Complete Examination
i) A complete physical examination shall include a complete detailed history and physical
examination of all parts and systems with special attention to local examination where
clinically indicated, adequate record of findings and, if necessary, discussion with patient.
The above should include complaints, history of present and past illness, family history,
personal history, functional inquiry physical examination, differential diagnosis and
provisional diagnosis.
ii) Routine or periodic complete physical examination (check up) is not a benefit under MSP.
This includes any associated diagnostic or laboratory procedures unless significant
pathology is found. The physician should advise the laboratory of patient’s responsibility for
payment.
Partial Examination
A visit for any condition(s) requiring partial examination or history includes both initial and subsequent
examination for same or related condition(s). A partial examination includes a history of the presenting
complaint(s), appropriate enquiry and examination of the affected part(s), region(s) and/or system(s)
as medically required to make a diagnosis, exclude disease and/or assess function.
Counselling
Counselling is defined as the discussion with the patient, caregiver, spouse or relative about a medical
condition which is recognized as difficult by the medical profession or over which the patient is having
significant emotional distress, including the management of malignant disease. Counselling, to be
claimed as such, must not be delegated and must last at least 20 minutes.
Counselling is not to be claimed for advice that is a normal component of any visit or as a substitute
for the usual patient examination fee, whether or not the visit is prolonged. For example, the
counselling codes must not be used simply because the assessment and/or treatment may take 20
minutes or longer, such as in the case of multiple complaints. The counselling codes are also not
intended for activities related to attempting to persuade a patient to alter diet or other lifestyle
behavioural patterns. Nor are the counselling codes generally applicable to the explanation of the
results of diagnostic tests.
