Services Not Listed in the Schedule

On recommendation of the BCMA Tariff Committee and agreed to by Government, interim listings may be designated by the MSC for new procedures or other services for a limited period of time to allow definitive listings to be established.

Miscellaneous Services

This section relates to services not listed in the MSC Payment Schedule that are:

• new medically necessary services generally considered to be accepted standards of care in the medical community currently and not considered experimental in nature; 

• unusually complex procedures, for established but infrequently performed procedures; 

• for unlisted “team” procedures, or 

• for any medically required service for which the medical practitioner desires independent consideration to be given by MSP

Claims under a miscellaneous fee code will be accepted for adjudication only if the following criteria are fulfilled:

• An estimate of an appropriate fee, with rationale for the level of that fee 

• Sufficient documentation of the services (such as the operative report) to substantiate the claim.  

The Medical Services Plan will review the fee estimate proposed and the supporting documentation and by comparing with the service provided with comparable services listed in the MSC Payment Schedule, determine the level of compensation. While an application for a new fee item is in process (as per Section C. 2.), MSP will pay for the service at a percentage of a comparable fee until the new fee item is effective. Should it be determined that a new listing will not be established due to the infrequency of the unlisted service, payments will be made at 100% of the comparable service.

ADMINISTRATIVE ITEMS

Fees Payable by the Medical Services Plan (MSP)

A Payment Schedule for medical practitioners is established under Section 26 of the Medicare Protection Act and is referred to in the Master Agreement between the Government of the Province of British Columbia and the Medical Services Commission (MSC) and the British Columbia Medical Association (BCMA). The fees listed are the amounts payable by the Medical Services Plan (MSP) of British Columbia for listed benefits. “Benefits” under the Act are limited to services which are medically required for the diagnosis and/or treatment of a patient, which are not excluded by legislation or regulation, and which are rendered personally by medical practitioners or by others delegated to perform them in accordance with the Commission’s policies on delegated services.

Services requested or required by a “third party” for other than medical requirements are not insured under MSP. Services such as consultations, laboratory investigations, anesthesiology, surgical assistance, etc., rendered solely in association with other services which are not benefits also are not considered benefits under MSP, except in special circumstances as approved by the Medical Services Commission

Setting and Modification of Fees 

The tri-partite Medical Services Commission (MSC) manages the Medical Services Plan (MSP) on behalf of the Government of British Columbia in accordance with the Medicare Protection Act and Regulations. The MSC is the body that has the statutory authority to set the fees that are payable for insured medical services provided to beneficiaries enrolled with the Medical Services Plan (MSP). The MSC Payment Schedule is the official list of fees for which insured services are paid by MSP.

The BC Medical Association (BCMA) maintains and publishes the BCMA Guide to Fees. The Guide mirrors the MSC Payment Schedule, with some exceptions including recommended private fees for uninsured services.

DEFINITIONS

“Age categories”

Premature Baby -2,500 grams or less at birth 

Newborn or Neonate -from birth up to, and including, 27 days of age 

Infant -from 28 days up to, and including, 12 months of age 

Child -from 1 year up to, and including, 15 years of age

Note: for pediatric specialists – up to and including 19 years of age

“Antenatal visit”

Pregnancy-related visits from the time of confirmation of pregnancy to delivery Same as prenatal

“CPSBC” 

College of Physicians and Surgeons of British Columbia

“Emergency department physician”

Either a medical practitioner who is a specialist in emergency medicine or a medical practitioner who is physically and continuously present in the Emergency Department or its environs for a scheduled, designated period of time

“General practitioner”

A medical practitioner who is registered with the College of Physicians and Surgeons of British Columbia as a General Practitioner

“Health care practitioner”

Any of the following persons entitled to practice under an enactment:

a) a chiropractor 

b) a dentist 

c) an optometrist 

d) a podiatrist 

e) a midwife 

f) a nurse practitioner 

g) a physical therapist 

h) a massage therapist 

i) a naturopathic physician or 

j) an acupuncturist

“Hospital”

An institution designated as a hospital under Section 1 of the BC Hospital Act - except in Parts 2 and 2.1, means a non-profit institution that has been designated as a hospital by the minister and is operated primarily for the reception and treatment of persons: 

a) suffering from the acute phase of illness or disability,

b) convalescing from or being rehabilitated after acute illness or injury, or 

CODING SPECIALTY CODES

General Requirements.--Specialty codes are self-designated and describe the kind of medicine physicians, non-physician practitioners or other healthcare providers/suppliers practice. Appropriate use of specialty codes helps reduce inappropriate suspensions and improves the quality of utilization data.

A physician, non-physician practitioner or other healthcare provider or supplier will submit a specialty code change via the Form CMS-855 application. Update the specialty code that is submitted to CWF on the Part B Claim Record and the one used for prepayment and post payment medical review. This should also be consistent with your UPIN files and provider files. Follow the most cost-effective method for updating specialty codes. 

Do not add any specialty codes to the list. Send all requests for expansion of the list to your regional office (RO). Your RO will forward the list to central office (CO). CO will consider whether the requestor has the authority to bill independently; the reason or purpose for the code expansion and if a current code would suffice; the requester is/are recognized by another organization, such as the American Board of Medical Specialties; and whether the specialty treats a significant volume of the Medicare population.

All physicians that have an UPIN must have a specialty code other than 70 multispecialty "Clinic" or "Group Practice". Contact physicians who are listed as specialty 70 and obtain a valid specialty. Osteopathic codes and health care prepayment plans codes have been phased-out and been replaced with new codes.

Not Covered for allergy testing

83516 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, multiple step method 

83518 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; qualitative or semiquantitative, single step method (eg, reagent strip) 

83519 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, by radioimmunoassay (eg, RIA)

83520 Immunoassay for analyte other than infectious agent antibody or infectious agent antigen; quantitative, not otherwise specified 

86160 Complement; antigen, each component 

86161 Complement; functional activity, each component 

86162 Complement; total hemolytic (CH50) 

86332 Immune complex assay 

88342 Immunohistochemistry or immunocytochemistry, per specimen; initial single antibody stain procedure 

88344 Immunohistochemistry or immunocytochemistry, per specimen; each multiplex antibody stain procedure

 88346 Immunofluorescent study, each antibody; direct method 

86352 Cellular function assay involving stimulation (eg, mitogen or antigen) and detection of biomarker (eg, ATP)

88184 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; first marker 

88185 Flow cytometry, cell surface, cytoplasmic, or nuclear marker, technical component only; each additional marker (List separately in addition to code for first marker)

 86343 Leukocyte histamine release test (LHR) 

86353 Lymphocyte transformation, mitogen (phytomitogen) or antigen induced blastogenesis 

95199 Unlisted allergy/clinical immunologic service or procedure (Explanatory notes must accompany claim) Code not covered if billed for service listed as “Not Covered in this policy.

 86356 Mononuclear cell antigen, quantitative (eg, flow cytometry), not otherwise specified, each antigen  

Immunotherapy

95115 Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection 

95117 Professional services for allergen immunotherapy not including provision of allergenic extracts; two or more injections 

95120# Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; single injection 

95125# Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; two or more injections 

95130# Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; single stinging insect venom 

95131# Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; two stinging insect venoms 

95132# Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; three stinging insect venoms 

95133# Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; four stinging insect venoms 

95134# Professional services for allergen immunotherapy in prescribing physicians office or institution, including provision of allergenic extract; five stinging insect venoms 

95144# Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy, single dose vial(s) (specify number of vials) 

95145 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); single stinging insect venom 

95146 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); two single stinging insect venoms 

95147 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); three single stinging insect venoms 

95148 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); four single stinging insect venoms 

95149 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy (specify number of doses); five single stinging insect venoms 

95165 Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; single or multiple antigens (specify number of doses)

95170# Professional services for the supervision of preparation and provision of antigens for allergen immunotherapy; whole body extract of biting insect or other arthropod (specify number of doses) 

95180 Rapid desensitization procedure, each hour (eg, insulin, penicillin, equine serum) 

95199 Unlisted allergy/clinical immunologic service or procedure (Explanatory notes must accompany claims billed with unlisted codes.)