|B. Maximums for Physical Therapy Services
The April 1, 1998, changes to the physicians’ Schedule of Benefits
introduced a new maximum of 20 Miscellaneous Therapeutic Services (G467) per patient per
year, with medical exception based upon specialist referral. This maximum applies to G467
services claimed by physicians. Physical therapy services claimed by Schedule 5 facilities
have a maximum of 150 services per patient per year.
C. Specific Services in April 1, 1998 Changes
(e.g., Bone Density)
The April 1, 1998, changes to the physicians' Schedule of
Benefits introduced a number of changes involving benefit periods. For Periodic
Oculo-Visual Assessments only, services prior to April 1, 1998, are included when
determining whether a service is an insured service. In all other cases, only those
services provided after April 1, 1998, are included when determining whether a service is
an insured service. For example, when determining whether bone density measurements are an
insured service, only services provided after April 1, 1998, are considered.
D. Non-Malignant Skin
Pre-malignant lesions, lesions suspected of being malignant
but with no biopsy done, and lesions suspected of being malignant but negative on biopsy
are all, by default, benign lesions and should be claimed using the fee codes for Group 1
to 5 lesions, as applicable, subject to the conditions in Appendix D.
E. Health Insurance Act - Record Keeping
As a reminder, for all services rendered after May 1, 1996,
an amendment to the Health Insurance Act dealt with requirements for records. In addition
to those requirements established by the respective professional regulatory bodies, the
Act requires physicians, practitioners and health facilities to maintain records that
- An insured service was provided.
- The service for which an account is submitted was the service
- The service provided was medically necessary or, in the case
of practitioners, therapeutically necessary.
In addition, records must be prepared promptly when the
service is provided.
In the absence of a record as described above, the fee
payable for the service is nil.