COVID-19 has brought many changes to healthcare, but one of most durable and dramatic may be increase in virtual care. Many physicians have added virtual care to their practice and healthcare services dedicated to virtual care, including Rocket Doctor and Maple, have expanded during the pandemic. Before COVID-19, only 4% of primary care visits were virtual; that number has increased to 60%. As virtual care tools continue to improve and physician/patient expectations change, many expect virtual care to become a regular part of healthcare delivery in Canada.
Previously, one of the biggest barriers to virtual care was the limits on virtual care billing for Alberta public health insurance. And while challenges remain in terms of remuneration for virtual care there has been progress with the addition of specific virtual codes the the fee schedule. In this post, we’re going to summarize the AHCIP virtual care codes: what the codes are, who can use them, what their value is, and how to correctly bill them. AHCIP groups virtual care codes into 2 categories: codes without limitations and codes with limitations (ie restrictions on the number of times a physician can bill the code in a given time period). Note codes without limitations may still have numerous restrictions and be capped for the number of times the codes can be billed per patient. We’ll review both billing code types in this post.
Alberta Health has restrictions that apply to most virtual care billing codes. Its important to be familiar with these to keep your billing compliant.
1. Service must be initiated by the patient (or their agent) or for a referred patient. If there are accommodations that need to be made in order to facilitate the request such as the physician calling the patient at a specific time, the service can still be claimed.
2. Service must be provided by the physician. Virtual codes cannot be used if the health service is provided by another healthcare professional under the supervision of the physician.
3. Only 1 Virtual Code can be claimed by day by patient per physician. For 03.03CV, 03.01AD, 03.01S, 03.01T, 03.03FV, 03.05JR, 03.08CV, 08.19CV, 08.19CW, and 08.19CX, if one of these codes is claimed none of the other codes can be claimed by the same physician for the same patient on the same day.
4. Documentation is required. Physicians should record the start and stop time of the service in the patient record and document all elements of the service. In the event of an audit, Alberta Health will reduce the claim to the lowest valued service in the absence of sufficient documentation to support the code claimed.
5. Some codes have minimum time requirements to be claimed. 03.03CV, 03.03FV, 03.08CV, 08.19CV, 08.19CW, or 08.19CX all have time based requirements. As noted above, documentation of the exact time spent with the patient is important.
6. Only time spent communicating with the patient can be claimed. Unlike other in-person billing codes, time spent on administrative tasks cannot be claimed.
7. Complexity modifiers or time premiums do not apply to virtual care codes. Most complexity, time modifiers and additional time codes cannot be billed in combination with virtual care codes.
8. Limited Codes. 03.05JR, 03.01S or 03.01T have restrictions on the number of times they can be used per week per physician (14 for each code) or per week per patient per physician (once). Only one of these codes can be claimed per week per patient per physician.
9. Virtual Codes do not count towards the daily limit cap. Virtual codes are classified as ‘V’ Visit category codes, but they do not count towards the AHCIP maximum 50 visit code cap.
Below is a more detailed review of each Alberta Health Virtual Billing Code.
Description: Advice to Patient or their Agent via Telephone, Email and Videoconference including Virtual Care during a Viral Epidemic. Maximum 1 per patient per physician per day.
Value: $20.00
Tips:
Only one per patient per physician per day
Use the location of the physician at the time of the call or tracking purposes, the diagnostic code that must accompany the claim is 079.82 if it is COVID-19 related.
May not be billed:
The assessment must last a minimum of 10 minutes. An assessment that does not meet the minimum requirements or is less than 10 minutes must be claimed using 03.01AD.
Benefit includes the ordering of appropriate diagnostic tests and procedures as well as discussion with the patient.
Description: Follow up assessments (visits), for referred patients only, provided by specialists via telephone or secure videoconference; 10+ minutes physician: patient direct time.
Restrictions: Specific specialties only.
Value: Rates will be equal to an in-person follow-up assessment (HSC 03.03F) and vary by skill. Example: $100.20 for Pediatrics.
Tips:
“Referred patients” means the patient was initially referred to a physician and the physician is continuing to care for the patient for their condition.
The service must last 10 or more minutes – if less than 10 minutes bill 03.01AD
03.03FA, complex modifiers or time premium are not billable in addition to this service.
Patient must be referred
Surcharge modifiers and time premium are not billable in addition to this service.
Description: Comprehensive psychiatric consultation provided via telephone or secure videoconference; consultation requirements apply.
Restrictions: May only be claimed by a psychiatrist (PSYC), a generalist in Mental Health (GNMH)
Value: Rates vary by skill and will be equal to an in-person psychiatric consultation (HSC 08.19A). Example: $189.58 for Psychiatry.
Tips:
Patient must be referred
Only billable by PSYC and GNMH
Surcharge modifiers and time premium are not billable in addition to this service
Description: Psychotherapy and other psychiatric services (such as group therapy) provided via telephone or secure videoconference by a Psychiatrist or a Generalist in Mental Health.
Restrictions: May only be claimed by a psychiatrist (PSYC), a generalist in Mental Health (GNMH) or by a specialist in Mental Health (SPMH).
Value: Rates will vary by skill and be equal to an in-person psychiatric assessment (HSC 08.19GA). Example: $55.92 for Psychiatry.
Tips:
Patient must be referred
Only billable by PSYC, GNMH or SPMH
Surcharge modifiers and time premium are not billable in addition to this service
Description: Psychotherapy and other psychiatric services (such as group therapy) provided via telephone or secure videoconference by a GP or Pediatrician, per full 15 minutes.
Restrictions: May only be claimed by GP, Pediatrician or any qualified physician for palliative care or chronic pain
Value: Rates vary by skill and will be equal to an in-person psychiatric assessment (HSC 08.19G). $47.54 for GPs.
Tips:
Virtual group therapy to be claimed using this HSC. Choose one patient and claim the total time providing group therapy under the one patient’s PHN.
Time premium is not billable in addition to this service.
For treatment of non-scheduled psychiatric treatment, the appropriate office visit health service code should be claimed (03.03CV).
Description: Physician Telephone Call Directly to Patient to Discuss Test Results. Maximum of 14 per week per physician.
Value: $20.00
Tips:
03.05JR may be claimed when speaking with:
03.05JR may not be claimed when the physician leaves a message for the patient.
Alberta Health’s payment system requires a different encounter numbers for 03.05JR and a visit item when they are provided on the same date of service. For example, if you are providing both services on the same day, you would add a separate encounter number for the visit (encounter 1) and the 03.05JR (encounter 2). This is an exception as phone calls do not ordinarily need an encounter number.
May not be claimed for management of patient’s anticoagulant therapy (billable under HSC 03.01N).
May be claimed in addition to visits or other services provided on the same day, by the same physician.
Neither HSCs 03.01S or 03.01T are payable if HSC 03.05JR is claimed in the same calendar week by the same physician for the same patient.
Description: Physician to Patient Secure Electronic Communication. Maximum 1 per patient per week to a maximum 14 per week per physician.
Value: $20.00
Tips:
May only be claimed once per week per patient per physician.
A visit service may not be claimed if provided within 24 hours following the electronic communication.
May not be claimed for inpatients.
HSC 03.01S is not payable in the same calendar week as 03.05JR or 03.01T by the same physician for the same patient.
May only be claimed for those patients where an established physician-patient relationship exists and the physician has seen the patient in the previous 12 months.
03.01S may only be claimed once per patient per week regardless of the number of email exchanges occur in the week with the same patient. This service may only be claimed when a response prepared by the physician is provided to the patient. This code is not to be claimed for receiving an email and proceeding to call the patient in for a face-to-face visit.
May only be claimed when the service is provided using a secure email system that is in compliance with the CPSA guidelines on secure electronic communication and when the physician/clinic has submitted a Privacy Impact Assessment for this service acceptable to the Office of the Privacy Commissioner of Alberta.
Description: Physician to Patient Secure Videoconference. Maximum 1 per patient per week to a maximum 14 per week per physician.
Value: $20.00
Tips:
May only be claimed once per week per patient per physician.
HSC 03.01T is not payable in the same calendar week as 03.05JR or 03.01S by the same physician for the same patient.
May not be claimed for inpatients.
May only be claimed for those patients where an established physician-patient relationship exist and the physician has seen the patient in the previous 12 months.
May only be claimed when the service is provided using a secure videoconference system that is in compliance with the CPSA guidelines on secure electronic communication and when the physician/clinic has submitted a Privacy Impact Assessment for this service acceptable to the Office of the Privacy Commissioner of Alberta.
A visit service may not be claimed if provided within 24 hours following the electronic communication.
The following is a table / cheat sheet for virtual care billing codes in Alberta
| Code | Description | Value | Specialty Restrictions | Billing Restrictions |
| 03.01AD | Advice to Patient or their Agent via Telephone, Email and Videoconference including Virtual Care during a Viral Epidemic. | $20.00 | N/A | Maximum 1 per patient per physician per day. |
| 03.03CV | Assessment provided by General Practitioners (GP) and Specialists via telephone or secure videoconference; 10+ minutes physician: patient direct time. | Rates will be equal to an in-person limited assessment (HSC 03.03A) and vary by skill | Rate Specific | Assessment must last a minimum of 10 minutes |
| 03.03FV | Follow up assessments (visits), for referred patients only, provided by specialists via telephone or secure videoconference; 10+ minutes physician: patient direct time. | Rates will be equal to an in-person follow-up assessment (HSC 03.03F) and vary by skill | Rate Specific | Service must last a minimum of 10 minutes |
| 03.08CV | Comprehensive consultations provided via telephone or secure videoconference; consultation requirements apply. | Rates will be equal to an in-person comprehensive consultation (HSC 03.08A) and vary by skill. | Rate Specific | Patient must be referred |
| 08.19CX | Comprehensive psychiatric consultation provided via telephone or secure videoconference; consultation requirements apply. | Rates will be equal to an in-person psychiatric consultation (HSC 08.19A) and vary by skill. | Psychiatrist (PSYC), a Generalist in Mental Health (GNMH) | Patient must be referred |
| 08.19CV | Psychotherapy and other psychiatric services (such as group therapy) provided via telephone or secure videoconference by a Psychiatrist or a Generalist in Mental Health. | Rates will be equal to an in-person psychiatric assessment (HSC 08.19GA) and vary by skill. | Psychiatrist (PSYC), a Generalist in Mental Health (GNMH), specialist in Mental Health (SPMH) | Patient must be referred |
| 08.19CW | Psychotherapy and other psychiatric services (such as group therapy) provided via telephone or secure videoconference by a GP or Pediatrician, per full 15 minutes. | Rates will be equal to an in-person psychiatric assessment (HSC 08.19G) and vary by skill. | GP, Pediatrician, any qualified physician for palliative care or chronic pain | Call based, per 15 minutes |
| Code | Description | Value | Specialty Restrictions | Billing Restrictions |
| 03.05JR | Physician Telephone Call Directly to Patient to Discuss Test Results. Maximum of 14 per week per physician. | $20.00 | N/A | Maximum of 14 per week per physician. |
| 03.01S | Physician to Patient Secure Electronic Communication. Maximum 1 per patient per week to a maximum 14 per week per physician. | $20.00 | N/A | Maximum of 14 per week per physician. Maximum once per week per patient per physician. |
| 03.01T | Physician to Patient Secure Videoconference. Maximum 1 per patient per week to a maximum 14 per week per physician. | $20.00 | N/A | Maximum of 14 per week per physician. Maximum once per week per patient per physician. |
Virtual care has arrived and is rapidly evolving in Canada. As healthcare expands virtually, we expect the Alberta Schedule of Medical Benefits (SOMB) to further evolve and add more virtual billing code options for physician billing. We’ll keep you posted. If you have any questions or comments, please let us know. We’re always happy to hear from you.
For more information on the rise and implications of virtual healthcare, we recommend reading a summary with the Canadian Institute for Health Information (https://www.cihi.ca/en/health-workforce-in-canada-highlights-of-the-impact-of-covid-19/increase-in-virtual-care-services) and a recently released Deloitte white paper (https://www2.deloitte.com/content/dam/Deloitte/ca/Documents/life-sciences-health-care/ca-covid-19-digital-health-and-virtual-care-aoda-en.pdf).