Complete Examinations by Family Physicians
Complete History and Physical Examinations are an integral part of most medical practices in Manitoba. The following sections provide further guidance and recommendations for Family Physicians/General Practitioners on how to claim for the visit services you provide to your patients. It aims to clarify when to claim a Complete, an Extended Visit or a Regional Intermediate exam. It is important to understand the different requirements for each of these visits.
Defining a Complete History and Physical Examination
It is important to know the requirements of a Complete History and Physical Examination. While there is no specific time requirement for a Complete, physicians report to us that this type of visit typically takes 15 – 30 minutes.
According to the Physicians Manual, by definition, a Complete History and Physical Examination will usually be comprised of the following elements:
- 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 claimed. Abnormal test results generally require a follow-up visit.
The patient’s condition should warrant a complete history and physical examination. Your documentation of the medical necessity and the service provided play a crucial role in justifying your claim.
If you are unsure whether your visit meets the definition of a complete exam, start by considering other visit types such as an extended visit or a regional intermediate exam.
Practical Advice
The most common question we hear from physicians is how to determine whether a visit should be billed as a Complete, an Extended Visit or a Regional Intermediate service. Understanding the distinction between the three tariff descriptions is important to ensure that services are billed appropriately.
A complete exam may be claimed every 60 days for the same patient for the same condition. Physicians should understand that while the Physicians Manual allows for this, in practice the additional visits in this sequence are most likely to align with a regional intermediate.
The following do’s and don’ts are intended to provide practical guidance and help physicians apply the appropriate tariff based on the services provided and documented.
| DO | DON’T |
|---|---|
| DO document accurately. Without appropriate documentation of the services provided, you cannot reasonably expect your claims to be processed correctly. The College of Physicians and Surgeons of Manitoba has requirements regarding documentation practices and inadequate records can lead to disciplinary actions by CPSM. | DON’T assume a once annual visit with a patient is automatically a Complete Exam. Similarly, don’t assume a second or more frequent visit with a patient in the same year is automatically a regional. Assess the merits of each visit service individually and claim accordingly. |
| DO add eligible premiums or components when appropriate (Pap test, pelvic examination, extended hours premiums) | DON’T claim an additional visit for following up with a patient to provide routine results from labs or imaging. |
| DO ensure the services are medically required; Tariff 8540 should be used when the patient’s condition requires a full assessment to establish a diagnosis or management. For example: New Complex Presentation, initial assessment of patient not recently evaluated, major change in health status. | |
| When examining a patient, verify that your records include the medical history pertinent to the presenting issue. The comprehensive medical history for a patient should always remain up to date. |
Quick Physician Self-Check Before Billing 8540
Ask yourself:
- Was it medically necessary for the patient’s problem?
- Did I perform a full history and physical exam?
- Was the level of assessment comprehensive?
- Is this not a follow-up for the same condition within 60 days?
- Is my documentation detailed enough to support it?
If the answer is yes to all, the claim for 8540 is likely appropriate.