BILLING CORNER

Billing Corner

  • Schedule of Benefits
  • Your Billing Process
  • Billing Complaints
  • Q & A
  • Financial Planning
  • Out of Province Billing - IFHP
  • Relativity

Schedule of Benefits (SOB)

MOH OHIP Schedule of Benefits and Fees - January 24, 2022 (Effective November 1, 2021): Download accessible via the MOH website.

COVID19 Income Stabilization

  • Ontario Income Stabilization for Physicians As of April 29/20 - nil
  • Ontario MOH Loans / COVID-19 Advance Payment Program - download
  • Federal Assistance for Small Business Renters - 75% Rent Relief (CECRA) - download
  • OMA Summary of COVID-19 Income Stabilization Discussions Across Provinces - download(gated)

Other Resources:
www.CFIB-fcei.ca
Canada's COVID19 Economic Response Plan - download
Ontario Gov't Relief for Small Businesses - download
Federal Programs for Ontario Physicians - download

COVID19 CODES

OMA Documents: March 13, 2020; April 13, 2020 - FAQ;
OHIP/MOH Bulletins: March 13, 2020;


2019 MSPC List of Code Increases/Decreases/ New /Deleted

This can be downloaded through your account on the OMA website here . (gated)

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

  1. Contact the OAGS Tariff Committee:
    Outline your issues in an email to our OAGS office "Attn. Tariff Committee": info@oags.org .
  2. 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.
  3. Ministry of Health/ Service Support Contact Centre (M-F, 8am-5pm) - Phone: 1-800-262-6524 or SSContactCentre.MOH@ontario.ca

Resources:
https://www.health.gov.on.ca/en/pro/programs/ohip/default.aspx
https://www.health.gov.on.ca/en/pro/programs/ohip/docs/billing_questions_help.pdf
Sign up for the MOH/SSCC infobulletin for future billing notices and updated contacts:
https://mailchi.mp/ontario/infobulletin-en

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 addressed to our OAGS Tariff Committee. Just click on the question to open the respective answer....

Q. How do you bill for debridement and packing changes done in the OR for necrotizing fasciitis when the patient is no longer in the ICU? (#36 - Spring 2022)
A. There are no good specific codes for this, since all Nec. Fasc. Codes require the patient to be admitted to the ICU on the same day. Overall, there is no great way to bill this. What has been used by other members of the board includes; Z085 is debridement into tendons/ligament/bursa Z228 , which is technically a biopsy, requires sending tissue – same value In case you find an abscess and the procedure is on a limb, there are some specific I&D codes for each region under MSK, and the new code for abscess drainage under GA in the OR.
Q. What is the plan with the K083 code going forward? Is there a deadline after which it cannot be used?  And if so, what happens after that point?  Does this mean we are back to in person follow ups for all these pts or is there a different way (not OTN)? (#37) Spring2022
Yes. Deadline is September 30, 2022. After that deadline, the specific details are on OMA website PSA section. Basically, if preexisting relationship, then video pays 100% and phone pays 85%. New consult by video pays 100%. Codes and/or code modifiers for billing don't seem to be available yet but will be forthcoming.
Q. When OHIP no longer covers phone / video appointments, can we start charging privately for them? Correct me if I'm wrong, but the principle is that we can't charge for something that OHIP does cover, right? So, when OHIP doesn't cover virtual appointments anymore, are they fair game for private rates? I'm guessing quite a few patients would appreciate the option. (#33) Spring2022
A. The virtual codes have been extended until September of 2022. At that point, I suspect there may be a negotiated code for this work, but time will tell. Whether privately billable or not beyond that point will depend on whether a code of some variety covers it off.
Q. How do you bill laparoscopic release of the arcuate ligament for arcuate ligament syndrome? (#32) Spring 2022
A. it seems you should be looking in the cardiac section of the SOB Q15 R935 - Mesenteric or celiac artery repair - removal of band only I am assuming you are lysing the arcuate ligament to release the compression on the celiac artery. This code seems to fit. There is no laparoscopic premium for it.
Q. How should I bill a small bowel resection for ischemia with no anastamosis and no stomas? This comes up in "damage control mode" with a plan to return to the OR for a second look. S188, S165, and S177 all seem to match equally badly. (#31) 2021
It would depend on the indication for the operation. If you were truly operating as the person had an SBO, and at the time, you found a dead loop and patient was too sick to reconstitute, and planned second look, then S177 is appropriate. Laparotomy for mechanical obstruction with resection. If you were operating for known/suspected ischemia or sepsis, and resected with planned second look, then S188 would be most appropriate in the spirit as it was intended. Resection without anastomosis. I appreciate in brackets it says colostomy and mucous fistula, but intent is the same. If no anastomosis was performed you can not bill S165, which is resection with anastomosis "other". S162 would be another loose possibility "local excision lesion of intestine", but I think this is more for GISTs etc, and suggesting an ischemic loop is a "lesion" might be a bit of a stretch. If we ever get the chance to edit the SOB, S188 would change to reflect this scenario.
Q. Can I bill a K730 SOB page A29, when I speak to my radiologist for an IR procedure, request for an urgent CT or discuss a report?
A. No. A29. 4b and 4c specifically PROHIBITS it for the reasons you outlined.
Q. Income Stabilization During COVID19? (Apr.29, 2020)

Ontario Income Stabilization for Physicians As of April 29/20 - nil
Ontario MOH Loans / COVID-19 Advance Payment Program - download
Federal Assistance for Small Business Renters - 75% Rent Relief (CECRA) - download
OMA Summary of COVID-19 Income Stabilization Discussions Across Provinces - download (gated)

Other Resources:
www.CFIB-fcei.ca
Canada's COVID19 Economic Response Plan - download
Ontario Gov't Relief for Small Businesses - download
Federal Programs for Ontario Physicians - download

Q. I am a bit confused on the COVID billing. Should I use K080, K081, and K082 for my minor or intermediate assessments, or should I ONLY use K083Xmultiplier? If only K083, then what are the appropriate multipliers, (i.e. Do I round to the closest amount to the actual value of the call - whether up or down - or do I round up or down?

OMA Documents: March 13, 2020; April 13, 2020 - FAQ;
OHIP/MOH Bulletins: March 13, 2020;


Q. Is there any OHIP rule that states you need to bill for a procedure you did? For example, you do a toe amputation (R620 - $155.90) and the patient is readmitted POD 3 for a wound infection. They remain in hospital for 2 weeks as you manage their other comorbidities. Could you omit the procedure code and just bill the rounding codes (C122, C123, C032x8, and E083x12 - $482.50)? (April, 2020)
A. The short answer is no.
Surgical Preamble page SP3 paragraphs 10 and 11 in the SOB.
10. When a procedure is performed, a procedural benefit, if listed, should be claimed. Substitution of consultation and/or visit benefits for procedural benefits (except as in paragraph 11), is not in keeping with the intent of the benefit schedule.
11. When a surgical benefit (non-IOP, Complete Care, Fracture or Dislocation) is less than the surgical consultation benefit, and the case is referred, a physician may claim a surgical consultation benefit instead of the surgical benefit. However, to avoid the consultation being counted as such under the Ministry of Health and Long-Term Care limitation rules on the number of consultations allowed per year, the physician should claim the consultation fee under the surgical procedure nomenclature or code. Since the consultation is replacing a procedural benefit which includes the pre- and post-operative and surgical care, no additional claims beyond the consultation should be made.
Q. Apparently, the OHIP computers have been updated with the new fee codes. S205 and S206 pay $0. The new appendectomy code is Sxxx. Does anyone know how to bill this code? (April, 2020)
It's S207 in the new SOB which is downloadable. http://www.health.gov.on.ca/en/pro/programs/ohip/sob/physserv/sob_master20200331.pdf
Q. What do you bill for an ACS model? DocA sees patient, books for Appy. Bills a035 and e082 plus visit premiums. DocB does the case the same day, bills C033 and Appy codes. Sign over day next day, DocC bills C033 and the following days bills C032 E083, C124 E083 discharge day if applicable. This sound right? (April, 2020)
A. So I would bill that a little differently.
If the patient was "referred" then I would bill a consult using the referring physician's billing number. For example, a referral from a surgeon at a smaller hospital refers someone they can't operate on, I would bill a consult using their number.

For a transfer, when the decision to operate has already been made (like an appy or a gallbladder), you may only be able to bill a visit, or can try a consult using your colleague's billing number a referring number. GP26 suggests that a patient is transferred, only one assessment fee is billable per admission (so the A035 will negate the C033). If it was an SBO, tics that you later decided to operate on, then a full consult should be billed, (as you will lose 2 days of billing before the surgery).

For post op care, I tried to find the language but couldn't. On GP28 it suggested that if a patient is transferred to your care, subsequent visits should be calculated based on the admission date. I believe this was clarified for us as follows.

So if you are being handed over a post op, you should only bill as if you did the surgery, so only 2 days post op (C032/E083) and day of discharge (C124/E083).
Q. Temporary COVID 19 Telephone/Virtual Code Questions: 1. What do I bill for an A034 done on the phone? a) K080 $23.75 OR b) 5 Units of K083 $25.00 2. What after hours premium do I apply to to any of these codes if done after 17:00? (March, 2020)
A1. You should bill 5 units of K083@ $25. I don’t think you can bill after hours premiums, as there was no “special visit”.
A2. If you are billing an elective visit after 5pm, then no special premiums apply. So, just the 5 units. I'm not sure I can think of a scenario where I would have to call a patient on call after hours. Even in COVID times, it should be able to wait until morning.
Q. How should I bill surgery for an incarcerated umbilical hernia with small bowel obstruction that doesn’t require bowel resection, where the umbilical hernia is repaired primarily? What if the hernia repair required mesh? (Jan.2020)

S175 (Intestinal obstruction (mechanical)….without resection) pg S18
If elective then bill S332/E757 (umbo hernia repair without resection of strangulated contents.) pg S30
method of repair is not relevant - mesh or primary - in this case.

- Tariff Chair

Q. Does OAGS have a policy on what the required minimum amount of call or minimum urgent case volume an Ontario General Surgeon should do to be deemed competent? … my division would like to give up most of their calls but want to remain full time on staff which is against out hospital policy. However, we do not have a policy of what is the maximum number of calls one can give up without affecting their resource allocation, nor do we have a policy of what the minimum number of calls a General Surgeon must/should do to remain competent. (May, 2019)

A. OAGS does not have a policy or recommendation on a "minimum" number of call nor on maintenance of competency. We have a statement regarding "maximum" number of calls. Competency to maintain practice is determined by the College of Physicians and Surgeons of Ontario and this question would be better answered by the CPSO. - OAGS

A. "The College considers a physician’s scope of practice to include the clinical areas in which they have engaged in during the immediate past 2 years. Beyond this 2 year threshold, the College does not set minimums for number of clinical cases, hours, or days spent in a particular practice area in order for a physician to maintain competence. Physicians are expected to keep up with their CPD requirements and any competency requirements stated by institutions in which they work (such as hospitals). Otherwise, we expect physicians to engage in self-reflection with respect to their own competency and limitations, and to report to the College if they have been out of an area of clinical practice for 2 years or more and wish to return." - CPSO, Re-Entry and Change of Scope, Applications and Credentials Department

Q. How do I bill re-excision of a malignant skin lesion which had positive margins? Can I bill the excision twice since both were done with curative intent for malignant lesion? What if the second excision done for positive margins has negative pathology? Can I still bill as malignant lesion? (March, 2019)
A. I have billed it twice as the intent for malignant excision is there. Same for pre-malignant. There really isn't a "re-resection" code, unless you flapped or zplasty it. I guess technically if you need to go back, your first "excision" could be considered a "biopsy", but I think the intent is complete resection both times, so I would bill it twice. - OAGS Response
Q. Is there a code I can bill when I personally perform a water soluble contrast enema on my patient with suspected large bowel obstruction (because we do not have an on site radiologist)? I take the patient to the xray dept, put them on the xray table, insert the catheter into their rectum, flow in the contrast, don leaded gown and work with the xray tech to generate the required images, and read the images to get an answer to my question of whether there's a complete obstruction. This usually happens after hours (is there a premium for that?), but can be in daytime during a stretch when we won't have a rad for several days. (Feb., 2019)
A. The radiology fee code is X112 which pays a pittance is only $29. No good ideas. - OAGS Response
Q. How do you bill colonoscopies post bowel resections? For example, if the patient had a previous right hemicolectomy and you intubate terminal ileum, do you bill a Z498, E740, and E705, because they no longer have a hepatic flexure or cecum? (Feb, 2019)
Part 1: We believe the correct way is to bill it as you describe, although it is a judgment call whether you cut off at the splenic flexure or hepatic flexure. You bill for the sections visualized, including the terminal ileum, and don’t bill for the sections not visualized. Billing the terminal ileum should mean going several centimeters past the anastomoses - not just looking at the anastomoses. That said, there are a lot of colonoscopies that are billed to the cecum that do not have a cecum, and the ministry billing computer doesn’t seem to have an understanding of colonic anatomy and accepts billing for parts that are missing and does not require all contiguous segments to be billed. There was an issue in the past for some researchers as well as for early versions of the provincial score cards as the algorithms for determining a complete colonoscopy did not make adjustments for the lack of a right colon, and surgeons who have many patients with right colectomies were perceived as having lower cecal intubation rates, when in reality it was just them being honest about their they billing codes. My understanding is that the current score card accounts for the lack of a right colon and does not consider an incomplete colonoscopy in a person with a right colectomy as a true incomplete colonoscopy. At least if you fill out the CIRT tool correctly and they had their right colectomy in Ontario. Our recommendation is that you bill only for the segments visualized.
Part 2: That being said, there is the intent of the code as well. It is outdated to bill all of this in sequence. The spirit of the code (could be) "how far did you get"? So, if you get to the "neocecum" after Right hemi, your call to bill to HF vs. "cecum" but you have essentially completed a full examination of the patients colon. I'm not sure CCO has rectified the OHIP vs. CIRT data for its calculations but has done so for our report cards. That being said, I'm not sure every colonoscopy site has to do this as of yet, does it? I would also suggest billing in sequence. If right colectomy, bill to HF. If sigmoid colectomy or left colectomy, thenbill to cecum, all four codes, but again my opinion. In hopefully the not so distant future, we can rewrite some of these codes to eliminate this issue as well as simplify billing.
Q. Can i bill a travel premium like K961 and first part seen k992? (Jan.2019)
Yes, you can. Make sure you bill the "A" prefix with the visit for all special visits though. Even though an inpatient C035, if special visit also being billed, bill the A035. As well, you need to travel to bill a special visit during the day. (i.e. you can't bill a special visit during the day if you don't have to travel to see the patient.) They need to be billed together. I believe the same is true for sacrifice of office hours as it is the same time frame - if rendered during daytime hours (07:00 - 17:00 hrs Monday through Friday) in circumstances in which a travel premium is eligible for payment. (General Preamble 45) Sacrifice of office hours means an insured service rendered when the demands of the patient and/or the patient's condition are such that the physician makes a previously unscheduled non-elective visit to the patient at a time when the physician had an office visit booked with one or more patients but, because of the previously unscheduled non-elective visit, any such office visit was delayed or cancelled. (General Preamble 44) So, if you had to travel to the hospital to see a patient and sacrificed office hours to do so, you could bill the visit, the travel and the special visit premium.
Q. How to bill Special Visit Premiums: (Dec,2018)

A. The OMA Tariff Department has posted a number of Quick Reference Billing Guides on their website. Below is a table excerpt from the Special Visit Premium Guide:

Source: https://www.oma.org/wp-content/wp-private.php?filename=QRG-SVP-3Aug18.pdf (gated)

Q. How do you bill as both an assistant and as a surgeon for an elective surgical case that after 3 hours' delay gets cancelled?
A. Rules are the same for both.
Surgeon - Surgical Preamble, SP6 section 27. If cancelled prior to induction, bill a visit. If cancelled after induction and while scrubbed, bill time plus 6 units.
Assist - General Preamble GP57. Same...Pre-induction: visit. Post and scrubbed: time +6 units. The "Surgical Assist Standby" only applies to a delay longer than 30 minutes, but surgery is performed. If cancelled altogether, then previous rules apply.
Q. Are you allowed to bill for TPN care for the first 14 days after surgery needing S code? How about if the patient is under your care, can you bill for TPN while billing C032 code? (Oct, 2018)
A. Yes, you can bill TPN fee code during the first 14 days post op. The fee code descriptor is specific that it cannot be billed in addition to hospital visits. A hospital visit pays slightly more so it makes more sense to bill a hospital visit if the patient is not within 14 days of Non-Z code surgery.
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. G510 Management of parenteral alimentation - physician in charge per visit...21.00, Page J44
Q. For surgical assisting, can you bill an A034 code for all patients in addition to the time units? (Oct, 2018)
A. You cannot bill an assessment A034 along with the assist codes. The assist codes include any assessments, attendance, assistance perioperatively that my be required.
Q. How would one bill removal of old Prolene sutures from remote umbilical hernia repair? I basically had to dissect the umbilical stalk up, cut out the sutures (some of which were coming through the skin), and then tack the umbilical stalk back down. All I can see is removal of foreign body, which seems minimal. Removal of infected sutures seemed a better bet, but it stipulates under GA. (Sept, 2018)
A. I would try # R517- Excision of foreign body .. $107.70, Page N3 under wound care. I can’t see anything in the description that would preclude it.
Q. Emergent surgery in patient from BC (out-of-province): How do I bill that, given they don't have an OHIP number? Also, are follow-up appointments in office payable, since I have had to do all his wound care and stoma care myself? (Homecare will NOT help for out of province patients.) (Sept, 2018)
A. For out-of-province patients, except Quebec, your billing program will bill the province directly. You just need to enter the province code in the appropriate spot (BC in this case) and their provincial health number. They will pay Ontario rates (except Quebec) for your billed services. For Quebec, you need to fill out a paper form.
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."

 

Financial Planning

Retirement Plan: Projecting your Savings, by Dr. Chris Vinden - download

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

LINKS OF INTEREST:
Out of Province Claim Form for Physician Services: download
Interim Federal Health Program – Information for health-care professionals: download
Information Handbook For Interim Federal Health Program Health-care Professionals: download
MOHLTC Fact Sheet for Healthcare Providers Re. Syrian Health Care Services:download
Medavie Blue Cross Health Professional Centre: https://www.medaviebc.ca/en/health-professionals
Schedule of Benefits: http://www.health.gov.on.ca/en/pro/programs/ohip/sob/

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 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
◦IFHP Information Handbook for Health Care Professionals
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

Relativity

See the Relativity Section here.