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SOMB Medical Procedure List, April 1, 2016

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SOMB Medical Procedure List, April 1, 2016 ALBERTA HEALTH CARE INSURANCE PLAN Medical Procedure List As Of 01 April 2016 Superseded © Government of Alberta ALBERTA HEALTH CARE INSURANCE PLAN Page 1 Schedule of Medical Benefits Generated 2016/03/22 Part B - Procedure List As of 2016/04/01 I. CERTAIN DIAGNOSTIC AND THERAPEUTIC PROCEDURES 01 NONOPERATIVE ENDOSCOPY 01.0 Nonoperative endoscopy of respiratory tract 01.01 Rhinoscopy BASE ANE 01.01A Sinus endoscopy . 83.82 V 103.77 NOTE: May not be claimed with 01.03. 01.03 Direct laryngoscopy . 68.46 V 109.92 NOTE: May not be claimed with HSC 01.01A. 01.04 Other nonoperative laryngoscopy 01.04A Video laryngeal stroboscopy . 102.48 01.05 Pharyngoscopy 01.05A Nasendoscopy . 121.66 109.92 NOTE: Payable only for the assessment of velopharyngeal incompetence. 01.09 Other nonoperative bronchoscopy . 132.07 V 154.11 NOTE: 1. No additional benefit for aspiration. 2. May be claimed in addition to HSC 43.96E and 45.88A. 3. For a repeat, during the same hospitalization, benefit will be reduced. Refer to Price List. 4. For patients aged 12 months or younger, the procedural benefit varies. Refer to the Price List; modifier L1. 01.1 Nonoperative endoscopy of upper gastrointestinal tract 01.12 Other nonoperative esophagoscopy, rigid . 107.71 126.83 01.12A Functional endoscopic esophageal study . 143.03 01.14 Other nonoperative gastroscopy . 113.99 131.78 Esophagogastroscopy NOTE: 1. HSCs 11.02, 12.12B, 12.13A, 13.99AF, 54.21C, 54.21D, 54.21E, 54.91A, 54.91C, 54.92E, 54.99A, 55.1 B, 55.41A, 55.41B, 56.34A, 56.99A and 58.39B may be claimed in addition. 2. Benefit includes biopsies. 01.16 Other nonoperative endoscopy of small intestine 01.16A Small bowel capsule endoscopy, interpretation, per 15 minutes or major portion thereof . 57.00 NOTE: A maximum of 2 1/2 hours may be claimed. 01.16B Balloon (single or double) enteroscopy, rectal route . 341.97 109.92 NOTE: May be claimed in addition to HSCs 01.16C, 56.34A, 57.13A, 57.21A and 58.99C. Superseded © Government of Alberta ALBERTA HEALTH CARE INSURANCE PLAN Page 2 Schedule of Medical Benefits Generated 2016/03/22 Part B - Procedure List As of 2016/04/01 I. CERTAIN DIAGNOSTIC AND THERAPEUTIC PROCEDURES (cont'd) 01 NONOPERATIVE ENDOSCOPY (cont'd) 01.1 Nonoperative endoscopy of upper gastrointestinal tract (cont'd) 01.16 Other nonoperative endoscopy of small intestine (cont'd) BASE ANE 01.16C Balloon (single or double) enteroscopy, oral route . 341.97 109.92 NOTE: May be claimed in addition to HSCs 01.16B, 56.34A, 57.13A, 57.21A and 58.99C. 01.2 Nonoperative endoscopy of lower gastrointestinal tract 01.22 Other nonoperative colonoscopy . 176.75 109.92 NOTE: 1. HSCs 13.99AE, 57.13A, 57.21A, 57.21B, 57.21C and 58.99C may be claimed in addition. 2. Benefit includes biopsies. 3. Refer to HSCs 01.22A, 01.22B and 01.22C for screening. 01.22A Other nonoperative colonoscopy for screening of high risk patients . 176.75 109.82 NOTE: 1. HSCs 57.13A, 57.21A, 57.21B, 57.21C and 58.99C may be claimed in addition. 2. Benefit includes biopsies. 3. May be claimed for screening purposes for those patients that have been considered to be of high risk for colon cancer. 4. High risk is defined as an individual that has a strong family history of colorectal cancer with multiple individuals affected but no genetic syndrome identified, family history of Hereditary Non-Polyposis Colorectal Cancer or a personal history of inflammatory bowel disease. 5. May be claimed once every year. 01.22B Other nonoperative colonoscopy for screening of moderate risk patients . 176.75 109.82 NOTE: 1. HSCs 57.13A, 57.21A, 57.21B, 57.21C and 58.99C may be claimed in addition. 2. Benefit includes biopsies. 3. May be claimed for screening purposes for those patients that have been considered to be of moderate risk for colon cancer. 4. Moderate risk is defined as an individual who has one or more first degree relatives with colorectal cancer or personal history of colorectal adenomatous polyps. 5. May be claimed once every 5 years. 01.22C Other nonoperative colonoscopy for screening of average risk patients. 176.75 109.82 NOTE: 1. HSCs 57.13A, 57.21A, 57.21B, 57.21C and 58.99C may be claimed in addition. 2. Benefit includes biopsies. 3. May be claimed for screening purposes for those patients that have been considered to be of average risk for colon cancer. 4. Average risk is defined as an individual that is asymptomatic and aged 50 Supersededto 74 years. 5. May be claimed once every 10 years. © Government of Alberta ALBERTA HEALTH CARE INSURANCE PLAN Page 3 Schedule of Medical Benefits Generated 2016/03/22 Part B - Procedure List As of 2016/04/01 I. CERTAIN DIAGNOSTIC AND THERAPEUTIC PROCEDURES (cont'd) 01 NONOPERATIVE ENDOSCOPY (cont'd) 01.2 Nonoperative endoscopy of lower gastrointestinal tract (cont'd) 01.24 Other nonoperative proctosigmoidoscopy BASE ANE 01.24A Rigid proctosigmoidoscopy . 52.31 V 109.92 NOTE: 1. HSC 58.99D may be claimed in addition. 2. Benefit includes biopsies and/or polypectomies. 01.24B Flexible proctosigmoidoscopy, diagnostic only . 74.92 V 109.82 NOTE: 1. May only be claimed in addition to HSCs 13.99AE, 57.13A, 57.21A, 57.21B, 58.99C and 58.99D. 2. Benefit includes biopsies. 01.24BA Flexible proctosigmoidoscopy for screening of patients considered to be of high risk for colon cancer due to a family history of Familial Adenomatous Polyposis (FAP) . 78.46 V 109.82 NOTE: 1. May only be claimed in addition to HSCs 57.13A, 57.21A, 57.21B and 58.99D. 2. Benefit includes biopsies. 3. May be claimed once every year beginning at the age of 10. 01.24BB Flexible proctosigmoidoscopy for screening of patients who are considered to be of average risk for colon cancer . 78.46 V 108.61 NOTE: 1. May only be claimed in addition to HSCs 57.13A, 57.21A, 57.21B and 58.99D. 2. Benefit includes biopsies. 3. Average risk is defined as an individual who is asymptomatic and aged 50 to 74 years. 4. May be claimed once every 5 years. 01.3 Other nonoperative endoscopy 01.32 Otoscopy . 27.47 109.92 NOTE: May only be claimed when performed under general anesthesia. 01.34 Cystoscopy . 84.89 108.71 NOTE: Includes urethral dilation and/or meatotomy. 02 DIAGNOSTIC RADIOLOGY AND RELATED TECHNIQUES Radiology Section - Please See Section X 02.7 Other x-ray 02.75 Other computerized axial tomography 02.75A Anesthetic for CAT scan or MRI . 154.11 154.11 Superseded © Government of Alberta ALBERTA HEALTH CARE INSURANCE PLAN Page 4 Schedule of Medical Benefits Generated 2016/03/22 Part B - Procedure List As of 2016/04/01 I. CERTAIN DIAGNOSTIC AND THERAPEUTIC PROCEDURES (cont'd) 02 DIAGNOSTIC RADIOLOGY AND RELATED TECHNIQUES (cont'd) 02.8 Diagnostic ultrasound 02.82 Diagnostic ultrasound of heart BASE ANE 02.82A Comprehensive diagnostic trans-esophageal echocardiography . 288.75 152.41 NOTE: 1. Benefit includes 2D, M-mode, Doppler, 3D acquisition and post-processing and bubble study if indicated. 2. May be claimed in addition to HSC 13.72A. 3. May be claimed in addition to a visit or a consultation. 4. May not be claimed for services provided intraoperatively. 02.83 Other diagnostic ultrasound of thorax 02.83A Intravascular ultrasound (IVUS), additional benefit . 122.19 87.32 NOTE: May only be claimed in addition to HSCs 48.98A, 48.98B, 48.92A, 49.96A, 49.98B, 51.59D, 51.59E and 51.59F. 02.83B Endobronchial Ultrasonography (EBUS) . 165.17 123.65 02.84 Diagnostic ultrasound of digestive system 02.84A Endoscopic ultrasound of esophageal or gastric lesions . 199.49 131.78 02.84B Endoscopic ultrasound of rectal lesions . 85.49 V 109.82 03 CLINICAL EVALUTION AND EXAMINATION 03.0 Diagnostic interview and evaluation or consultation 03.01 Diagnostic interview and evaluation, unqualified 03.01AD Telephone advice to a patient or their agent (agent as defined in the Personal Directives Act (RSA 2007c37s3)) regarding H1N1 virus. 20.00 NOTE: 1. May only be claimed when a declaration of a public health emergency is made pursuant to 52.1(1), of the Public Health Act; or when the Chief Medical Officer of Health determines, in his discretion, that it is appropriate to implement this health service code even though a public health emergency has not been declared. 2. May only be claimed for direct physician telephone advice provided to a patient or their agent about the patient's suspected or active H1N1 symptoms. 3. May only be claimed when the request for advice is initiated by a patient or their agent. 4. May only be claimed once per patient, per physician, per day. 5. Benefit includes providing a new prescription or prescription renewal if provided. 6. May not be claimed for providing general information on H1N1. 7. May not be claimedSuperseded for services provided through Health Link. 8. Documentation of the request and advice given must be recorded. © Government of Alberta ALBERTA HEALTH CARE INSURANCE PLAN Page 5 Schedule of Medical Benefits Generated 2016/03/22 Part B - Procedure List As of 2016/04/01 I. CERTAIN DIAGNOSTIC AND THERAPEUTIC PROCEDURES (cont'd) 03 CLINICAL EVALUATION AND EXAMINATION 03.0 Diagnostic interview and evaluation or consultation 03.01 Diagnostic interview and evaluation, unqualified BASE ANE 03.01MT Completion of a Physician Report form under the Mandatory Testing and Disclosure Act . 82.42 NOTE: May only be claimed for preparing Physician's report as outlined in the Mandatory Testing and Disclosure Act when requested by a patient for purposes of seeking a court order to require a source individual to submit to testing for blood-borne infections.
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