Overview
SOMB code 03.03CV is paid for an assessment conducted by telephone or secure videoconference. It requires substantive clinical work: history, assessment, and a plan. It is not billable for purely administrative calls, booking, or the communication of results alone. Document the modality used (phone vs. video) and the clinical content of the encounter.
Billing Requirements
- Synchronous encounter by telephone or secure videoconference
- History, assessment, and plan documented
- Clinical decision-making reflecting a substantive encounter
Common Audit Traps
⚠️ Alberta Health auditors specifically look for these mistakes when reviewing 03.03CV claims:
- Billing 03.03CV for results-only or administrative phone calls
- Failing to document which modality (phone vs. video) was used
- Billing 03.03CV together with an in-office visit code for the same encounter
Clinical Example
Scheduled video visit for a patient with a new rash. History taken, lesions examined on video, diagnosis made, treatment plan discussed. Bill 03.03CV.
Documentation Tips (Audit-Proof)
- State the modality explicitly in the note (e.g., 'Encounter by secure video')
- Document the clinical issue, assessment, and plan as for an in-person visit
- Record patient verbal consent for the remote encounter when required
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Related SOMB Codes
Limited Assessment — In Office
Limited assessment of a patient's condition requiring a history related to the presenting problems, a directed examination, and advice. The default GP office visit code.
Read GuidePhysician Telephone Call to Patient — Management or Results
Physician-initiated telephone call directly to a patient to discuss management or diagnostic test results. Subject to SOMB frequency and eligibility rules.
Read GuideTelephone Advice to Patient or Agent
Advice provided to a patient or their agent (as defined in the Personal Directives Act) via telephone. Strict SOMB rules apply — read the full text before billing.
Read Guide