OHIP Billing Theory

* Fees accurate as of November 9, 2010

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)

Payment Programs

HCP RMB WCB

Payee “P” “S”

Diagnostic Codes

Identifies physician’s diagnosis – basis for treatment decisions Codes can be specific or vagueEx – 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)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

E542 – Tray fee $11.15 For procedures performed outside of

the hospital Ex IUD insertion, suturing, biopsies, etc

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

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

C003 General Assessment $71.20in Hospital

C002 Subsequent visits $30.10up to 5 weeks

C007 Subsequent visits $30.106-13 weeks (max 3 per week)

C009 Subsequent visits $30.1014 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)

“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