Bulletin 4762 — Kaplan Board of Arbitration Award Year 4 — Release 2 Changes

Keeping Health Care Providers informed of payment, policy or program changes

To: Providers
Published by: Claims Services Branch, Ministry of Health
Date Issued: July 3, 2020

The Ministry of Health (ministry) and the Ontario Medical Association (OMA) have been working together to implement physician compensation increases in accordance with the 2019 Kaplan Board of Arbitration Award.

This will be achieved through amendments to physician compensation under contracts and to regulations under the Health Insurance Act, including the Schedule of Benefits for Physician Services (the Schedule).

Please see INFOBulletin #4753 for a summary of all Schedule changes effective April 1, 2020. These changes are being implemented in the OHIP claims system through phased releases.

Release 2 changes were implemented May 1, 2020 with an effective date of April 1, 2020 for the following Fee Schedule Codes.

New Fee Schedule Code R731-Tricuspid Valvuloplasty

• R731A is allowed with R727A (at 85%) if service is provided by same physician, same patient and same service date
• When submitting a claim for R731A, a diagnostic code, Master Number and admission date are required
• R731C is elgible for automated anaesthesia age premiums

New Fee Schedule Code E084-Subsequent visit and palliative care visit by the Most Responsible Physician premium

• If E083A and E084A are billed together on a weekend or a holiday, the E084A will pay 45% of the first relevant code found, and the E083A will pay $0 explanatory code ‘D7-Not allowed in addition to other procedure’
• When E084A and E083A are submitted together and the service date is not a weekend or a holiday, E083A will pay and E084 will pay at $0 with explantory code ‘V4-Date of service was not a Saturday, Sunday or statutory holiday
• E084 is only eligible for payment for subsequent visits provided on Saturdays, Sundays and holidays; if the service date is not a weekend or a holiday, E084 will be paid at $0 with explantory code ‘V4-Date of service was not on a Saturday, Sunday or statutory holiday’
• If E084A has been previously paid and a claim is submitted for E083, E083 will pay at $0 with explanatory code D7-Not allowed in addition to other procedure
• E084 is not eligible for payment for palliative care visits to patients in designated palliative care beds in a Long-Term Care Institution
• E084 is not applicable to any other service or premium
• E084 is only eligible for payment with subsequent visits and palliative care visits rendered by the MRP
• E084 is not eligible for payment with C121 additional visits for intercurrent illness
• E084 must be billed with a relevant subsequent visit code. If a relevant code is not found on history or on the same claim, the claim will pay at $0 with explanatory code ‘DF-Corresponding fee code has not been claimed or was approved at $0’
• E084A is payable at 45% of the first relevant code found
• Submitting claims for E084A is restricted to the following specific specialties:
  • 00 (Family Practice and Practice in General)
  • 02 (Dermatology)
  • 07 (Geriatrics)
  • 12 (Emergency Medicine)
  • 13 (Internal Medicine)
  • 15 (Endocrinology and Metabolism)
  • 16 (Nephrology)
  • 18 (Neurology)
  • 19 (Psychiatry)
  • 22 (Genetics)
  • 26 (Paediatrics)
  • 28 (Pathology)
  • 31 (Physical Medicine)
  • 34 (Therapeutic Radiology)
  • 41 (Gastroenterology)
  • 44 (Medical Oncology)
  • 46 (Infectious Disease)
  • 47 (Respiratory Disease)
  • 48 (Rheumatology)
  • 60 (Cardiology)
  • 61 (Haematology)
  • 62 (Clinical Immunology)
• If a claim is submitted for E084A with any other specialty identified above the claim will be paid at $0 with explanatory code ‘45-Specialty code restriction on FSC’
• If a claim is submitted for E084A without a Master Number and an admission date the claim will reject to the providers’ error report with error code ‘AH8-Invalid Admit Date/Hospital Number’.

Subsequent visit codes for E084

C002A, C007A, C009A, C022A, C027A, C029A, C072A, C077A, C079A, C122A, C123A, C124A, C132A, C137A, C139A, C142A, C143A, C152A, C157A, C159A, C162A, C167A, C169A, C182A, C187A, C189A, C192A, C197A, C199A, C222A, C227A, C229A, C262A, C312A, C317A, C319A, C342A, C347A, C349A, C412A, C417A, C419A, C442A, C447A, C449A, C462A, C467A, C469A, C472A, C477A, C479A, C482A, C487A, C489A, C602A, C607A, C609A, C612A, C617A, C619A, C622A, C627A, C629A, C882A, C982A

New Fee Schedule Code E515A-Incision of abscess or hematoma-general anaesthetic

• The percentage will be applied to the sum of all relevant codes (Z102, Z172, Z105, Z107)
• If a claim is submitted for E515A and there is no relevant code on the same claim or previously paid, E515A will be paid at $0 with explanatory code ‘DF-Corresponding fee code has not been claimed or was approved at $0’
• If a claim is submitted for E515A and there is a relevant code on the same claim, for the same patient, with the same service date and the same physician, the relevant code is paid in full and the E515A pays 100% of the relevant code.

Unit Fee Increases effective April 1, 2020

The Assistant Unit Fee (B suffix) has been increased from $12.04 to $12.25.
The Anaesthesiologist Unit Fee (C suffix) has been increased from $15.01 to $15.29.

E100-Attendance at Delivery

• E100C time units are payable for time spent in constant attendance at delivery, exclusive of time spent engaged in any separately payable services except for P016C. Start and stop times must be recorded in the patient’s permanent medical record.
• E100C time units for attendance at delivery are calculated as 4 basic units and 1 unit for each ¼ hour.
• Extra units cannot be claimed (E021C, E010C, E011C, E024C, E025C, E012C, E022C, E017C, E016C, E020C as listed on GP95 of the Schedule). The system will pay these codes at $0 when billed with E100C with explanatory code ‘D7-Not allowed in addition to other procedure’. If E100C is submitted, and an ‘Extra Unit’ fee code is already paid on history, the system will pay E100C at $0 with D7 explanatory code.
• After Hours premiums (E400C, E401C) and Special Visit premiums (C998C, C985C, C999C) may be billed with E100C. If these premiums are on history or on the same claim, the E100C will be paid by the system provided the claims have the same service dates, the same patient and the same physician.

Medical Claims Adjustments (MADJ)

Due to staged implementations, Medical Claims Adjustments (MADJ) may be required. Further information will be provided in advance of a MADJ.

• Please also note that during the MADJ process, the claims processing system selects an entire claim and reprocesses it.
• A single claim can include multiple fee schedule codes and all codes will be reprocessed.
• Claims that were reprocessed with no change in payment will appear on the Remittance Advice (RA) with explanatory code ‘55-This deduction is an adjustment on an earlier account’ and ‘57-This payment is an adjustment on an earlier account’. These two transactions will net out to zero with no payment impact but will report on the RA for reconciliation purposes.

For more information

For any further inquiries, please contact the Service Support Contact Centre via email or by phone at 1-800-262-6524.

The latest version of the Schedule of Benefits for Physician Services is available on the Ministry of Health website. Hard copies of the Schedule of Benefits for Physician Services will not be distributed. If you would like to order a paper copy or compact disk (CD) of the Schedule for a fee, please visit Publications Ontario. Physicians without access to the Internet can contact ServiceOntario at 1-800-668-9938.

This bulletin is a general summary provided for information purposes only. Physicians are directed to review the Health Insurance Act, Regulation 552, and the schedules under that regulation, for the complete text of the provisions. You can access this information at ontario.ca/laws. In the event of a conflict or inconsistency between this bulletin and the applicable legislation and/or regulations, the legislation and/or regulations prevail.