening mammography (age 70 years and over)
NOTE: 1. Benefits for X27C, X27D and X27E include patient education. A visit benefit may not be claimed in conjunction with these services by the radiologist performing the screening mammogram or by a different radiologist in conjunction with the same radiological examination.
2. Only one Screen Test or fee-for-service benefit may be claimed every calendar year for X27C or X27D. Only one Screen Test or fee-for-service benefit may be claimed every two calendar years for X27E.
3. X27C and X27E must be referred. Subsequent yearly referrals are not required. X27D does not require a referral.
4. X27C or X27D may not be claimed if an X27 was provided within the same
calendar year. X27E may not be claimed if an X27 was provided within the previous calendar year.
5. Supplementary views, refer to X27F.
6. X27C, X27D and X27E require submission of data to the Alberta Breast Cancer Screening Program through either the Alberta Society of Radiologists or the Alberta Cancer Board.
92.32B, 92.32C and 92.32D – Add the following modifier:
TYPE CODE EXPLCT ACTION AMOUNT
LVP LVP75 Y Reduce Base To 75%
Modifier definition amendments
Amend the text of modifier type LVP and modifier code LVP50 to read as shown below. LVP LESSER VALUE PROCEDURE - (Explicit) - Indicates that the procedure should be
processed at a reduced rate. IF BASE RATE AMOUNTS ARE EQUAL ON THE HSCS
CLAIMED, LVP50 OR LVP75 ARE NOT TO BE USED.
ADD ADDITIONALS - (Explicit) - Indicates that the procedure is paid in addition to a specific procedure at a specified rate.
ADD2 ADDITIONAL SECOND CALL - (Explicit) - Used to replace ADD modifier if two of the same procedures were performed.
LVP50 LESSER VALUE PROCEDURE AT 50% - (Explicit) - Indicates the procedure of lesser value so that the General Rules to pay the second procedure at a reduced rate can be applied.
LVP75 LESSER VALUE PROCEDURE AT 75% - (Explicit) - Indicates the procedure of lesser value.
Health service code amendment - Part D Procedure List - Schedule of Anaesthetic Rates Applicable to Podiatric Surgery
90.07PA – Amend the text to read as follows: 90.07PA Calcaneum
