GPs Billing for fee codes outside of "core" general practice

[Prince Medward]

To what extent can GPs bill for and be paid for fee codes outside their "core" group of provincial insurance fee codes?

 

Here is an example. Dr. Jones is a GP sharing office space and overhead with an Optometrist (the "OD"). The OD bills patients privately for retinal imaging (they have a limited number of fee codes that they can bill the province for and retinal imaging is not one of them but ODs are trained and proficient in retinal imaging). Ophthalmologists bill the government insurance plan for retinal imaging so there is a fee code for it although it is almost always billed by ophthalmologists.

 

If the GP sees a patient who has the risk factors for a retinal disease like AMD, can the GP take the image using the OD's machine and bill MSP for it? Can the GP then refer the patient to the OD so that the patient can have the image interpreted and explained?

 

Can practice arrangements like this serve to increase the procedures that GPs bill and get paid for?

[Prince Medward]

Section 17 of the Preamble to the British Columbia MSP Payment Schedule states:

 

17. Specialist/General Practitioner Payment

To be paid by MSP or WCB for specialist consultations, visit items and/or other specialty-restricted fee items listed in the specialty sections of the Payment Schedule, one must be a Certificant or a Fellow of the Royal College of Physicians and Surgeons of Canada and/or be so recognized by the College of Physicians and Surgeons of British Columbia in that particular specialty. A specialist recognized in more than one specialty by the College of Physicians and Surgeons of British Columbia should bill consultation and referred items under the specialty most appropriate for the condition being diagnosed and/or treated for that referral/treatment period.

 

The underlined portion suggests that GPs cannot bill "specialty-restricted fee items listed in the specialty sections of the Payment Schedule"

 

Retinal photography (i.e. fundus photography $130) is listed in the "Ophthalmology" section of the Payment Schedule but I'm not sure if this is a "specialty-restricted fee item".

 

Does the mere fact that an item is listed in the Ophthalmology section mean that only an opthalmologist can bill for it? Or is it the case that "specialty-restricted fee items" are a smaller subset of the total fee items listed in a particular specialty's section of the Payment Shedule?

 

Here is the source of the Preable and various sections of the Payment Schedule: http://www.health.gov.bc.ca/msp/infoprac/physbilling/payschedule/index.html

[Prince Medward]

It seems that if a GP is not entitled to bill a fee item because it is restricted to a particular specialty, them the item will be rejected and the following explanitory code (in BC at least) would appear on the MSP statement:

 

"WF Fee item billed and doctor's specialty/practitioner number do not correspond."

(see this link: http://www.health.gov.bc.ca/msp/infoprac/physbilling/payschedule/explancodes.pdf)

 

Have any British Columbia GPs out there received such a code and are willing to describe the circumstances?

[ghost dog]

It seems that if a GP is not entitled to bill a fee item because it is restricted to a particular specialty, them the item will be rejected and the following explanitory code (in BC at least) would appear on the MSP statement:

 

"WF Fee item billed and doctor's specialty/practitioner number do not correspond."

(see this link: http://www.health.gov.bc.ca/msp/infoprac/physbilling/payschedule/explancodes.pdf)

 

Have any British Columbia GPs out there received such a code and are willing to describe the circumstances?

 

I seriously question a family physician's ability to perform such a specialized test ( I am a family doc for the record).

 

Anyways: for this sort of testing protocol to be profitable, you would need to have a number of patients lined up for it. The machine ain't gonna be cheap, and I seriously doubt the OD would let you use it for free.

 

I live my life by : ethics > profits.

[Prince Medward]

The ethics of the example aside, as a GP are you restricted to billing only the fee codes in the General Practice section of the payment schedule?

[moo]

It seems that if a GP is not entitled to bill a fee item because it is restricted to a particular specialty, them the item will be rejected and the following explanitory code (in BC at least) would appear on the MSP statement:

 

"WF Fee item billed and doctor's specialty/practitioner number do not correspond."

(see this link: http://www.health.gov.bc.ca/msp/infoprac/physbilling/payschedule/explancodes.pdf)

 

Have any British Columbia GPs out there received such a code and are willing to describe the circumstances?

 

Yes. I once billed a urology fee code for giving a lupron injection. The urologist I was working with told me that there was a special code for that and to just bill it (something like 40 dollars). It got rejected.

[ghost dog]

The ethics of the example aside, as a GP are you restricted to billing only the fee codes in the General Practice section of the payment schedule?

 

Perhaps there is a good reason for this.

 

I would not want to be responsible for missing someone's obscure eye disease.

[cheech10]

I think there are provincial differences on this topic. I'm an intensivist/internist in Ontario, and I've successfully billed for anesthesia, GI, cardiology, respirology, and nephrology procedures (all have been within my ICU scope of practice, but listed under those specialities in the fee schedule).

[Prince Medward]

Perhaps there is a good reason for this.

 

I would not want to be responsible for missing someone's obscure eye disease.

 

Ok. You have not answered the initial question explicity but I take it as implied in your posts on this thread that your view is that a GP is not permitted to bill for codes outside of those in the general practice section of the payment schedule.

 

And of course, you feel that it is not ethical for a GP to practice any procedure that is not listed in the general practice section of the payment schedule and so such a restriction is, in your view, justified.