If you are a FRCPC EM you will be in Section 28. You are a Royal College trained Emergency Physician but may not be eligible to bill things that say “Only billable by Family Practitioners”. If you did your LMCC 1 & 2 you may have your CCFP or 00 classification (often while going through Residency to moonlight). If you presented that to CPSBC upon registration you will have both a 28 & 00 listed on the CPSBC website and be eligible to bill FP codes that are restricted to Family practitioners as long as no other restrictions prevent you from doing so within the fee item description. An example is the 14104 which has been restricted now to family practice for deliveries. Section 28 EPs if they performed this would have to bill it under the 01899 misc code and use this as a comparator.

If you trained as a family physician you will have your 00 and then did your CAC (Clinical Area of Competence) in EM you will also be in Section 76 and also have the 00. The Section 76 will allow you to bill the EM Specialist consultation code 01810. Those with the 00 and that are not in Section 76 may not bill this code and are only eligible to bill the age related FP consultation codes. If in Section 76 CCFP-EM, ABEM or grandparented in due to experience you can NOT pick and choose, you must bill the 01810. In other words when the patient is over 80 you can NOT select to bill the 18210 (out of office consult fee) just because it pays more than the 01810 in that age group.

This “Guide to Emergency Billing” is intended to provide guidance to all Physicians seeing patients in an Emergency Department, particularly those who are dedicated Emergency Medicine Specialists (CCFP-EM, ABEM, FRCPC(EM) and FRCPC (Peds EM)) but also Family Physicians working in smaller and Rural sites.

 

Goal:

Our hope in creating this guide is to provide a tool to enable veteran Section of Emergency Medicine (SEM) members to get paid for all of their work, improve their billing accuracy and help lower their risk of audit. We also hope this tool will help new graduates – early in their careers – learn how to bill and document appropriately.

 

Disclaimer:

We have done our best to provide accurate information based on a thorough review of the Medical Service Commission Payment Schedule. We believe the information presented in the Guide to Billing is superior to asking your colleagues “How do you bill this?” and their response “It must be okay because they keep paying me for it”.  An updated copy of MSC payment schedule can be found here: https://www2.gov.bc.ca/gov/content/health/practitioner-professional-resources/msp/physicians/payment-schedules/msc-payment-schedule .  You are also responsible for keeping abreast of any changes that may affect your billing practices (Not your Billing Agent) based on bimonthly bulletins that are released by MSC with your remittance.

 

Content:

The guide includes all codes in the Emergency Medicine Preamble in the MSC Payment Schedule as well as codes from other Sections.   We also include codes mistakenly used by Emergency Physicians, often when no official MSC billing code exists for a similar procedure, intervention or task. We provide specific direction outlining the appropriate MSC billing rules to use for each situation. We also add suggestions regarding what documentation may be required in each situation for members to bill with accuracy, transparency and increased efficiency.

 

Report issues:

Nothing is perfect. SEM appreciates being alerted to errors, omissions, issues or any other salient feedback regarding this Billing Guide. Please report your concerns by emailing SEMpresidents@gmail.com and using the subject line “Billing guide” to provide your feedback.

 

Search for advice by:

• billing code
• procedure name or related question
• key word

 

In most sections we provide as a reference the unadulterated language from the MSC Fee Schedule.

 

We often paraphrase the MSC Fee Schedule, repeating, restating and clarifying the same concepts that the Fee Schedule is attempting to convey. Medical Services Commision (MSC) Fee Schedule & Medical Services Plan (MSP) will often be used interchangeable throughout the guide.

 

We recommend that you do use these codes properly.

You will find that we frequently and repeatedly recommend that you do use these codes properly.

 

Caveats are warnings regarding what not to bill, how best to document, and advice on how to avoid frequently made billing errors. We strongly recommend you follow our advisories to avoid the pain of an audit.

 

Billing tips explain best ways to document or bill for the work you have done. Documentation is essential for the medical record. Proper documentation is considered part of any fee code that can be billed. We provide advice about the minimum proper documentation needed for each fee code.

 

Where relevant and deemed useful we have provided examples that illustrate the advice we provide.
Blue = links to other codes – When there is no billing code provided by MSP for work you have conducted in the course of doing an ED doctor’s job, embedded will be links in blue to advice on how to properly bill for that work.

Billing

You bill MSP and usually you are paid. It is an honour system. The fact that you have been paid does not preclude you from being audited for that same service and found to have billed incorrectly (or worse yet, fraudulently).

 

Documentation

Thorough documentation is your friend and ally. If you adequately document your rationale for considering a patient very, very, sick and you document the type of history and physical and treatments that would be expected of such a sick patient you will very likely have no problems in billing for high-level care. In an ambiguous situation, add a dictated note or extra documentation explaining your thought process. When billing for an extra-ordinary situation, go the extra step to add a billing notation or request manual adjudication to create a paper trail that can serve your interests should you be audited.

 

Audit

These do not happen randomly. Your practice – whether referral, billing decisions, documentation and/or communication has set you apart from your peers to the extent that you have come to the attention of the Billing Integrity Program. The MSP billing system trusts doctors to be honest and thorough; the Billing Integrity Audit verifies that to be the case. Both Programs assume you have a good working knowledge of the fee guide and the codes you bill. Neither program will accept “it was my billing clerk’s fault” as a reason for inappropriate billing. You are solely responsible for any submitted claims whether you submit them personally or someone does it for you.

An audit can be an anxiety provoking experience, especially if it demonstrates inadequacies in your documentation, poor judgment, or at the worst, outright fraud. The potential penalties can be avoided by educating yourself and/or your billing clerk to submit claims that can always be justified by your documentation and the service you provided.

1. Have a good working knowledge of the fee guide and the codes you bill.
2. Document thoroughly the work you do; embrace the reality that proper documentation is part of the service that you are asking to be paid for –e.g. a Level 3 requires a Level 3 amount of detail.
3. Don’t bill a higher-level 1800 code than the patient’s condition or complaint can justify.
4. Don’t try to artificially justify a higher-level code with extra extraneous documentation. Thorough documentation is essential, but there needs to be a true reason to do a Level 3 history and exam.
5. Don’t bill codes that your training precludes you from.
6. When a code for a procedure or service does not exist don’t arbitrarily and unilaterally bill a similar or analogous code – use the 01899 or 01999 Miscellaneous code instead – and use those same similar or analogous codes as comparators in your written submission for manual adjudication.
7. Don’t bill for treating family members. If you are treating a Colleague ensure they are registered and be as thorough as you should with any other patient. A desk-side, “let me have a look at that” is only billable with appropriate documentation. If you feel uncomfortable doing an appropriate history and physical tell them and ask them to see their Primary Care Physician to ensure they get the care they desire.
8. Don’t do procedures that cannot be justified by the patient’s condition or complaint.
9. Back up your thought process or justification for a code with a written argument attached to the billing notes if there is any ambiguity regarding your choice of codes.
10. Be consistent, and above all else………   BE HONEST!

EMERGENCY MEDICINE PREAMBLE– May 1, 2021

1. The following listings apply only to examinations rendered by the emergency physician designated by the medical staff who is on hospital Emergency Department duty and on-site. Other physicians (e.g.: on call) who choose to attend their patients in the Emergency Department but who are not the designated emergency physicians as defined above, shall not bill these listings but shall refer to other sections of the Payment Schedule for billing the appropriate examinations. The physicians working in hospital Emergency Departments that are covered on a call-in basis as opposed to an on-site basis shall not bill these listings but shall refer to the section of Family Medicine. Physicians working in diagnostic treatment centers or freestanding emergency clinics should also refer to the listings in the section of Family Medicine. Call-in fees (i.e. 00112) or call-out charges for patients seen in the Emergency Department are not applicable to emergency physicians while on duty and on-site in the hospital Emergency Department. These fees, in addition to continuing care non-operative surcharges, are only appropriate for the Emergency Physician providing on-call Trauma Team Leader Services.

2. Separate day, evening, night and weekend/statutory holiday listings are defined as follows:
Day fee items (01811, 01812, 01813): 0800 to 1800 hrs, weekdays
Evening fee items (01821, 01822, 01823): 1800 to 2300 hrs, weekdays
Night fee items (01831, 01832, 01833): 2300 to 0800 hrs
Saturday, Sunday or Statutory
Holiday fee items (01841, 01842, 01843): 0800 to 2300 hrs

Time Care Starts:
Care starts when you pick up the chart and begin reviewing the patient’s past history within the hospital’s computer system or the information provided by the patient or other health care providers and subsequently document this review OR when you begin your interaction with the patient. Start time must be accurately entered on the claims and documented in the patient’s chart, as this determines the correct time listings to submit.
The billing period time is NOT determined by:
 When the majority of care is provided
 When the patient checks in at Triage or is registered

Example:
If you start to see a patient at 07:58 hrs, this is a night fee item patient, (fee items are 01831, 01832 or 01833). If you see a patient at 17:57 hrs, this is either a day fee item patient (fee items are 01811, 01812 or 01813) or a weekend/statutory holiday fee item patient (fee items are 01841, 01842 or 01843). Times between patients should be reasonable for levels billed. For example, it is reasonable that you may see a patient and begin care at 07:58 and bill a night fee item for this care. It is not reasonable that you can initiate care on multiple patients in the two minutes preceding the change to a day (or lower) fee item.

3. Emergency Department visit listings are further categorized into three levels of complexity.
LEVEL I (01811, 01821, 01831, 01841)
Evaluation and treatment of a single and/or simple condition affecting a single body system, which requires:
 An abbreviated and/or focused documented history
 Review of relevant labs and/or X-rays
 Organization or guidance of any follow-up required

Examples of Level 1:
 INR check
 Single joint injuries – ankle, foot, knee, shoulder or non-displace uncomplicated fractures
 Balanoposthitis
 Radial head subluxation
 Simple uncomplicated adult UTI, acute otitis externa or media
 Simple sore throat with the absence of systemic and/or lower respiratory tract symptoms
 Corneal abrasion, conjunctivitis
 Localized rash in the absence of systemic symptoms
These patients often do not require observation and/or reassessment nor do they present with features that are potentially serious and/or indicative of systemic disease.

Examples NOT Level I: which would require a more thorough evaluation and
warrant Level II:
 Concussion
 Low impact head trauma on blood thinners
 Open fracture
 Acute glaucoma, retinal detachment, central artery occlusion
 Mastoiditis
 Localized and/or generalized rash with fever and/or systemic symptoms
However, medical complexity, socioeconomic factors, mental illness, behavioural actions of these patients that led to increased time and effort by the physician should be clearly documented if a Level II is billed for a patient that otherwise would have been a Level I.

LEVEL II (01812, 01822, 01832, 01842)
Pertains to the evaluation of a new or existing medical condition that necessitates:
 An appropriate detailed history and pertinent physical exam including documentation of at least two systems
 Review of labs, ECG & imaging where required
 Initiation of appropriate therapy
 Organization or guidance of any follow-up required
 Includes observation and/or reassessment of patients within 2 hours, but does not preclude another physician billing another level fee or resuscitation code with appropriate documentation if the patient deteriorates or a change in treatment is required and the initial billing physician is no longer available.

LEVEL III (01813, 01823, 01833, 01843)
Pertains to evaluation of patients with serious and/or complex medical problem(s) where the emergency condition necessitates a detailed history and appropriate physical examination by the emergency room physician. These patients may require prolonged observation, continuous therapy and/or multiple reassessments. Documentation of the findings shall include:
 The chief complaint(s)
 History of past and present illness
 Relevant personal, family and social history
 Physical examination with special attention to local examination relevant to the present complaint
 Review and interpretation of relevant laboratory, imaging and ECG studies
 Initiation of therapy provided
 Includes observation and/or reassessment of patients within 3 hours, but does not preclude another physician billing another level fee or resuscitation code with appropriate documentation if the patient deteriorates or a change in treatment is required and the initial billing physician is no longer available
 Discussion with the patient and or family and/or family physician and/or specialist(s) including organization or guidance of any follow-up required
This level of care shall also pertain to the management of a life threatening illness/injury which requires immediate evaluation and emergent treatment by the emergency physician but does not meet the criteria of the Emergency Medicine Resuscitation fee and hence does not require constant care by the emergency physician.

4. If a patient that required Level I, II or III care, after their initial work-up and/or treatment deteriorates, to the point of requiring active resuscitation they are also eligible for the Emergency Medicine Resuscitation fee item in addition to the initial level fee items.

5. Emergency Medical Consultations 

a) A specialist emergency medicine consultation (fee item 01810) only applies to certified emergency physicians either by the Royal College of Physicians and Surgeons of Canada (FRCPC) or the Canadian College of Family Practice (CCFP-EM).

Note: Some Full time Emergency Physicians have been grandfathered in to this eligibility.  If you would like to be considered,  send an email to SEMpresidents@gmail.com with a brief account of your EM experience and training. 

b) An emergency medicine consultation (billed as 01810) applies only when a patient is referred by another physician or nurse practitioner (other than an emergency physician or nurse practitioner within the same institution’s department) who has seen and examined the patient and, because of the complexity, obscurity or seriousness of the problem, the referring physician or nurse practitioner has requested a consultation.
Exception: If the consulting physician is an emergency physician who is designated on-call Trauma Team Leader they may bill emergency medicine consultations if called in by the on-site emergency physician at the same institution.

c) An emergency medicine consultation shall include a detailed history and appropriate physical examination, review of previous medical records, discussion with family, friends or witnesses when appropriate, evaluation of appropriate laboratory, imaging and ECG findings and report of opinions and recommendations clearly documented and accessible to the referring physician.

d) A copy of the Emergency Department chart does not constitute a consultation report unless it is within the Electronic Medical Record and section c. above has been satisfied.

e) A consultation cannot be charged for the routine transfer of care to the emergency physician or for the provision of treatment for a stable medical condition.

f) A consultation does not apply in cases of self-referral by patients who present themselves to the Emergency Department or are brought by persons acting on their behalf.

g) If a consultation is charged in addition to the Emergency Resuscitation fee, the consultation fee can be paid, but shall constitute a half-hour of the time spent with patient.

h) No service charges (i.e. call-out charges, non-operative surcharges) may be billed in addition to the emergency medicine consultation fee, except for Trauma Team Leaders, with a note record.

6. Transfer of care:
The transfer of care between emergency physicians at the change of shift shall not generate a new visit or consultation fee. However, in the event of a significant deterioration in a patient’s status that medically requires both a new examination and/or modification of the treatment plan, then the appropriate visit fee item may be claimed. This does not preclude the second physician from billing a resuscitation code if the patient has declined to the point of requiring this type of care. The assessment and/or modification of the treatment plan must be documented in the medical record and the time of the intervention should be noted on the billing claims.

7. An appropriate level fee is billable in addition to a procedural fee whether the diagnostic code is the same or different. The greater fee is paid at 100% and the lesser fee(s) are paid at 50%.

These fees cannot be correctly interpreted without reference to the Preamble.
Non-MSPInsured Fee ($)    Anes.Lev.        MSP & WSBCFee ($)
REFERRED CASES
01810 Consultation:……………………………………………….130.28……… 378.00
Level I:
01811 Level I, Day ……………………………………………………… 35.37……………82.50
01821 Level I, Evening ………………………………………………..42.28…………. 104.00
01831 Level I, Night …………………………………………………….64.67………… 159.00
01841 Level I, Saturday, Sunday or Statutory Holiday ……51.34…………. 131.00
Level II:
01812 Level II, Day ……………………………………………………..76.00…………. 167.00
01822 Level II, Evening ………………………………………………..88.53………… 195.00
01832 Level II, Night …………………………………………………….122.22………. 269.00
01842 Level II, Saturday, Sunday or Statutory Holiday ……..107.29………… 274.00
Level III:
01813 Level III, Day ………………………………………………………..96.14…………212.00
01823 Level III, Evening ………………………………………………….110.25……….. 243.00
01833 Level III, Night ………………………………………………………163.63………. 377.00
01843 Level III, Saturday, Sunday or Statutory Holiday ………130.82……….. 341.00

Fractures:
01850 and 01851 can only be billed by the emergency physician working within the Emergency Department and requires documentation of the history including mechanism, focused physical exam and a discussion with the patient (or guardian) about temporary immobilization for comfort and arranging orthopaedic follow up as required. Cannot be billed in addition to a visit or Emergency Medicine Level I, II, or III fee items.
Must be performed in the Emergency Department
(location code E).
01850 Clavicle ……………………………………………………………..105.60…………….. 323.00         2
01851 Fibula – shaft or malleolus not requiring reduction …91.34……………… 279.00

Dislocations:
Must be performed in the Emergency Department (location code E)

01860 Temporo-mandibular joint, dislocation – closed reduction .68.95……. 210.00        3
01861 Patella – closed reduction ……………………………………….66.05…………… 202.00          2
01862 Toe – closed reduction ……………………………………………49.54…………… 151.00          2

Resuscitation: 

01870 Medicine Resuscitation fee: Treatment of acute life threatening emergency that requires constant bedside resuscitative care – per 5 minutes or part thereof…$27.70.Uninsured rate… $63.10.

Notes:

i) Applicable only to emergency physicians designated by the medical staff who are on hospital Emergency Department duty and designated on-site. Not applicable to on call Emergency physicians. (see Emergency Medicine Preamble).

ii) Includes endotracheal intubation, cricothyrotomy, vascular access (including intraosseous), invasive monitoring, chest tube drainage, and pacemaker insertion and/or other procedures which are central to the resuscitation for acute life-threatening emergencies.

iii) Start and end times must be entered in both the billing claims and the patient’s chart.

iv) If multiple patients are resuscitated, the billings shall be for consecutive, non overlapping time periods and services are to be claimed for each individual patient OR for concurrent services the whole time shall be claimed on only one patient on whom the majority of time was spent. No more than 12 units may be claimed within a 60 minute period.

v) When a consultation is charged in addition to the resuscitation fee, for billing purposes, the consultation shall constitute a half hour of the time spent with the patient. Start and end times for the consultation must also be entered in both the billing claims and the patient’s chart.

vi) Emergency Level fees and other procedure fees not considered life, limb or sight saving which are not included in Note ii) and/or central to the resuscitation for acute life-threatening emergencies, by the same practitioner on the same day are payable if not performed concurrently. Start and end times for these fees must also be entered in both the billing claims and the patient’s chart.

vii) Out-of-office hours premiums are not applicable.

01871 Trauma Team Leader Resuscitation fee: Treatment of acute life threatening emergency that requires constant bedside resuscitative care – per 5 minutes or part thereof………$27.70. Uninsured rate $63.10

Notes:

i) Applicable only to Trauma Team Leaders on contract with a Health Authority to provide on call Trauma Team Leader Services and where the contract does not include provision of this service. Not applicable for General Surgery Trauma Team Leaders.

ii) Includes endotracheal intubation, cricothyrotomy, vascular access (including intraosseous), invasive monitoring, chest tube drainage, and pacemaker insertion and/or other procedures which are central to the resuscitation for acute life-threatening emergencies.

iii) Start and end times must be entered in both the billing claims and the patient’s chart.

iv) If multiple patients are resuscitated, the billings shall be for consecutive, non overlapping time periods and services are to be claimed for each individual patient OR for concurrent services the whole time shall be claimed on only one patient on whom the majority of time was spent. No more than 12 units may be claimed within a 60 minute period.

v) When a consultation is charged in addition to the resuscitation fee, for billing purposes, the consultation shall constitute a half hour of the time spent with the patient. Start and end times for the consultation must also be entered in both the billing claims and the patient’s chart.

vi) Emergency Level fees and other procedure fees not considered life, limb or sight saving which are not included in Note ii) and/or central to the resuscitation for acute life-threatening emergencies, by the same practitioner on the same day are payable if not performed concurrently. Start and end times for these fees must also be entered in both the billing claims and the patient’s chart.

vii)Out-of-office hours premiums are applicable if physician is specially called to render emergency or non-elective services and only when the physician must travel from one location to another to attend the patient(s). Claims must be submitted with a note record.

DO NOT USE for non-critical patients.

LEVEL I (01811, 01821, 01831, 01841)

Evaluation and treatment of a single and/or simple condition affecting a single body system, which requires:

• An abbreviated and/or focused documented history
• Review of relevant labs and/or X-rays
• Organization or guidance of any follow-up required

Examples of Level I:

• INR check

• Single joint injuries – ankle, foot, knee, shoulder or non-displace uncomplicated fractures

• Balanoposthitis

• Radial head subluxation

• Simple uncomplicated adult UTI, acute otitis externa or media

• Simple sore throat with the absence of systemic and/or lower respiratory tract symptoms

• Corneal abrasion, conjunctivitis

• Localized rash in the absence of systemic symptoms

These patients often do not require observation and/or reassessment nor do they present with features that are potentially serious and/or indicative of systemic disease.

Examples NOT Level I: which would require a more thorough evaluation and warrant Level II:

• Concussion
• Low impact head trauma on blood thinners
• Open fracture
• Acute glaucoma, retinal detachment, central artery occlusion
• Mastoiditis
• Localized and/or generalized rash with fever and/or systemic symptoms

However, medical complexity, socioeconomic factors, mental illness, behavioural actions of these patients that led to increased time and effort by the physician should be clearly documented if a Level II is billed for a patient that otherwise would have been a Level I.

LEVEL II (01812, 01822, 01832, 01842)

Pertains to the evaluation of a new or existing medical condition that necessitates:

• An appropriate detailed history and pertinent physical exam including documentation of at least two systems
• Review of labs, ECG & imaging where required
• Initiation of appropriate therapy
• Organization or guidance of any follow-up required
• These patients may require observation and/or reassessment. Includes observation and/or reassessment of patients within 2 hours, but does not preclude another physician billing another level fee or resuscitation code with appropriate documentation if the patient deteriorates or a change in treatment is required and the initial billing physician is no longer available.

LEVEL III (01813, 01823, 01833, 01843)

Pertains to evaluation of patients with serious and/or complex medical problem(s) where the emergency condition necessitates a detailed history and appropriate physical examination by the emergency room physician. These patients may require prolonged observation, continuous therapy and/or multiple reassessments. Documentation of the findings shall include:

• The chief complaint(s)
• History of past and present illness
• Relevant personal, family and social history
• Physical examination with special attention to local examination relevant to the presenting complaint
• Review and interpretation of relevant laboratory, imaging and ECG studies
• Initiation of therapy provided
• Includes observation and/or reassessment of patients within 3 hours, but does not preclude another physician billing another level fee or resuscitation code with appropriate documentation if the patient deteriorates or a change in treatment is required and the initial billing physician is no longer available.
• Discussion with the patient and/or family and/or family physician and/or specialist(s) including organization or guidance of any follow-up required

This level of care shall also pertain to the management of a life threatening illness/injury which requires immediate evaluation and emergent treatment by the emergency physician but does not meet the criteria of the Emergency Medicine Resuscitation fee and hence does not require constant care by the emergency physician.

If a patient that required Level I, II, or III care, after their initial work-up and/or treatment deteriorates, to the point of requiring active resuscitation they are also eligible for the Emergency Medicine Resuscitation fee item in addition to the initial level fee items.

 

General Assessment Codes – 1800 Emergency Care Codes

• 1800 Series
• Level 1 vs. 2 vs. 3
• Time of Day – Issue
• Billing a Procedure with a General Assessment

 

Critical Care and Ongoing Monitoring

• 1870
• 1871
• 00081
• 00082
• Associated Procedures Used in Resuscitation (also in Procedures Section)

 

Consultations

• What is Required For a Proper Consultation?
• 01810- FRCPC(EM)  & CCFP-EM Consultations
• 00510 – Pediatric Consultations

 

Anesthesia and Sedation

• Local
• General – Sedation

 

Procedures

• Casts and Reductions
• Tubes and Needles
• Comparators
• Local Anesthetic
• Cardiac
• Miscellaneous
• Cutting and Sewing
• Wounds: Avulsed and Complicated (in Special Areas)
• Abscess: Incision and Drainage (in Special Areas)
• Stop Bleeding
• Repair Fingers and Toes

 

Miscellaneous

• Certification Mental health
• Crisis Intervention
• Telephone Advice
• Reassessments in Emergency Department
• Hospital Visit Fees
• Handover Fee(s)

 

Billing ER as a GP

• 1800 Codes
• Call-Out Charges
• Call-In Charges
• Continuing Care Charges