When can I bill a complete history and physical (8540) in Manitoba, and what is the 60-day rule?

The fees

When 8540 applies

• The manual says 8540 "will usually comprise of" (A-119):
  • "A full patient history"
  • "An inquiry into and an examination of all relevant parts or systems required to make a diagnosis or differential diagnosis"
  • "A review of results of investigations ordered by the physician"
  • "A complete written or electronic record"
  • "Advice to the patient during the visit, and/or later by telephone, if appropriate"
• "Where medically indicated, a return visit to advise the patient may be claimed. Abnormal test results generally require a follow-up visit." (A-119)
• "Tariff 9795 (cytological smears for cancer screening) may be claimed in addition to tariff 8540, where appropriate." "Tariff 8448 may be claimed in addition to 8540 where a pelvic examination is provided." (A-119)
• The manual says an age premium is applied automatically to 8540: 10% for patients aged 65 to 69, and 20% for patients 70 or older. (A-119)

When 8540 does not apply: the 60-day rule (Rule 6)

• "A Subsequent Visit is one that follows either a complete or regional history and examination by the same physician, for the same condition within a period of sixty (60) days". (Rules-2)
• The rule goes on: "if the patient has been seen by the same doctor within any sixty (60) day period for the same condition, only a subsequent visit may be claimed for any visit following the initial visit." (Rules-2)
• The rule covers the same doctor and the same condition. It applies after a regional visit too, not only after 8540. (Rules-2)
• In the office visit list, the tariffs named for a subsequent visit are 8529 and 8509. Both names include "Regional or Subsequent Visit". (A-119 to A-120)
• 8529 needs "a minimum of ten (10) minutes of physician time or the patient is over 65 years of age" (A-120). For 8509, "Generally, less than ten (10) minutes of physician time is required." (A-120)
• For some illnesses, such as "the continuing management of a chronic illness", a fuller exam within the 60 days "may be allowed but only by Special Report." (Rules-2)
• "8459 may be claimed on any day after another visit or consultation, notwithstanding Rule of Application 6." (A-119) In plain terms, Rule 6 does not block 8459. 8459 has its own conditions (A-119).

Worked example

What is often not billed

The return visit to go over results. The manual says a return visit to advise the patient "may be claimed" where medically indicated, and that abnormal test results "generally require a follow-up visit". Rule 6 does not stop that visit. It sets the tariff: within 60 days for the same condition, bill a subsequent visit (8529 or 8509). You can claim the return visit only when there is a medical reason for it, such as an abnormal result. On their own, the review of results and advice by phone are usually part of 8540 itself. (A-119; Rules-2)