OHIP Billing Theory

OHIP Billing Theory

* Codes accurate as of November 1, 2011

Ontario Health Insurance Plan (OHIP)

Operated by the Ministry of Health and Long-Term Care (MOH) Set fees for services in negotiation with

professional organizations, such as the Ontario Medical Association (OMA)

Decides which services will be insurable

Produces the Schedule of Benefits

Registering with OHIP

Two requirements for registering with the provincial health plan: Must hold a valid certificate from the

College of Physicians and Surgeons of Ontario (CPSO)

Must have an Ontario practice address

Once registered, the provider will receive a permanent Billing Number

Provider Billing Number

Identification number used on all billing and correspondence with the Ministry

0000-123456-00Group Identification Number

Unique Billing Number

Specialty Identification Number

Claim Types

HCP – Health Claims Program RMB – Reciprocal Medical Billing WCB – Worker’s Compensation

Board

Payee “P” - Provider “S” - Subscriber (Patient)

Diagnostic Codes

Identifies the reason for a service or procedure (diagnosis) Based on ICD-9 coding

Examples: - 460 Common cold - 388 Wax in ears - 477 Hay fever; rhinitis - 487 Influenza - 009 Diarrhea - 787 Gastrointestinal symptoms – vague

Service (Billing) Codes

Identifies which service has been provided and determines fee Example:

A 003 AAlpha Prefix

Numeric Component

Alpha Suffix

Alpha Prefix

Indicates: Type of service Where service occurred Circumstances of service

Alpha Prefix

Prefix Meaning

A Office Visit

B Special Visit to Patient’s Home

C Service to Hospital In-Patient

E Extra Premiums or Procedure Fees

G Diagnostic and Therapeutic Procedures

H ER Visit; Newborn Care

K Psychotherapy; Counselling

P Obstetrical Care

W Visits to Long-Term Care Facilities

Numerical Component

Identifies the type and/or complexity of the service

001 is a Minor Assessment

003 is a General Assessment

007 is an Intermediate Assessment

Alpha Suffix

Identifies who has rendered the service

Physician Services / Procedures

Suffix Meaning

A Provider or their staff rendered service

B Assistant rendered service

C Anaesthetist rendered service

Alpha Suffix

Diagnostic Tests Sometimes can be billed in two

components: Professional and Technical

Suffix Meaning

A Provider performed both components

B Provider performed technical component

C Provider performed professional component

MOH Age Definitions

Definition of Age for Billing

Newborn From birth up to and including 28 days of age

Infant Aged 29 days up to and less than 2 years old

Child Aged 2 years up to and including 15 years

Adolescent Aged 16 and 17 years

Adult Aged 18 and over

Commonly Used Codes

Family Practice

Consultations / Visits

A007 Intermediate Assessment/ Well-Baby Care Most frequently used code in family

practice Well-baby care refers to a periodic visit

made by an infant before the 2nd birthday

Indicated by DC 916

Consultations / Visits

A003 General Assessment A full assessment done in response to a

complaint or as an adolescent or adult Annual Health Exam (DC 917)

Can only charge for 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

Consultations / Visits A004 General Re-assessment

Performed if a patient returns for another assessment of the same problem

Paid at a lower rate because the provider will not need to perform all components of a General Assessment

A001 Minor Assessment Brief history, exam and advice

Consultations / Visits A005 Consultation

Performed by one provider upon written request from another referring provider

Provider 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 again for an unrelated complaint

Requires the billing number of the referring provider

Consultations / Visits

A006 Repeat Consultation Primary provider re-refers patient for a

follow-up on the same complaint as the original consultation

A777 Pronouncement of Death In a location other than the patient’s

home Includes counselling of relatives and

completion of the death certificate

Consultations / Visits A901 Housecall Assessment

An intermediate assessment done at the patient’s residence

Only billable for the first patient seen at a location Can charge a premium for evening, night, weekend,

or office hour visits

A902 Housecall – Pronouncement of Death In the patient’s home Includes counselling and completion of the death

certificate

Consultations / Visits

A903 - Predental/Preoperative General Assessment Evaluation of patient’s health and to

determine whether anesthesia or surgery will present risks

(maximum of 2 per 12-month period)

Consultations / Visits

K017 Annual Health Exam For a child between 2-15 years No complaint (diagnostic code) needed Includes primary and secondary school

exams

A008 Mini Assessment Used when patient is seen for a WSIB

assessment, but also seeks care for an unrelated complaint

WSIB is billed for a minor assessment and OHIP is billed for the mini assessment

Consultations / Visits

E079 Initial Discussion with Patient Re: Smoking Cessation Limited to 1 per 12 month period Documentation must prove the

discussion took place

K039 Smoking Cessation Follow up Visit E079 must occur previously in the 12

month period Max 2 per year

Consultations / Visits

K013 Individual Care / Counselling Billed in ½ hour units Used for the first three units per 12-

month period

K033 Individual Care / Counselling Billed in ½ hour units Used for any additional hours of

counselling in the 12-month period

Obstetrical Services

P003 General Assessment (Major Prenatal visit) first visit once pregnancy is confirmed

P004 Minor Prenatal Assessment

P005 Antenatal PreventativeHealth Assessment Initial review of antenatal risk including

psychosocial, genetic and medical issues

Testing performed - Only 1 per pregnancy

Obstetrical Services

P006 Vaginal Delivery Includes assessment of the patient on

admission, attendance at labour, delivery of baby and care of mother and baby immediately following delivery

P009 Attendance at Labour and Delivery If the family physician attends the mother

but another physician performs the delivery

Obstetrical Services

P007 Postnatal Care in Hospital Flat fee to include all postnatal visits to

mother in hospital

P008 Postnatal Care in Office Flat fee for the postnatal examination

of mother in the office

H001 Newborn Care in Hospital Flat fee to cover all care for newborn in

the hospital for up to 10 days

Hospital In-Patient Visits

C003 General Assessment in Hospital If first assessment for this patient in the 12-

month period for the diagnosis Can add E082 premium (30%) if MRP

Most Responsible Physician (MRP) Visits Can be claimed if family physician is most

responsible physician for the patient while in hospital

C122 – second day following admission C123 – third day following admission C124 – day of discharge, if patient has been in the

hospital for 48 hours

Hospital In-Patient Visits

Subsequent Visits C002 7 visits per week for the first 5

weeks

C007 up to 3 visits per week in weeks 6-13

C009 up to 6 visits per month from week 14 on

E083 premium that can be added to MRP and subsequent visits

Hospital In-Patient Visits

C008 Concurrent Care Claimed for visits by the family physician

if a surgeon or specialist is also asked to visit

No more than 4 visits the first week and 2 per week thereafter

C010 Supportive Care Minor assessments by the non-MRP for

liaison (max 4 times in first week, 2 thereafter)

Procedure Codes

Venipuncture +G480 - Infant +G482 - Child +G489 - Adult

Hyposensitization (Allergy Injection) G202 - if performed with visit G212 – if sole reason for visit

Urinalysis G010 – routine without microscopy

(dipstick urinalysis)

Procedure Codes

Immunization +G590 Influenza Agent (Flu shot) +G848 Varicella (VAR) – Chicken Pox

Pap Smear (Papanicolaou) +G365 periodic – 1 per 12-month

period +G394 Additional – for follow-up of

abnormal or inadequate smears

Premiums / Additional Fees

G700 Basic Fee – Sole Reason for Visit Claimed when a procedure is the sole

reason for a visit to a doctor’s office Used with procedure codes marked with

“+” if no assessment is performed

Premiums / Additional Fees

Age Premiums Family physicians receive a 15% premium

for patients 65 and older on general and intermediate assessments and housecall assessments

Special Visit Premiums Extra fees if the provider sees a patient

outside of working hours (after-hours, weekends, holidays), or sacrifices office hours to assess a patient at another location

Premiums / Additional Fees

First Person Seen Premium Payable for the first person seen at a

destination if the service meets specific criteria

Additional Person Premium Payable for additional people seen at a

destination, up to a maximum

Premiums / Additional Fees

Travel Premiums Payable if the provider had to travel

from one location to another to assess a patient

Only payable once, even if multiple patients are seen

Premiums / Additional Fees

E542 – Tray fee For procedures performed outside of

the hospital Ex IUD insertion, suturing, biopsies, etc

E430 PAP Smear Premium Can be added to A005, A006, A003,

A004, routine postnatal if performed outside the hospital

Family Health Group

Q200 New Patient Accepted to Practice Fee for filling out rostering form Applies to forms filled out by new and

current patients

Q013 New patient Registration Fee Bonus for taking a new patient into an

already full practice

Health Claim Form

Used to submit OHIP and WCB claims Used

For Reciprocal Claims, use the Out of Province Claim form

1

2 3 4 5 6 7

8 9 10

11 1312 14 15

Example

Ursula Hyatt is seen for an annual health exam. While she is there, Dr. Newman (0000-652145-00) also takes blood, performs a basic dipstick urinalysis and a pap smear:

Ursula Hyatt OHIP number: 9824 556 551 GV DOB: May 28, 1968

Answer

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 does not match the policies and regulations of the billing guidelines

Physician must submit documentation supporting the need for the claim