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: General Surgery, Gastroenterology, Anaesthesia, GP-Anaesthesia
Date Issued: June 27, 2024

Background

As of April 1, 2023, the Schedule of Benefits – Physician Services (Schedule) includes changes to fee codes for excision of polyps during colonoscopy. This change introduces new fee codes that reflect the size of polyps that are removed.

Note that fee codes for polyp fulguration have been removed from the Schedule, reflecting current best practices.

Excision of polyps

Claims tip: The largest excised polyp that is 3 to 29 mm should be used to determine the appropriate fee code to claim as one of Z571, Z518, Z517 or Z516). Note that the largest polyp does not need to be removed first.

Polyps less than 3 mm

Consistent with the previous version of the Physician Schedule of Benefits, excision of polyps less than 3 mm are not eligible for payment.

Removal of largest polyp – 3 to 29 mm

Four new fee codes have been introduced for the resection of the largest polyp during colonoscopy. Although these are named “first polyp” the order of excision is not relevant to claims submission.

Only one of these fee codes is eligible for payment per patient per day.

  • Z571 – excision of first polyp – polyp size from 3 to 5 mm
  • Z518 – excision of first polyp – polyp size from 6 to 9 mm
  • Z517 – excision of first polyp – polyp size from 10 to 19 mm
  • Z516 – excision of first polyp – polyp size from 20 to 29 mm

Note that if more than one of these fee codes is submitted for the same patient on the same day, the additional fee code(s) will pay at zero.

Removal of additional polyp(s) – 3 to 29 mm

Four new fee codes have been introduced for the resection of additional polyps (if applicable) during colonoscopy.

A maximum of two services of any combination of these fee codes, E720, E520, E519, or E518, are eligible for payment per patient per day.

  • E720 – excision of additional polyp – polyp size from 3 to 5 mm
  • E520 – excision of additional polyp – polyp size from 6 to 9 mm
  • E519 – excision of additional polyp – polyp size from 10 to 19 mm
  • E518 – excision of additional polyp – polyp size from 20 to 29 mm

Note that if more than two of these fee codes are submitted for the same patient on the same day, the additional fee code(s) will pay at zero.

Removal of sessile polyps greater than 30 mm (3 cm)

Large sessile polyps (over 30 mm) excised through the colonoscope will continue to be payable using fee code E685.

Excision of these polyps does not contribute to the maximum of three excisions of polyps less than 30 mm eligible for payment per patient per day.

Fulguration of polyps

Fee codes for fulguration of polyps (Z570 and E719) have been removed from the Schedule to reflect current practice.

Fee codes Z497, Z499, Z492, Z493, Z496, Z494, Z498, Z495, Z491, Z555, and E685 include fulguration, if performed.

Examples

Example 1 – excision of more than 3 polyps (all larger than 3 mm)

Dr. Cousineau performs a routine follow-up colonoscopy of a 72-year-old patient and removes one 15 mm polyp, one 8 mm polyp and three polyps ranging between 3 mm and 5 mm.

What fee codes are eligible for payment to Dr. Cousineau for the excision of these polyps in addition to the appropriate colonoscopy fee code(s)?

Explanation

  • The largest polyp excised was 15 mm therefore fee code Z517 is eligible for payment.
  • Excision of the 8 mm polyp is eligible for payment using fee code E520.
  • Excision of one of the polyps between 3 and 5 mm is eligible for payment using fee code E720.
  • A maximum of three polyps from 3 to 29 mm are eligible for payment.
  • The additional excised polyps are not eligible for payment.

Example 2 – fulguration of polyps

Dr. Ahmad performs a colonoscopy on a 55-year-old patient, because of a positive fecal occult blood test. In the descending colon Dr. Ahmad excised three 5 mm polyps and fulgurated two smaller polyps.

What fee codes are eligible for payment to Dr. Ahmad for treatment of these polyps in addition to the appropriate colonoscopy fee code(s)?

Explanation

  • The largest polyp excised was 5 mm, therefore fee code Z571 is eligible for payment.
  • Excision of the second and third 5 mm polyps are eligible for payment using fee code E720 which may be claimed twice.
  • Fulguration of the additional polyps are included in the base fee for the colonoscopy and are not eligible for payment as polyp excision fee codes.

Example 3 – excision of a sessile polyp larger than 30 mm

Dr. Brennan performs a colonoscopy to investigate intermittent episodes of bleeding. During the procedure Dr. Brennan excises a 35 mm sessile polyp in the patient’s colon and removes three additional polyps (12 mm, 8 mm and 4 mm).

What fee codes are eligible for payment to Dr. Brennan for treatment of these polyps in addition to the appropriate colonoscopy fee code(s)?

Explanation

  • Fee code E685 is eligible for payment for the removal of the 35 mm sessile polyp.
  • Excision of the 12 mm polyp is eligible for payment using fee code Z517.
  • Excision of the 8 mm and 4 mm polyps are eligible for payment using fee codes E520 and E720 respectively.

Example 4 – excision of polyps less than 3 mm

Dr. Brennan performs a repeat colonoscopy on the same patient one year later. Dr. Brennan identifies no polyps 3 mm or greater but does remove three 2 mm polyps.

What fee codes are eligible for payment to Dr. Brennan for treatment of these polyps in addition to the appropriate colonoscopy fee code(s)?

Explanation

  • Excision of polyps less than 3 mm are included in the base fee for the colonoscopy and are not eligible for payment as polyp excision fee codes.

Keywords/Tags

OHIP Claims; OHIP Payment; Colonoscopy; Polyps; Fulguration; Excision; General Surgery; Gastroenterology; Anaesthesia

More information

InfoBulletin 231203

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 billing or claims submission inquiries, please contact the Service Support Contact Centre (SSCC) by email or by calling 1-800-262-6524.

To provide feedback on EPC Billing Briefs, or to suggest topics for future EPC Billing Briefs, send an email to the attention of the joint Ministry of Health/OMA Education and Prevention Committee.

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.

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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 .