BILLING CORNER


Billing Corner

  • Schedule of Benefits
  • Your Billing Process
  • Billing Complaints
  • Q & A
  • IFHP - Billing Sans OHIP

Schedule of Benefits (SOB)

MOHLTC OHIP Schedule of Benefits and Fees (Effective March 1, 2016 ...as most recently amended Dec.22/15): Download accessible via the MOHLTC website.


UPDATED: The excerpts below now reflect the non-negotiated, government imposed 1.3% fee reduction that became effective after October 1st 2015 and any subsequent amendments up until Dec.22/15.

GENERAL SURGERY CODES: Selected excerpts from SOB as of Dec.22, 2015 - effective March 1, 2016


GENERAL SURGERY CODES: Miscellaneous excerpts from SOB


FULL SECTIONS FROM THE SCHEDULE OF BENEFITS


GENERAL SURGERY CODES: OAGS Billing Summaries

Colonoscopy Procedure Codes Diagnostic Code
Z491 - FU incomplete polypectomy, large sessile polyp
• Or piecemeal or high grade dysplasia
• Payable only within 6 months
546
surveillance
Z492 - 5 year FU of a normal colonoscopy
• Payable every 5 years after Z499
546
surveillance
Z493 - 10 year FU of a normal colonoscopy
• Payable every 10 years after Z497,Z555
546
surveillance
Z494 - Very high risk screening - HNPCC, FAP, IBD >10 yrs
• Payable within “clinical practice guidelines”(q 1-2yr)
546
surveillance
Z495 - Repeat due to poor prep/ incomplete
• No interval limit
Use
Original Code
Z496 - Symptomatic
• No interval limit
569
symptoms
Z497 - FU+FOBT, +DCBE, +sigmoidoscopy, +CT
• Confirmatory - no interval limit
545
FOBT+
Z498 - Polyp Surveillance Standard Intervals 3 or 5 years
• 5 yrs if 1-2 tubular adenoma
• 3 yrs if 3+TA, >1cm, villous, any HGD, or Rt. SSA
• <3yrs if >10 adenomas
• use for colon cancer follow-up at 1, 3, 5 yr intervals
546
surveillance
Z499 - Family History + first scope
• 1st degree or two 2nd degree relatives at 40yrs+ (or 10 yrs
younger than earliest age of relative's diagnosis)
547
family history
Z555 - Average Risk Screening
• Payable at 10-year interval
548
screening

Source: MOHLTC Schedule of Benefits (Dec, 2015); Other MOHLTC Schedules-Documents(current).

Your Billing Process

(Scroll to bottom for problem-solving contacts.)
  • Billing claims are usually submitted by Electronic Data Transfer (EDT) to your local MOHLTC Claims Services Branch.
  • Cut-off for submissions is the 18th of each month or next business day if it falls on the weekend (claims received after the 18th may also be processed and included in the same Remittance Advice, not necessarily in the same month)
  • Providers must submit claims within 6 months of the date of service (claims submitted beyond this time frame are considered stale-dated and will be rejected to the Error Report)
  • If you feel a complicated claim is going to require further documentation, make sure to submit/fax it on the same day as the EDT. Be sure to make a paper trail and get confirmation that they received it. Email confirmation is preferred, but if you call, make note of the time, date and contact person in a journal.
  • Cases with multiple procedure codes and duplicate billings are automatically forwarded to a Claims Assessor (other criteria such as billing history may also be used) and will likely be rejected; you'll only be asked to be resubmit the claim with the manual documentation. Save time and delay, and do it the first time!
  • Majority of billings are initially assessed through a computer
  • Approximately 80% of billings are immediately approved and paid out
  • Approximately 20% of billings are not system assessed and are forwarded to Claims Assessors for assessment
  • Paid claims will appear on the Remittance Advice (RA)
  • Unpaid/rejected claims will appear onthe Claims Error Report or the Remittance Advice with an explanatory code
  • Rejected claims appearing on the Claims Error Report MUST BE RESUBMITTED, as they are deleted from the system
  • IMPORTANT NOTE: Inquiries regarding overpaid or underpaid claims on the Remittance Advice must be made in writing using the Remittance Advice Inquiry Form. Do not resubmit the claim.
  • Claims under review by a Claims Assessor may require further documentation by the physician.
  • Fax this documentation to the Ministry office where the physician claims services are performed. Ensure that your billing number is clearly labeled at the top of EACH PAGE of your documentation being faxed. ALSO, remember to flag the claim using your billing software to indicate to the Ministry that special attention is required for that particular claim. Phone/email your local Ministry office if uncertain.
  • Once these manual documents are received, your claim is then escalated to an Assessment Officer for further review.
  • If the claim and documentation is still too complex or convoluted, it will be further escalated to a Medical Advisor. Once it's been assessed this time, it will appear on the provider's monthly Remittance Advice (RA) either as full, partial or denied payment.
  • If the claim has been partially paid or completely denied, the surgeon/provider may appeal this by completing what is called a Remittance Advice Inquiry (RAI) (form#1). This needs to be accompanied with a letter, a note and any other additional documentation which may be of benefit.
  • NOTE: Questions to the Medical Advisor should be IN WRITING ONLY. KEEP ALL CORRESPONDENCE for future reference.
  • If this additional letter/document supports your appealed claim, then the claim will be adjusted.
  • If the Assessment Officer or Medical Advisor stand by their initial rejection, then a response will be sent to the provider/surgeon with an explanation.
  • If the surgeon still does not agree, you can appeal one final time with another Remittance Advice Inquiry (RAI) (form#2). This must be accompanied with a formal letter. At this point, it will be escalated a final time to be reviewed/discussed by a panel of three Medical Advisors. All 3 must be in agreement on the assessment. If one of the three advisors does not agree, then the provider's claim is adjusted automatically by default.
  • Time Frame: As a rule, it should take about 1 month for each stage - 3 months maximum for the entire process IF you've been diligent in submitting all documentation promptly.
  • Stale Billing: This refers to a claim which was not submitted correctly within 6 months of the performance of the procedure. It pertains only to the initial billing and the first response to the Claims Assessor. (After the first response to the Claims Assessor, the 6 month stale billing rule should no longer apply and payment should be made out beyond the 6 months by default, as long as you've complied to their requests in a timely manner.)
  • IMPORTANT NOTE: Each physician is responsible for all claims submitted and paid in conjunction with his/her OHIP billing number. So, even if you have a 3rd party submitting your billing, you are still liable for the consequences and fraudulent claims which could jeopardize your license. Be aware of what is submitted under your name and billing number. As such, the MOHLTC recommends that physicians promptly reconcile all claims by reviewing their monthly Remittance Advice and Error Report.

  • COMMON ERRORS RESULTING IN NON-PAYMENT: a) missing/illegible 6-digit billing number, clinic's 4-digit ID number, patient's health card number/info, b) documents sent to the wrong district office, or c) requested documentation is not sent along with the submitted/resubmitted claim.
  • MOHLTC/OHIP Billing Claims Recommendations: •Contact patients for updated information, • Perform a monthly reconciliation of your Remittance Advice and Error Report, • Keep copies of the Remittance Advice, • Diligently follow up all underpaid/overpaid claims, • Retain all Error Reports until claims are paid, • Make corrections and re-submit claims ASAP, • Ensure new billing staff are properly trained.

Sources: MOHLTC Health Services Branch/Claims Services Branch (OAGS AGM, 2014), OAGS Billing Corner (Issue #36, 2014).

Billing Complaints

MOHLTC/OHIP Billing Claims Services Branches

  • Oshawa (incl. Ottawa & London) - 1-855-250-3696 or 905-576-2870
  • Toronto (incl. Sudbury & Thunder Bay) - 1-855-645-1282 or 416-314-7770
  • Hamilton (incl. Mississauga & Kingston) - 1-888-630-8066 or 905-521-7100 (or -7547)
  • General Claims Office - 1-800-262-6524
  • Websites: www.health.gov.on.ca / MOHLTC-OHIP / OHIP Claims Offices

STILL HAVING PROBLEMS?

  1. Contact the OAGS Tariff Committee:
    Outline your issues in an email to our OAGS office "Attn. Tariff Committee": info@oags.org .

  2. Have a Complaint about your MOHLTC/OHIP Health Claims Services Branch or Your Stale-dated Claim?
    This Ministry website provides a contact listing for the central Health Services Provider Facility Payment Unit. There are several fee-for-service medical advisors who can assist you. Call initially, but all communications should be in writing (and/or logged).
    MOHLTC Health Services Branch & Medical Advisory Contacts: www.infogo.gov.on.ca ; 613-536-3164.

  3. OMA Economics Department
    The OMA Economics & Analysis department can also offer billing advisory and mediation: economics@oma.org , 416-599-2580 / 1-800-268-7215.

Sources: MOHLTC Health Services Branch/Claims Services Branch (OAGS AGM, 2014), OAGS Billing Corner (Issue #36, 2014).

Billing Corner Q&A

Do you have a question for our Tariff Committee?
Online Form:  Submit Now  
Email us:  info@oags.org

Below are some common queries from our members. Just click on the question to open the respective answer....

Q. How do I bill for visits as MRP on patients with an early postop SBO (beyond the two weeks from surgery) who I've placed on TPN? I've billed the G510 TPN code and C032+E083 on same day and only received payment for G510. (March, 2018)
A. The code description for TPN G510 is explicit: you can’t bill it with visits.
"For Management of parenteral alimentation: In addition to the common elements, this service includes the specific elements of assessments (see General Preamble GP11). Not to be claimed in addition to hospital visits."
You have to choose between billing TPN or visits. For day 2 -14 post op, you can’t bill visits, so bill TPN, but after that, visits pay more so bill visits. Some larger centers with shared or group practices designate one member of a group to do surgical nutrition rounds and order TPN but that is stretching things a bit.

Would suggest just billing the visits and forgoing the TPN billings.
TPN = $21
C032+E083 = $40.30

- OAGS Tariff Committee
Q. We’d like clarification/verification on the appropriate billing for Port-a-Cath vs. Hickman and related scenarios. How about removal of loop recorder? (March, 2018)
A. Fee code Z456 is to be billed when inserting an implantable (tunneled) central venous catheter (e.g. Hickman). Fee code Z446 is to be billed when inserting an implantable venous access port (e.g. port-a-cath). These two codes are not payable together for the same catheter. Z457 is for the surgical removal (or repair) of implantable (tunneled) central venous catheter (e.g. Hickman). Z447 may be claimed for revision (or removal) of an implantable venous access port (e.g. port-a-cath). There is no fee code for removing an implanted loop recorder. - MOHLTC Health Services Branch
Q. 1) How do I bill component separation? 2) Can I bill direct laryngoscopy with gastroscopy if I am also assessing for reflux laryngitis? 3) When rounding on the group's inpatients on the weekend, what codes should I bill for rounding? Can I also bill special visit if the patient is not admitted to me? 4) When seeing patients in the office in follow-up, when to bill A034 vs A033? 5) When removing a suspicious skin lesion for ?BCC, do I just bill it up front as R049/R040 to reflect the clinical suspicion or do I have to wait for the pathology report to come back so that I can bill according to the final pathology? (Jan, 2018)
A. 1) COMPONENT SEPARATION: There just isn’t an actual code that was ever created for this. Seems like non-sense, since many of these are being done now. There have been many discussions at meetings re. best way to bill these, and it seems everybody does it differently. Some just bill massive hernia, and eat the rest. I’m also aware of surgeons who do many of these and bill the Rectus Abdominus myocutaneous flap - R155, under plastic surgery procedures. Seems to be the closest we have in the schedule. 2) GASTRO WITH LARYNGO: NO. Not unless you pulled out the gastroscope and used a laryngoscope. If you look at the cords, it's part of your gastro. You might get away with it but I think it is out of keeping with the intent. 3) WEEKEND ROUNDS: When "handed over" patients, you have to bill as if you are the original surgeon. You can't bill special visits for rounding as far as I am aware. This is in the preamble for consults/visits (GP28) 4) A033 VS A034 general preamble GP15 and 16. A033 specific assessment could be billed for a "consult' limited to the presenting complaint. Full H and P not needed, only looking at the specific issue. Example: GP asks you to pull a GJ tube. No full H and P, just deal with the tube. References a "new" problem. A034 is a limited assessment, and basically constitutes a followup to discuss results, check wounds etc. 5) ?BCC: To be by the book, I would wait until the final path comes back, then there are no questions. IF audited and path doesn't match up, you will get "clawed back". M4/M5 in skin.... I think this one is pretty clear that you need path confirming skin malignancy.  Not just suspicion. - OAGS Tariff Committee
Q. Our general surgery group has been having debates regarding "lumps and bumps". One opinion is that there is a billing code within OHIP SOB, so it has to be billed to OHIP (this same group goes out of their way to avoid these cases as the remuneration is suboptimal). The other opinion is that these are cosmetic procedures and the patient should pay. This group points to the plastic surgeons as an example. This group is doing most of the cases. What is the guidance from the OAGS? (Jan.11,2018)

A. OAGS Tariff Committee Response: These procedures are covered by OHIP and should be billed as such. ...The remuneration is pathetic, but since they are covered, extra billing out of OHIP may put you in jeopardy.... //...If these lumps are "symptomatic" (arguably a broad application here), then (a General Surgeon can) deal with them and bill OHIP. If someone wants it off for COSMETIC reasons, (General Surgeons may not) do it and suggest (the patient) see a Plastic surgeon. It is definitely a grey zone, because it can be done as a "cosmetic" procedure, which the SOB doesn't cover. (Jan.12/18)

A. MOHLTC/OHIP Health Services Branch Response: "Thank you for your question to the Health Services Branch of the Ministry of Health and Long-Term Care (the ministry). We appreciate the time you have taken to write us. Appendix D describes circumstances where removing benign lesions are insured. In general, surgery solely for the alteration of appearance is uninsured. Appendix D describes circumstances where OHIP insures benign skin lesions such as nevi, haemangioma, keratoses, neurofibromata, warts etc. If the physician suspects that a lesion is diseased or malignant, the service to remove the lesion is considered medically necessary whether or not subsequent pathology results shows it to be benign. With prior authorization from the Ministry of Health and Long-Term Care, removal may also be insured if the lesion is very large and disfiguring or if it is to alleviate significant physical symptoms. If the physician is uncertain whether OHIP would consider the service insured, the physician can submit a Request for Prior Authorization for Payment form at http://www.forms.ssb.gov.on.ca/mbs/ssb/forms/ssbforms.nsf/FormDetail?openform&ENV=WWE&NO=014-0691-84." (Jan.22/18)

Q. Is there any billing code for the placement of a seton in the anal canal? (Sep/17)
I use S251. Note that the fee code descriptor is "Fistula-in-ano". It does not say anal fistulotomy, so technically there is not a code for that either. I use S251 for all cases under GA when I deal with a fistula -in-ano, whether I divide a fistula or insert a seton. - CV (Sep.18/17)
Q. Spigelian hernia: I bill as an inguinal hernia as it seems the closest, but it's not specified in the Schedule. Is that the general recommendation? (Aug/17)
I agree that billing the inguinal hernia code is the most applicable. It's not truly a ventral - post-operative, so I wouldn't bill that one. It is a bit more work/effort to dissect out than either an epigastric or umbilical and more akin to an inguinal hernia dissection (multiple layers, layered closure, etc.) (Aug.28/17)
Q. Billing Assisting Fee and Procedures (performed during the same time): I was assisting a colleague in a laparoscopic partial gastric resection and performed an intra-operative gastroscopy. Can I bill for both the gastroscopy and the assisting fee? (July/17)
The short answer can be found in the Schedule of Benefits on page SP2 (surgical preamble) subheading 6. Claim the benefit of the procedure you performed, not the basic units assigned for the procedure you are assisting for, but may claim time units for assisting (other than the time you spent doing the EGD).
Q. Varicose Veins: I know EVLT is outside the OHIP schedule, but what are the current rules on stripping and ligation, ligation of individual veins post stripping and injection with sclerosing agents ? (June, 2017)
A. The "rules" are outlined on page Q14 of the Schedule of Benefits (SOB). If the patient meets those, you can bill for the listed procedures. The sclerotherapy codes are on page J44, code G536. Again, they come with criteria (>5mm vessels), which may not apply to spider veins. Outside of those parameters, I don't think there are any other ways to bill it other than privately.
Q. My second surgical procedure claims rendered within 14 days of a previous surgical procedure claim is automatically discounted to 85% of the submitted fee. What can I do? (May, 2016)
A. According to the OMA, "the Ministry has identified that the cause is related to system modifications that support changes to reduce the number of surgical adjudications subject to manual review. These system changes have reduced the volume of claims subject to manual review but resulted in this subsequent unintended consequence. The OHIP Schedule of Benefits states that when a procedure is carried out by a surgeon within 14 days during the same hospitalization for the same condition, then 85% of the listed benefit(s) applies. Further, when a subsequent elective procedure is done for a different condition within 14 days during the same hospitalization by the same surgeon, the benefit for the lesser procedure shall be reduced by 15%. However, the OHIP Schedule allows for the full benefit to be paid when a subsequent operation for the same condition becomes necessary because of complications, or for a new condition. Likewise, the full benefit applies when a subsequent non-elective procedure is done for a new condition by the same surgeon. The Ministry is working on a solution to address these rejections and will advise when it is in place. In the interim, in situations where a subsequent operation is rendered and the full benefit should apply, physicians should flag the second incoming surgical procedure for manual review with an explanation that the subsequent operation is due to a complication or a new condition. This will avoid the automated discounting of the claim. Please note that due to manual processing of the claim, payment may be delayed."

 

Interim Federal Health Program (IFHP)

The Interim Federal Health Program, funded by Citizenship and Immigration Canada (CIC), provides limited, temporary coverage of health-care costs to protected persons, including resettled refugees, refugee claimants, certain persons detained under the Immigration and Refugee Protection Act and other specified groups, who are not eligible for provincial or territorial health insurance plans and where a claim cannot be made under private health insurance. The program helps protect public health and public safety, and offers access to urgent or essential health services and products to some of the eligible groups above. The IFHP primarily offers five types of coverage: health care coverage, expanded health care coverage, public health or public safety health care coverage, coverage for the Immigration Medical Examinations, and coverage for detainees. The IFHP provides coverage to eligible beneficiaries, via a contracted claims administrator, through a network of registered health-care providers across Canada. Health-care providers are reimbursed directly for covered services rendered to eligible beneficiaries. - IFHP Program / Medavie Blue Cross

Syrian Refugee Relocation Aid - As of December 3, 2015...
"The OMA is deeply concerned for those impacted by the incredible disruption in war-torn Syria....The OMA ...encourages members to participate in the Syrian relief effort and will update members as the needs of the new refugee communities become known. For those interested in providing health care to refugees coming to your community, the memo from Minister Hoskins (https://www.oma.org/Resources/Documents/HoskinsMemoSyrianRefugees20151201.pdf) outlines the province’s plans to ensure health care delivery for those refugees resettling in the province. The federal government will be covering the costs associated with care for the first year in Canada. Medavie Blue Cross maintains a list of registered providers at http://www.ifhp-pfsi.ca so that private sponsors, clients and others stakeholders can readily identify providers in their community...."
- Ontario Medical Association

Other References:

  • Medavie Blue Cross - website
  • Gov't of Canada IFHP Program - Information for Health Care Professionals - website
  • List of IFHP Providers in Ontario- download

Become a Medavie Blue Cross Registered Provider

Refer to the IFHP Information Handbook for Health Care Professionals (PDF, 9.4 MB) to find out how to submit the registration form to become a Medavie Blue Cross registered provider.

Determine Client Eligibility

To ensure reimbursement for your services or products by the IFHP, you must verify that a patient is eligible for IFHP with Medavie Blue Cross before providing a service or product each time you see that patient, as a person may cease to be eligible or have their coverage changed at any time.

Before providing a service or product, you can quickly and easily verify your patient’s IFHP coverage:
•Call Medavie Blue Cross at 1-888-614-1880 (08:30 to 16:30 in each Canadian zone); or,
•Log into the secure section of the provider web portal.
•Use these resources to help you navigate the portal and provide services to your patient:

◦Quick Reference Guide – Verify Patient Coverage (PDF, 242 KB)
◦IFHP Information Handbook for Health Care Professionals (PDF, 9.4 MB)
Note that it takes at least two business days for coverage to be activated in Medavie Blue Cross’ system after it is issued by CIC.

Submit a claim and receive payment

You must not charge beneficiaries for services or products covered under the IFHP. You must directly bill the IFHP through Medavie Blue Cross. Claims can be submitted electronically via the provider web portal, by mail or can be faxed to 506-867-3841.

Before you provide treatment:

Ask patients if they are eligible for any other private health insurance program or plan that covers the service or product. If the patient has another plan or program, you cannot be reimbursed by the IFHP. Find out more about IFHP coverage types. See the Medavie Blue Cross Provider Portal for benefit grids for each coverage type.

After you provide treatment:

You must ask the beneficiary to sign the claim form before you submit it to Medavie Blue Cross. Submit a claim to Medavie Blue Cross:
•Online: Submit your claim through the Secure Provider Web portal
•By mail: Interim Federal Health Program Medavie Blue Cross 644 Main St. PO Box 6000 Moncton, NB E1C 0P9
•By fax: 506-867-3841
Consult the following Medavie Blue Cross guides for more information on how to submit a claim and receive payment: •IFHP Information Handbook for Health Care Professionals (PDF, 9.4 MB)
•Quick Reference Guide – Verify Patient Coverage (PDF, 242 KB)
•Secure Web Portal and Electronic Claims Submissions Service Guide (October 2011) (PDF, 125 KB)
•Electronic Dental Claims Quick Reference Guide (PDF, 110 KB)
•Claims Procedures for Point of Sale (POS) Claims Transmissions (PDF, 73 KB)

Resource: Government of Canada Citizen and Immigration - IFHP - website