Doug Mark MD, President        Allan Studniberg MD CCFP, Interim Vice President

and the

Executive Committee, Coalition of Family Physicians of Ontario

Please feel free to send us any other suggestions for improving the MRC.

For more on the MRC, please visit COFP’s Web Site (www.cofp.com) and see our Op Ed from the July 30, 2002 issue of the Medical Post (“Time to Review the Medical Review Committee”).

WE CANNOT DO THIS WITHOUT YOUR SUPPORT:
In order to do this, we need as many Family Physicians as possible to get on board and join our colleagues as members of COFP.

If you’d like to help us in our fight for a fairer and more transparent MRC process, please complete the attached Membership/Pledge Form and return by fax now to 416-412-7297. We would urge you to become a member (if you haven’t already done so) of our Association, and make an additional donation towards our Political Action Campaign. Even if you do not choose to become a member at this time, I’d urge you to consider supporting the Coalition’s Political Action, Lobbying and Advocacy Activities by making a donation of $250, $500 or $1,000.

Together, we really can make a difference.

^{TO MEMBERSHIP PAGE}

GENERAL ASSESSMENT (A003) & ANNUAL HEALTH EXAM ADULT/ADOLESCENT (A003) & ANNUAL HEALTH EXAM CHILD (K017)

The General Manager of the Ontario Health Insurance Plan refers to the Medical Review Committee services billed for General Assessment (A003), Annual Health Exam Adult/Adolescent (A003) and Annual Health Exam Child (K017) for adjudication.

The General Manager requests the Medical Review Committee to conduct a review of the provision of the insured service and determine whether the service was rendered, whether it was medically necessary, whether it was misrepresented in its billing and whether or not the service was provided in accordance to standard and/or if it was in accordance with the Regulations and the Schedule of Benefits.

The April 1, 2002 Schedule of Benefits, General Preamble, page xi - xii defines General Assessment (A003) as:

“a. General Assessment: a service provided, somewhere other than the patient’s home and requires a full history (the elements of which must include a history of the presenting complaint, family medical history, past medical history, social history, and a functional inquiry into all body parts and systems) and an examination of all body parts and systems, and may include a detailed examination of one or more parts or systems.”

Further information pertaining to Annual Health Exams Adult/Child (A003/K017) is found in the Schedule’s General Preamble, on page xvii.

“w. Annual Health or Annual Physical Examination: is a general assessment as it pertains to an individual after the second birthday who presents and reveals no apparent physical or mental illness, including instruction to the patient or patient’s representative(s) regarding health care.”

Appendix ‘B’ of the Schedule of Benefits identifies record keeping requirements for each patient assessment.  On the date of each professional encounter with the patient, the record of the assessment of the patient shall include the history obtained, the particulars of each medical examination and a note of any investigations ordered and the results of the investigations.  In addition, an indication of each treatment prescribed or administered along with a record of professional advice given and particulars of any referrals made, are necessary.  (Refer to Part v, Ontario Regulation 114/94, Amended to Ontario Regulation 77/98).

The Medical Review Committee has developed a scoring tool to use when interviewing a physician and reviewing his/her records pertaining to General Assessments (A003) and Annual Health Exams (A003/K017).  This scoring tool will assist the Committee in scoring the documentation of a record and determine whether all the expected elements of documentation are recorded.  It will also assist the Committee in identifying specific documentation inadequacies in order to effectively address them to the physician.  This form utilizes the SOAP format, as suggested in the College of Physicians and Surgeons of Ontario’s publication “A Guide to Current Medical Record-Keeping Practices”.

The Medical Review Committee, in reviewing charts and interviewing the physician, would need to determine that the service accurately represented what was billed.  Once the Committee has determined that a general assessment was the appropriate service code billed, the documentation of the record is assessed.

The Committee may find a repetitive pattern of major deficiencies in the record where the services provided do not meet all the elements required by the Fee Schedule.  In this instance, the Committee may reduce the payment to a lesser fee code.

If the Committee finds there are varying degrees of inadequacy in the record keeping and some elements of documentation are missing, but most of the elements are present and a general assessment was done, then depending on the degree to which the documentation is found to be repetitively deficient, the Committee may proportionally reduce the fee paid to the physician and recommend that a repayment to the General Manager of OHIP be recovered from the physician.

A perfectly documented chart entry is not always present.  This tool reflects a compromise position as to the minimum documentation required in recording a general assessment and annual health exam codes.  The Committee expects to find at least the minimal scores in each subsection in order to find the record satisfactory for documentation.

The Medical Review Committee trusts that in distributing this form to the profession, they are openly showing the profession how the MRC functions.  It is believed that publishing this scoring tool will help all practitioners have a better understanding of the documentation requirements for these fee codes.

GENERAL ASSESSMENT (A003) and ANNUAL HEALTH EXAM ADULT/ADOLESCENT (A003)ANNUAL HEALTH EXAM/CHILD (K017)

An ideal chart would contain all of this information, but the committee feels that not all charts will be perfect, hence the required minimum scores. These minimums must be present in each category.  If scores are not met the service will be found to be deficient in documentation and payment will be reduced by a percentage proportional to the deficiency.

*This form assists the committee in recording its concerns with documentation.

(We apologise for the small error in the faxed version of this table in the Functional Enquiry Score box - one extra score line was included)

(To view only this actual A003 Scorecard, click here) ^{(requires )}