K229 complex genetic test interpretation, new surgical procedure codes R766 and R767 and medical claims adjustment effective April 1, 2020

To: All Providers
Category: Physician Services
Published by: Claims Services Branch, Ontario Health Insurance Plan Division
Date Issued: February 2, 2021

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 (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.

The following Release 6 changes are being implemented January 1, 2021 with an effective date of April 1, 2020.

K229A - Complex genetic test interpretation

K229A is restricted to physician specialists in genetics and/or specialists with a Fellow of the Canadian College of Medical Geneticists (FCCMG) designation.

Claims processing - K229A

  1. K229A may be submitted for up to two services per patient, per physician, per 365 days.
  2. If a claim is submitted for more than two services, it will be paid at $0 with explanatory ‘M1-Maximum number of services has been reached’ on the providers Remittance Advice RA.
  3. K229A must be submitted by a provider who has also submitted a claim for a consultation or genetic care service for the same patient.
  4. If a claim for K229A is submitted and there is no consultation or genetic care service on history, the claim will pay at $0 with explanatory code ‘DF-Corresponding fee code has not been claimed or was approved at zero’.

New fee schedule codes effective April 1, 2020

R766A: In-situ saphenous vein arterial bypass-tibial-two Vascular Surgeons-first surgeon.

R767A: In-situ saphenous vein arterial bypass-tibial-two Vascular Surgeons-second surgeon.

Claims processing - R766A/B/C and R767A

  1. R766A and R767A are only eligible for payment to a physician that is a vascular surgeon with a specialty designation in General Surgery (03) or Vascular Surgery (17).
  2. R766A and R767A are not eligible for payment with R804A.
  3. If a claim is submitted for R766A/B and/or R767A with R804A on the same claim, the R804A will pay and the R766A/B and/or R767A will be paid at $0 with explanatory code 'D7 Not allowed in addition to other procedure’.
  4. If a claim is submitted for R766A/B and R767A for the same patient, same physician, same service date, the R766A/B will pay and R767A will be paid at $0 with explanatory code 'D7 Not allowed in addition to other procedure’.
  5. If a claim for R766A/B is submitted and there exists on history a R767A that has been previously paid for the same patient, same surgeon and same service date, the incoming claim will be paid at $0 with explanatory code 'D7 Not allowed in addition to other procedure’.
  6. If a claim for R767A is submitted and there exists on history a R766A/B that has been previously paid for the same patient, same surgeon and same service date, the incoming claim will be paid at $0 with explanatory code 'D7 Not allowed in addition to other procedure’
  7. Surgical assistant units associated with R766 are only eligible for payment to one physician.
  8. R766C is eligible for automated anaesthesia age premiums.
  9. R766C-Anaesthesiologists are eligible to bill extra units listed on page GP95 of the Schedule.
  10. If a claim is submitted for R767B/C it will be rejected to the providers error report with error code ‘A3F-No Fee for Service’.

R766A/R767A Medical Claims Adjustments (MADJ)

Due to staged implementations, a Medical Claims Adjustments (MADJ) was required to reprocess claims for the Fee Schedule Codes (FSCs) R766A and R767A. The new rules for these FSCs were implemented January 1, 2021 with an effective date of April 1, 2020.

  1. Claims already submitted for R766A and R767A with service dates between April 1, 2020 and December 31, 2020 that were previously paid were subject to the MADJ. If necessary, these claims were adjusted in accordance with the changes to the Schedule of Benefits for Physician Services effective April 1, 2020.
  2. Adjustments will appear on the February 2021 Remittance Advice RA.
  3. Please note that during the MADJ process, the claims processing system selects an entire claim for reprocessing.
  4. A single claim can include multiple fee schedule codes and all codes will be reprocessed.
  5. 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 to zero with no payment impact but will report on the Remittance Advice for reconciliation purposes.

K229A processing

K229A will not have a system medical claims adjustment due to the low volumes of claims requiring action, therefore K229A claims that require action will be handled internally by claims assessors and will appear on future Remittance Advices (RAs).

Contact information

Do you have questions about this INFOBulletin? Email the Service Support Contact Centre or call 1-800-262-6524.