Complete Examinations by General Practitioners
What is a Complete Examination?
The Physician’s Manual, in rule of Application 4, states:
A Complete History and Physical Examination is a service that will vary from specialty to specialty. In the case of regional specialties, the service may comprise only a full history of the presenting complaint, inquiry concerning and detailed examination of the affected part, region or system, as needed to make a diagnosis, exclude disease and/or assess function, a complete record and advice to the patient. In the case of general practitioners, the service is defined with Tariff 8540.
Tariff 8540 defines a Complete History and Physical Examination as follows:
Complete History and Physical Examination is a service provided to a patient, which will usually comprise of:
- A full patient history;
- An inquiry into and an examination of all relevant parts or systems required to make a diagnosis or differential diagnosis;
- A review of results of investigations ordered by the physician;
- A complete written or electronic record; and
- Advice to the patient during the visit, and/or later by telephone, if appropriate
- Where medically indicated, a return visit to advise the patient may be claims. Abnormal test results generally require a follow-up visit.
How often may a Complete Examination under Tariff 8540 be claimed?
To claim for a Tariff 8540:
- A complete examination must have been medically required, and
- The examination must comply with the foregoing criteria set out in the Physician’s Manual.
Suppose you perform more than one complete examination on the same patient. In that case, the Physician’s Manual contains one restriction as to how often you may submit a claim for a Complete History and Physical Examination. Rule of Application 6 states:
“A Subsequent Visit is one that follows either a complete or regional history and examination by the same physician, for the same condition within a period of sixty days; i.e., if the patient has been seen by the same doctor within any sixty day period for the same condition, only a subsequent visit may be claimed for any visit following the initial visit. However, in the case of certain illnesses, for example the continuing management of a chronic illness, when the physician deems it necessary to do a more extensive examination such as a complete physical examination or a regional or a reassessment within the sixty day period, a claim for such a visit may be allowed but only by Special Report.”
Consequently, by performing a complete examination of a patient, and then, within 60 days, another complete examination is performed of the same patient for the same condition, the second complete examination should be claimed as a Subsequent Visit, and not as a Complete History and Physical Examination. (The exception to this restriction is that you may claim a Complete History and Physical Examination for the second visit by Special Report if you are managing the patient for a chronic illness.
Other than this one restriction set out in Rule of Application 6, there are no restrictions on how often you may submit a claim for a Complete History and Physical Examination for services provided to the same patient.
- If you perform a complete examination of a patient, and, within 60 days, you perform another complete examination of the same patient for a different condition, the second complete examination may be claimed as a Complete History and Physical Examination.
- If you perform a complete examination of a patient, and, outside of a period of 60 days, you perform another complete examination of the same patient for the same condition or a different condition, the second complete examination may be claimed as a Complete History and Physical Examination.
For internal monitoring purposes, Manitoba Health may automatically reject/downgrade multiple claims for complete examinations on the same patient that occur within a set time frame (e.g., 60 days, one year, etc.). As such, it is essential that you carefully review your remittance statements to determine if any of your claims have been rejected/downgraded and need to be queried.