OHIP Billing Theory

1. OHIP Billing Theory * Codes accurate as of November 1, 2011

2. 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

3. 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

4. Provider Billing Number • Identification number used on all billing and correspondence with the Ministry 0000-123456-00 Group Identification Number Specialty Identification Number Unique Billing Number

5. Claim Types • HCP – Health Claims Program • RMB – Reciprocal Medical Billing • WCB – Worker’s Compensation Board • Payee • “P” - Provider • “S” - Subscriber (Patient)

6. 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

7. Service (Billing) Codes • Identifies which service has been provided and determines fee • Example: A 003 A Alpha Prefix Numeric Component Alpha Suffix

8. Alpha Prefix • Indicates: • Type of service • Where service occurred • Circumstances of service

9. Alpha Prefix

10. 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

11. Alpha Suffix • Identifies who has rendered the service Physician Services / Procedures

12. Alpha Suffix • Diagnostic Tests • Sometimes can be billed in two components: Professional and Technical

13. MOH Age Definitions

14. Commonly Used Codes Family Practice

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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)

22. 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

23. 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

24. 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

25. Obstetrical Services • P003 General Assessment (Major Prenatal visit) • first visit once pregnancy is confirmed • P004 Minor Prenatal Assessment • P005 Antenatal Preventative Health Assessment • Initial review of antenatal risk including psychosocial, genetic and medical issues • Testing performed - Only 1 per pregnancy

26. 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

27. 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

28. 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

29. 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

30. 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)

31. 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)

32. 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

33. 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

34. 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

35. 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

36. 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

37. 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

38. 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

39. Health Claim Form • Used to submit OHIP and WCB claims • Used • For Reciprocal Claims, use the Out of Province Claim form

40. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 • Provider Billing Number • Patient Health Card Number • Patient Health Card Version Code • Patient Date of Birth • Optional Account Number • Payment Program • Payee • Referring Provider Number • Master Facility Number • Inpatient Admission Date • Service (Billing) Code • Fee Submitted • Number of Services • Date of Service • Diagnostic Code

41. 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

42. Answer

43. 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

44. 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