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: Academic Physicians; Clinical Fellows
Date Issued: August 9, 2023

The Supervision of Postgraduate Medical Trainees section of the Schedule of Benefits – Physician Services (Schedule) (beginning on page GP79) specifies that claims submitted by a Resident or Clinical Fellow with an OHIP billing number to OHIP for insured services that they provide are only eligible for payment under certain specific circumstances

Common claims issues

  • A Clinical Fellow with an OHIP billing number submitting claims (other than surgical assistant services) while working in their training program.
  • A Clinical Fellow submitting a claim as second surgical assistant using an inappropriate fee code.

Services provided by a Postgraduate Medical Trainee with an OHIP billing number while working outside of their training program

Except for surgical assistant services by Clinical Fellows with OHIP billing numbers (see explanation below), other insured services such as assessments, consultations, operating surgeon “A” suffix procedure codes, etc. that are provided by a Postgraduate Medical Trainee within their training program (including “on call” services) are not eligible for payment to the Trainee.

Some of these services may be eligible for payment to the Supervising Physician if the payment rules specified in the Schedule have been met (see pages GP81-84).

Please see EPC Billing Brief – Billing by a Supervising Physician for OHIP services provided by Postgraduate Medical Trainees for additional information.

Surgical assistant services provided by Clinical Fellows with OHIP billing numbers

Where a procedure (as defined in the General Preamble – Supervision of Postgraduate Medical Trainees section of the Schedule) is rendered by a Clinical Fellow with an OHIP billing number under the supervision of a Supervising Physician, the procedure is eligible for payment to the Clinical Fellow as a surgical assistant if the procedure has basic units listed in the Schedule column headed with “Asst”. This includes where the Clinical Fellow acts as a surgical assistant or where they perform the procedure as primary surgeon. In this situation, the Supervising Physician should submit a claim as the operating surgeon (“A” suffix), and the Clinical Fellow should submit a claim as the assistant (“B” suffix).

Claims by Clinical Fellows are only payable for a second surgical assistant for procedures listed as eligible for a second assistant on page GP90 of the Schedule. Both assistants should submit their claims using the same “B” suffix fee code.

In exceptional circumstances, claims for second assistant services for other procedures may be considered for payment following review by a ministry medical consultant. Such claims should be submitted with the manual review flag, accompanied by a letter from the surgeon outlining the reason the second assistant was required.

Please note: E003B is not eligible for payment for second surgical assistant claims.

Services provided by a Postgraduate Medical Trainee with an OHIP billing number while working outside of their training program

Where a Resident or Clinical Fellow with an OHIP billing number is providing insured services outside of their training program (example, working without supervision at a location not affiliated with their training program), the insured service is not eligible for payment to a Supervising Physician.
 

In this scenario, the Postgraduate Medical  Trainee is working independently and would bill OHIP for the services provided.

Examples

Example 1:

Dr. Alejandrez is a Urology Clinical Fellow with an OHIP billing number. Dr. Alejandrez assesses a new patient in clinic, referred by the patient’s family physician to the Supervising Physician. Dr. Alejandrez provides all the elements of a consultation, including appropriate review with the Supervising Physician, Dr. So.

What is eligible for payment to each physician?

Explanation:

  • Dr. So is Dr. Alejandrez’s Supervising Physician and has fulfilled the payment rules specified on pages GP81-84 of the Schedule. A claim for a Consultation (A355A) is eligible for payment to Dr. So.
  • Dr. Alejandrez is working within their training program. Therefore, despite Dr. Alejandrez having a billing number, the service provided is not eligible for payment to them.

Example 2a:

The following day, Dr. Alejandrez participates in two surgical procedures with Dr. So for two different patients. The first patient undergoes a radical nephrectomy, and the second patient undergoes drainage of a kidney abscess.

For the first patient, Dr. Alejandrez provides surgical assistant services for the nephrectomy performed by Dr. So. For the second patient, Dr. Alejandrez performs the abscess drainage under Dr. So’s supervision.

What is eligible for payment to each physician?

Explanation:

  • Claims for the primary surgeon fee codes (S416A for the nephrectomy; S401A for the abscess drainage) are eligible for payment to Dr. So.
  • Claims as surgical assistant for both procedures (S416B and S401B), claiming basic and time units for each procedure, are eligible for payment to Dr. Alejandrez.

Example 2b:

Dr. McLean is another Urology Clinical Fellow with an OHIP billing number working with Dr. So. Dr. McLean also participates in the two surgical procedures described in Example 2a. In both cases, Dr. McLean and Dr. Alejandrez are present for the entirety of each procedure.

What is eligible for payment to Dr. McLean?

Explanation:

  • A claim for payment by Dr. McLean as second surgical assistant for the nephrectomy (using S416B) is eligible for payment because the procedure is listed in the table on GP90 of the Schedule as eligible for payment for a second assistant.
  • A claim for payment as assistant for the abscess drainage is only payable to one of the two Clinical Fellows because this procedure is not listed on GP90. It is unlikely that this procedure would have required a second assistant barring exceptional clinical circumstances. It is not appropriate to submit a claim for payment for this service with any other fee code (including E003B).
  • The two Clinical Fellows should discuss which one of them will submit a surgical assistant claim for this procedure.

Example 3:

Dr. Clauss is an Orthopaedic Surgery Clinical Fellow with an OHIP billing number currently completing a trauma fellowship with several different Supervising Physicians, including Dr. Freas. Dr. Clauss and Dr. Freas are involved in the surgical care of John Doe who is brought to the hospital following a severe motor vehicle collision with multiple fractures and other injuries. Mr. Doe is transferred urgently to the Operating Room where multiple fractures are repaired by the two surgeons. The procedure is eligible for the multiple trauma premium (E420A) which allows payment for two surgeons working concurrently.

What is eligible for payment to each orthopaedic surgeon?

Explanation:

  • Claims for a consultation (either personally performed or performed by Dr. Clauss in accordance with the Supervision of Postgraduate Medical Trainee payment rules) as well as the primary orthopaedic surgery (“A” suffix) codes that were performed by either surgeon during the operation are eligible for payment to Dr. Freas.
  • Dr. Clauss is providing services within the training program. A claim as a surgical assistant (“B” suffix) code for the duration of the time Dr. Clauss participated in the operating procedure (whether as primary surgeon or assistant) is eligible for payment to Dr. Clauss.
  • Claims for any assessment, consultation or procedural codes are not eligible for payment to Dr. Clauss.

Example 4:

Dr. Clauss, still a Clinical Fellow, has admitting privileges at a community hospital in a neighbouring town. Dr. Clauss provides locum Orthopaedic Surgery services at the hospital. These services are provided outside of the training program and Dr. Clauss is working as an independent orthopaedic surgeon with no supervision.

What is eligible for payment?

Explanation:

  • Claims for the insured services (assessments, consultations, procedures, etc.) provided by Dr. Clauss while working at the community hospital are eligible for payment to Dr. Clauss.

Example 5:

Dr. Zacharias is a resident in the final year of Infectious Disease sub-specialty training, who previously completed a residency in Internal Medicine and has an OHIP billing number. Dr. Zacharias completes an assessment of a repeat patient in the supervisor’s, Dr. Oja’s, clinic. During the assessment, Dr. Zacharias drains a subcutaneous abscess under local anaesthetic.

What is eligible for payment?

Explanation:

  • Dr. Zacharias is working within the residency training program and therefore claims for the services provided to the patient are not eligible for payment to Dr. Zacharias.
  • If Dr. Oja has fulfilled the requirements for Supervision of Postgraduate Medical Trainee specified in the Schedule, claims for the assessment and the procedure (Z101 – not associated with “Asst” units) that were performed by Dr. Zacharias, provided that the specified maximums have not been exceeded, are eligible for payment to Dr. Oja.
  • Note: Unlike Clinical Fellows with OHIP billing numbers, claims by Residents with OHIP billing numbers for surgical assistant fees for procedures performed within their training program are not eligible for payment, even if the procedure is associated with “Asst” units.

Example 6:

Dr. Zacharias works at a local multi-specialty clinic one Saturday a month, when not scheduled to work “on call” for their residency program. The clinic is not affiliated with Dr. Zacharias’ training program. Dr. Zacharias provides internal medicine assessments, consultations and some minor procedures (example, venipuncture) to patients at the clinic.

What is eligible for payment?

Explanation:

  • Claims for the insured services (assessments, consultations, procedures, etc.)  provided by Dr. Zacharias at the clinic are eligible for payment to Dr. Zacharias.
 

Keywords/Tags

Academic Medicine; Clinical Fellow; Postgraduate Medical Trainee; Resident; Supervising Physician; Supervision; OHIP Claims; OHIP Payment

More Information

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EPC Billing Brief: Billing by a Supervising Physician for OHIP services provided by Postgraduate Medical Trainees

Claims Contact Information

For additional information, please visit the Resources for Physicians and the How to Get Help with Billing Questions pages on the ministry website.

If you have any questions, please contact Inquiry Services, Service Support Contact Centre (SSCC) by email or by calling 1-800-262-6524.

The Ministry of Health (MOH) and the Ontario Medical Association (OMA) have jointly prepared this educational resource to provide general advice and guidance to physicians on specific billing matters.

The Ministry of Health (MOH) and the Ontario Medical Association (OMA)
have jointly prepared this educational resource to provide general advice
and guidance to physicians on specific billing matters.

The Ministry of Health and the Ontario Medical Association logos

Note: This document is technical in nature and is available in English only due to its limited targeted audience. This publication has been exempted from translation under the French Language Services Act. For questions or support regarding this document, please contact the Service Support Contact Centre (SSCC) by email or by calling 1-800-262-6524.

 

Remarque : Ce document est de nature technique et est disponible en anglais uniquement en raison de son public cible limité. Ce document a été exempté de la traduction en vertu de la Loi sur les services en français. Pour toute question ou de l’aide concernant ce document, veuillez contacter Les Services de renseignements, Centre de contact pour le soutien des services par courriel ou en téléphonant le 1-800-262-6524.