OHIP Billing Theory

1. OHIP Billing Theory * Fees accurate as of November 9, 2010

2. Provider Registration • Identification number used on all billing and correspondence with the Ministry • 12 digits • First 4: Group ID (0000 if solo practice) • Second 6: Provider ID • Last 2: Specialty identifier (00 if general practice)

3. Payment Programs • HCP • RMB • WCB • Payee • “P” • “S”

4. Diagnostic Codes • Identifies physician’s diagnosis – basis for treatment decisions • Codes can be specific or vague Ex – 460 common cold - 388 Wax in ears (goes with G420 – syringing) - 477 Hayfever (often used with G202, G212) - 487 Flu shots (often used with G590, G591) - 917 Annual Health Exam (with A003) - 916 Well Baby Care (with A007)

5. Service Code • Identifies which service has been provided and determines fee • Configuration: 1 3 1 • Alpha Prefix: indicates where service occurred or under what circumstances • Can also indicate category of service • Ex “A” General “C” Acute Inpatient service “W” Long term facility inpatient service “H” Emergency service or rehabilitation service

6. Service ID: identifies the type and/or complexity of the service • Ex 003 is a general assessment 001 is a minor assessment 007 is an intermediate assessment

7. Alpha Suffix: identifies who has rendered the service • A means the provider was responsible for the service – or performed both the professional and technical portions of a diagnostic and procedures code • B means the provider assisted during the service – or performed only the technical component of a diagnostic and procedures code • C means the provider administered anesthetic – or performed only the professional component of a diagnostic and procedures code

8. Codes with a # beside them have both a technical and a professional component, and those can be billed separately or together • Ex #P018 – Caesarean Section

9. Independent Consideration • - Codes marked with IC require special evaluation before a fee can be determined • - set fee is not listed • - service isn’t listed in schedule • - Must be submitted with supporting documentation and reviewed by a consultant at an OHIP office

10. Manual Review • Occurs when a claim is submitted that violates the policies and regulations of the billing guidelines • Physician must submit documentation supporting the need for the claim

11. Commonly Used Codes • A003 General Assessment $71.25 • A full assessment done in response to a complaint, or as an annual medical checkup • Can only give 1 per 12 month period unless there is an unrelated diagnosis, or unless a new assessment is required for hospital admission more than 90 days since the original assessment

12. A004 General Re-assessment $35.40 • Performed as a follow-up to a general assessment (only limited history needed) • A007 Intermediate/Well-Baby $33.10 Assessment • Most frequently used code • Well-baby assessment applies whether the visit is for a checkup or is complaint driven

13. A001 Minor Assessment $20.60 • Brief history, exam, and advice • A005 Consultation $67.50 • Performed upon written request from a referring provider • Referee performs a general or specific assessment and submits findings to the referring provider • May only bill for 1 in a 12 month period, unless referred for an unrelated complaint

14. A006 Repeat Consultation $42.35 • Primary provider re-refers patient for a follow-up on the same complaint as the original consultation • E430 PAP Smear Premium $11.50 • Can be added to A005, A006, A003, A004, routine post-natal if performed outside the hospital

15. A901 Housecall Assessment $43.05 • An intermediate assessment done at the patient’s residence • Only billable for the first patient seen • Can charge a premium for evening, night, weekend, or office hour visits • A902 Housecall – Pronouncement $43.05 of Death • Includes counselling

16. A903 - Pre-dental/pre-operative general assessment $65.05 • (maximum of 2 per 12-month period) • A777 Pronouncement of Death $33.10 • In a location other than the patient’s home

17. K017 Annual Health Exam $41.60 • For a child between 2-15 years • No complaint needed • Includes primary and secondary school exams • A008 Mini Assessment $12.50 • Used when WSIB is billed for the minor assessment, but the patient is also seen for an unrelated complaint

18. E079 Initial Discussion with Patient Re: Smoking Cessation $15.40 • In addition to assessment • Limited to 1 per 12 month period • Documentation must prove the discussion took place • K039 Smoking Cessation Follow up Visit $33.45 • E079 must occur previously in the 12 month period • Max 2 per year

19. E542 – Tray fee $11.15 • For procedures performed outside of the hospital • Ex IUD insertion, suturing, biopsies, etc

20. P003 General Assessment $71.20 • Major Prenatal visit • P004 Prenatal Office Visit $33.10 • P005 Antenatal Preventative $41.65 Health Assessment • Initial review of antenatal risk including psychosocial, genetic and medical issues • Testing performed - Only 1 per pregnancy

21. P009 Assisting with Labour and Delivery $479.05 • H001 Newborn Care $52.20 • Care for newborn in the hospital for up to 10 days • K013 Individual Counseling $58.35 • Billed in ½ hour units

22. C003 General Assessment $71.20 in Hospital • C002 Subsequent visits $30.10 up to 5 weeks • C007 Subsequent visits $30.10 6-13 weeks (max 3 per week) • C009 Subsequent visits $30.10 14 week on (max 6 per month) • C010 Supportive Care $18.30 • Minor assessments by the non-primary physician for liaison (max 4 times in first week, 2 thereafter)

23. “G” codes are procedural codes • Most are preceded by a + and can be billed in addition to the assessment • If the “+” procedure is the only reason for the visit, a G700 can be billed ($5.10) instead of an assessment code • +G480 Venipuncture Infant $9.90 • +G482 Venipuncture Child $7.35 • +G489 Venipuncture Adult $3.54 • G202 Allergy injection with visit $4.45 • G212 Allergy injection without visit $9.75