Personal Care Home Visits

You should be certain to claim the appropriate tariff(s) for visits to Personal Care Home (PCH) patients. Here are some tips for specific instances to help ensure your claims are processed without any hassle.

Visits during routine attendance at a PCH

According to Rule of Application16 in the Physician’s Manual, visits for routine attendances at PCHs are paid as follows:

  1. Benefits listed under Tariff 8511 (Chronic Care) in the General Schedule shall apply for a routine visit to a chronic care patient in such an institution to examine, assess or evaluate the patient’s condition, and give advice as necessary to the patient and/or the nursing staff concerning management of the patient.
  2. A visit to a patient with an “acute illness”, which occurs during the physician’s routine attendance at the institution, shall be paid as an office visit appropriate to each bloc of practice.

Therefore, there are two types of visits which can occur during your routine attendance at a PCH:

Routine visit

A “routine” visit, which occurs during your routine attendance at a PCH, should be claimed under tariff 8511, Chronic Care.

Bear in mind that tariff 8511 is a visit fee (and not a daily care fee) and, therefore, you are required to personally attend to the patient and make the appropriate notation on the patient chart to evidence the interaction between you and the patient.

Visit to patient with an “acute illness”

A visit to assess a patient with an “acute illness”, which occurs during your routine attendance at a PCH, should be claimed under the appropriate office visit tariff. Which tariff is appropriate (e.g., tariff 8513, Regional or Subsequent Visit – patients aged 70 years and over, tariff 8500, Complete History and Physical Examination – patients age 70 years and over, etc.) will depend upon the nature of the service provided by you.

The Manual defines an “acute illness” as:

an illness of such a nature that the physician would likely have been requested to make a special trip to visit the patient, were the physician not scheduled for a routine attendance at the institution on the day the illness arises

However, an illness which is chronic, or which has previously been diagnosed by the physician but is not in an acute phase at the time of the visit, does not qualify as an “acute illness”.

The Manual stipulates that a claim for a visit to assess a patient for an acute illness, which occurs during a physician’s routine attendance at a PCH, must include the words “acute illness” as well as a brief description of the illness.

Visits During a Special Trip to a PCH

When you are required to make a special trip to a PCH home to visit a patient, the appropriate office visit fee, as well as a special call fee, should be claimed. (Where appropriate, an after-hours premium may also be claimed.)

If, during a single special trip, you see more than one patient, you are only permitted to claim a special call fee in relation to the first patient seen; you cannot claim an additional special call fee in relation to the second or subsequent patients seen during that single attendance.

If, during a single special trip to a PCH, you see only one patient, your claim for the appropriate visit fee/special call/after-hours premium does not have to include any remarks.

On rare occasions, when you are required to make a special trip to a PCH, you may attend upon more than one acutely ill patient during that single special trip. Although you are entitled to submit a claim for the appropriate visit fee with respect to each patient seen, as noted above, you are not permitted to claim a special call fee in relation to the 2nd and subsequent patients seen.

Therefore, when Manitoba Health receives a claim for a visit fee in relation to these 2nd and subsequent patients, the claim will not be accompanied by a special call claim. Accordingly, Manitoba Health will have no way of determining whether your attendance upon this patient was a routine visit during the course of your regular rounds of the PCH, or whether it related to a special trip to see an acutely ill patient. Due to this lack of clarity, your claim for a visit fee may be downgraded by Manitoba Health to tariff 8511.

In order to avoid your claim being downgraded, it is recommended that your claims regarding the 2nd and subsequent patients seen during a single special trip to a personal care home include the words “acute illness” as well as a brief description of the illness.

Billing Note:

No visit fee (either under tariff 8511 or under an office visit tariff) should be claimed when your attendance at a PCH is solely for the purpose of performing a Quarterly Medical Review (i.e., where you do not visit with the patient(s).  For Quarterly Medical Reviews, physicians are remunerated on the basis of the hourly rates set out in the Sessional Rates Agreement between Manitoba Health and Doctors Manitoba.

Questions?

Roger Jamieson
rjamieson@docsmb.org
(204) 985-5849

 

Updated: November 2016