Visits related to a surgical procedure

Education and Prevention Committee Billing Briefs

Education and Prevention Committee (EPC) Billing Briefs are prepared jointly by the Ministry of Health (MOH) and the Ontario Medical Association (OMA) to provide general advice and guidance to physicians on billing matters.

Category: All physicians providing Surgical Services; Anaesthesiology; Surgical Assistants    
Date Issued: October 18, 2024
Date Updated: October 28, 2024 – Correction made to explanation under example 5a

Definitions

The following definitions are provided in the General Preamble section of the Schedule of Benefits – Physician Services (Schedule):

• Major preoperative visit – the consultation or assessment where the decision to operate is made, regardless of the time interval between the major preoperative visit and the surgery.

Visits included as specific elements of non-IOP surgical procedures (Schedule surgical fee codes not listed with a Z-prefix)

• Pre-operative hospital visits which take place one or two days prior to surgery.
• The hospital or day care admission assessment (or consultation) rendered by the surgeon on the day of surgery unless this constitutes the major pre-operative visit as defined above or is associated with a special visit for a non-elective surgical procedure.
• Post-operative care and visits to a hospital in-patient associated with the procedure for up to two weeks post-operatively except for:
  • The first and second post-operative visits in hospital (payable at the specialty specific subsequent visit fee; not payable as any of C122, C123, C142 or C143); and,
  • Subsequent visit by the Most Responsible Physician (MRP) on the day of discharge (C124) – provided that the payment requirements associated with that fee code have been met.

Visits eligible for payment in addition to a surgical procedure

• Major preoperative visit.
• Certain visits when a physician makes a special visit to perform a non-elective surgical procedure. (Note that this is not applicable for scheduled elective procedures where special visits do not apply):
  • Assessment (for existing patients or where there is transfer of care,) or
  • Consultation (if the case is referred and payment requirements related to consultations are met).
• Pre-operative hospital visits rendered more than two days prior to surgery.
• Assessment of a completely unrelated and significant problem at the time of a minor surgical procedure. Note that these claims should be submitted using the manual review indicator, along with documentation to support the assessment claimed.
• Post-operative care and visits to a hospital outpatient. Note that the two-week timeframe for visits that are not eligible for payment for in-patient visits (noted above) does not apply to outpatient visits.
• For Z-prefix surgical procedures, if the major pre-operative visit is rendered in the previous 12-months prior to the service by the same physician, only the following services are eligible for payment on the same day prior to the service:
  • A minor assessment if rendered by a family Physician, or
  • A partial assessment if rendered by a specialist.

Examples

Example 1: Assessment on the day of surgery (not the major pre-operative visit)

Dr. Simeon saw Ms. Juniper in consultation for intermittent right upper quadrant pain, diagnosed cholelithiasis, and booked Ms. Juniper for elective cholecystectomy. The surgery is scheduled three months later following this visit. At the time of the consultation, Dr. Simeon submitted a claim for A035A. This visit meets the definition of major preoperative visit.

Dr. Simeon reviews Ms. Juniper’s condition just prior to surgery, reconfirms Ms. Juniper’s consent and performs an uncomplicated cholecystectomy.

What is eligible for payment for the services provided on the day of surgery?

Explanation:

• S287A is eligible for payment for the surgical procedure performed.
• As the major preoperative visit was previously claimed and paid, the assessment provided just prior to surgery is included in the surgical fee. No additional visit fee is separately payable.

Example 2: Assessment on the day of surgery (major pre-operative visit)

Dr. Margareta, a general surgeon, is called to the Emergency Department to see Victor, a 13-year-old patient in consultation for sudden-onset right lower quadrant pain and fever. Dr. Margareta assesses the patient, makes a diagnosis of acute appendicitis, and arranges to take the patient to the operating room that day. In the operating room Dr. Margareta removes the patient’s appendix without any complications.

What is eligible for payment for the services provided on the day of surgery?

Explanation:

• S207A is eligible for payment for the surgical procedure performed.
• As the Emergency Department consultation (A035A) meets the definition of major preoperative visit, this visit fee is also eligible for payment.

Example 3: Assessment on the day of IOP surgical procedure (not the major pre-operative visit)

Dr. Caleb, an otolaryngologist, assesses a patient, Mr. Pullman, with hoarseness and determines the need for a laryngoscopy which is scheduled one week later. The initial visit meets the definition of major pre-operative visit, and a claim is submitted by Dr. Caleb using the applicable consultation or assessment fee code (example, A245).

One week later, Dr. Caleb reassesses Mr. Pullman and subsequently performs the laryngoscopy with biopsy.

What is eligible for payment for these services?

Explanation:

• Z293A (an IOP) for the laryngoscopy with biopsy and A244A for a partial assessment are eligible for payment.

Example 4: Assessment of a completely unrelated and significant problem at the time of a minor surgical procedure

Jennifer is a 56-year-old patient who is scheduled for a minor surgical procedure to revise a two cm post-surgical facial scar in Dr. Frazier’s (a plastic surgeon) clinic. Just prior to the procedure, Jennifer mentions to Dr. Frazier that there is a new, irregular pigmented leg lesion. Dr. Frazier assesses the new lesion, determines that it is pre-malignant and performs an excisional biopsy the same day.

What is eligible for payment for these services?

Explanation:

• R021A is eligible for payment for the planned scar revision procedure.
• An assessment (example, A083 or A084) is also eligible for payment for the evaluation of the unrelated skin lesion.
• R163A is eligible for payment for simple excision of the single pre-malignant skin lesion.
• Dr. Frazier should submit this claim with the manual review indicator, including documentation to support the additional assessment claim, and clarifying that it is unrelated to the scar revision procedure.

Note: The remaining examples all relate to the same patient scenario.

Example 5a: Non-elective surgery with a special visit

Dr. Deepak, an orthopaedic surgeon, travels to the hospital on Sunday afternoon to make a special visit to assess Ms. Minnes, a patient with a trimalleolar ankle fracture at the request of the emergency physician. Dr. Deepak determines that open reduction, internal fixation is required, and the surgical decision is made. The patient is admitted to the hospital by Dr Deepak who books the patient for surgery in the operating room schedule.

Dr. Deepak gets called back to the hospital the following evening (Monday) to perform the surgery, as that is when the operating room becomes available for non-elective cases.

What is eligible for payment for the services provided?

Explanation:

• A065A and associated special visit premium fee codes (in this case K963A and K998A) are payable to Dr. Deepak for the initial consultation, which also meets the definition of a major preoperative visit. As Dr. Deepak is the MRP and a visit is eligible for payment, the MRP admission assessment (E082A) is eligible to be added to the visit fee.
• Dr. Deepak may claim the surgical procedure (F077A) and evening procedural premium (E409A).
• No additional visit fee is eligible for payment to Dr. Deepak for Monday, as the consultation provided the previous day was the major preoperative visit, and the surgical procedure is a non-IOP (Z-prefix surgical procedure).
• As no assessment is eligible for payment on the day of surgery, travel and first person seen special visit premiums are not eligible for payment.
• Note that in a different clinical scenario where a specialist performs one or more Z-prefix surgical procedures and does not provide non-Z prefix services at the same time, a partial assessment may be claimed on the same day. In this circumstance, if all other criteria are met, a special visit premium may be eligible for payment.

Example 5b: Anesthesiology assessment on the day of surgery

Dr. Parks, an anesthesiologist, assesses Ms. Minnes immediately prior to the surgical procedure to repair the ankle fracture and subsequently provides general anaesthesia services for the procedure on the same day.

What is eligible for payment for these services?

Explanation:

• F077C (basic and time units) is payable to Dr. Parks for the time providing general anaesthesia to the patient.
• The general anaesthesia service includes a pre-anaesthetic evaluation (with specific elements as for assessments), the anaesthetic procedure and post-anaesthetic follow-up. No additional visit is eligible for payment.

Example 5c: Surgical assistant assessment on the day of surgery

Dr. Chen, a family physician, is working as surgical assistant for Ms. Minnes’ surgery. Dr. Chen introduces themself to the patient in the pre-op waiting area and reviews the patient chart and clinical status. Dr. Chen provides surgical assistant services during open reduction and internal fixation of Ms. Minnes’ ankle fracture.

What is eligible for payment for these services?

Explanation:

• F077B (basic and time units) is payable to Dr. Chen for the time providing surgical assistant services during the surgical procedure.
• Assessments on the day of surgery are not eligible for payment unless they are the major pre-operative visit, which would be expected to be rendered by the surgeon and not the surgical assistant, or unless they are unrelated to routine surgical care.
• Surgical assistant services include preparing the patient for the procedure and discussion with and providing advice and information to the patient on matters related to the service.
• Note that an assessment may be payable if Dr. Chen had rendered a separate, medically necessary assessment of the patient on the day of surgery (example, if Dr. Chen were called to the ward to assess the patient postop because of acute shortness of breath). The medical record must support that the assessment was not a routine element of the surgical procedure. The claim should be submitted using the manual review indicator accompanied by supporting documentation from the patient’s medical record. An assessment or consultation would not be payable if the service rendered was for preparing the patient for surgery or reviewing the risks/benefits of the procedure, etc.

Example 5d: Postoperative surgical visits

Dr. Deepak assesses Ms. Minnes on rounds on post-operative day 1 and day 2. Ms. Minnes is discharged home on day 2 post-op.

What is eligible for payment for these visits?

Explanation:

• C062 is payable to Dr. Deepak for the subsequent visit for post-operative day 1.
• For post-operative day 2, C124 (subsequent visit by MRP day of discharge) is eligible for payment if Ms. Minnes was discharged 48 hours or more following admission to hospital. However, had discharge taken place within 48 hours following admission, only C062 would be payable.

Keywords/Tags

OHIP Claims; OHIP Payment; Surgery; Surgical Service; Surgical Assistant; Anaesthesiology; Assessment; Consultation; Visit; Major-preoperative visit

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