. Long-Term-Care Institution Visits

When visits are required to patients in long-term-care institutions (such as nursing homes, intermediate care facilities, extended care units, rehabilitation facilities, chronic care facilities, convalescent care facilities and personal care facilities, whether or not any of these facilities are situated on the campus of an acute care facility) claims may be made to a maximum of one visit every two weeks. It is not sufficient, however, for the medical practitioner simply to review the patient’s chart. A face-to-face patient/medical practitioner encounter must be made. For acute concurrent illnesses or exacerbation of original illness requiring institutional visits beyond the foregoing limitations, additional institutional visits may be claimed with accompanying written explanation.

Palliative Care 

The Palliative Care listings are applicable to the visits for palliative care rendered to terminally ill patients suffering from malignant disease or AIDS, or end-stage respiratory, cardiac, liver and renal disease and end-stage dementia with life expectancy of up to 6 months. These listings only apply where aggressive treatment of the underlying disease process is no longer taking place and care is directed instead to maintaining the comfort of the patient until death occurs.

 Claims for these listings should be billed continuously from time of determination of patient’s palliative status, for a period not to exceed 180 days prior to death. Under extenuating circumstances palliative listings billed beyond 180 days will be given independent consideration upon receipt of an explanatory note record. 

The listings are applicable to patients in acute care hospitals, hospice facilities or other institutions whether or not the patient is in a designated palliative care unit. The palliative care listings do not apply when unexpected death occurs after long hospitalization for a diagnosis unrelated to the cause of death.

Sub Acute Care 

Sub acute care is payable twice per week under fee items 00108, 13008. If more services or concurrent care is required an explanatory note record should accompany the claim submission. Independent consideration will be given to these claims.

Emergency Department Examinations 

Emergency department examinations are designated by various intensity levels of emergency department care. These fee codes apply only to those circumstances where either specialists in emergency medicine or other medical practitioners are physically and continuously present in the Emergency Department or its environs for an arranged designated period of time. For complete details, please refer to the Emergency Medicine section of the MSC Payment Schedule.

House Calls 

i) A house call is considered necessary and may be billed only when the patient cannot practically attend a physician’s office due to a significant medical or physical disability or debility and the patient’s complaint indicates a serious or potentially serious medical problem that requires a medical practitioner’s attendance in order to determine appropriate management;

 ii) A house call may be initiated by the patient, the patient’s advocate, or the physician when planned proactive care is determined to be medically necessary to manage the patient’s condition;

iii) If a house call is determined to be necessary and is rendered any day of the week between 0800 and 2300 hours, the house call should be billed as a home visit (use 00103); 

iv) If the house call is initiated and rendered between 2300 and 0800 hours, the visit may be billed as an out-of-office visit with the night call-out charge (01201). 

v) A house call provided for patient convenience should be billed as an out-of-office visit (12200, 13200, 15200, 16200, 17200 or 18200) without a service charge;

vi) The above also applies to house calls rendered by medical practitioners taking call for other medical practitioners; 

vii) As practicality dictates, the necessity and detail and the time of the call should be documented in the patient’s clinical record.