Bulletin 210302 — COVID‑19 Temporary Modifier Payment for AGMPs

Reactivation of the E405A in-hospital AGMP modifier, creation of new E404A out-of-hospital AGMP modifier, and expansion of list of eligible AGMPs

To: All Providers
Category: Physician Services
Published by: Claims Services Branch, Ontario Health Insurance Plan Division
Date Issued: March 8, 2021

Background

To further support the government’s efforts to stop the spread of COVID-19 in Ontario, the Ministry of Health (ministry) and the Ontario Medical Association (OMA) have reached an agreement to implement temporary 30% modifier payments for eligible Aerosol-Generating Medical Procedures (AGMPs) performed both in and outside of hospitals, for the period of October 1, 2020 to September 30, 2021.

On March 1, 2021, the ministry has implemented the following changes with an effective date retroactive to October 1, 2020:

• Reactivation of the E405A fee code-Hospital Complexity Modifier
• Creation of a new E404A fee code-Modifier payment for AGMPs performed outside of hospital
• Expanded the list of eligible AGMP services

Related communications

Please refer to the additional communications listed below regarding AGMP services for further information.

• INFOBulletin 4758 titled ‘Temporary Fees for Identified AGMP Procedures-COVID-19-Hospital Physician Compensation’
• INFOBulletin 201105 titled ‘COVID-19 Hospital Physician Compensation: E405A Changes’
• INFOBulletin 201108 titled ‘Temporary Fees for Identified AGMPs in Community Settings’
• INFOBulletin 201202 titled ‘System solution for E405A effective December 1, 2020’

Reactivation of E405A hospital complexity modifier

The ministry has reactivated fee schedule code (FSC) ‘E405A-Hospital Complexity Modifier’ with an effective date of October 1, 2020. E405A will be eligible for payment for eligible services between October 1, 2020 and September 30, 2021.

E405A should only be billed for patients who are COVID-19 positive or who are treated as at risk of being COVID-19 positive under local hospital policy. This FSC can only be billed for providing general anesthesia and for performing certain procedures which are listed in ‘Appendix A-Complete List of Eligible AGMPs’.

The eligible AGMP list has also been expanded effective October 1, 2020. E405A will be paid at 30% of the fee paid value (fee approved for shadow billed claims) of the applicable services for the same patient, same physician on the same day.

Fee for service claim submissions for E405A

• A Master Number is required to be submitted with FSC E405A.
• E405A does not require a diagnostic code.
• When E405A is billed with a Northern Specialist Hospital-based group number (group numbers 64AA-64DZ) the 30% premium will be calculated on the pre-reduction amount.
• E405A is payable on the sum of fee paid (fee approved for shadow billed claims) for all eligible claims, submitted on the same claim or previously paid claims with same service date, same physician, and same patient.
• E405A is a daytime premium for services that commence between 7:00 a.m. and 5:00 p.m. on weekdays (not to be used for services on weekends or holidays).
• E405A is not payable with E400C, E401C, E409A, E410A, E412A, E413A, Q012A, Q016A, Q017A and Q018A (after-hours premiums).
• Travel, first and additional persons seen premiums are eligible for payment with E405A for the same patient, same physician, same service date.
• E405A is not eligible to be billed with virtual care claims.
• Additional fee schedule codes E173A, E174A, E839A, F138A, F139A, F140A, F142A, F143A, F144A, M027A, M063A, M144A, R788A, R789A, Z313A, Z314A and Z317A are eligible to be billed with E405A.
• If a claim is submitted with a service date of October 1, 2020 onwards for E405A, and an eligible AGMP code from Appendix A has been paid for same patient, same service date, same provider on the same claim or on a previous claim, the E405A will be paid at 30% of the fee paid (fee approved for shadow billed claims) on the AGMP service.
• E405A is not eligible for payment for service dates between August 1, 2020 and September 30, 2020. If E405A is submitted with a service date between August 1, 2020 and September 30, 2020, the claim will be rejected to the provider’s error report with error code ‘A3E-No such FSC’.
• If E405A is submitted and there is no AGMP service on the claim or previously paid for same patient, same service date, same physician, the E405A will pay at $0.00 with error code ‘DF-Corresponding fee code has not been claimed or was approved at zero’.
• A stale-date exemption on E405A has been extended until June 30, 2021 for E405A submissions with service dates approaching stale-dating.

New E404A modifier for AGMPs outside of hospital

The ministry has implemented a new temporary 30% modifier payment for eligible AGMPs performed outside of hospitals, which will be applicable for eligible AGMPs rendered outside of a hospital on or between October 1, 2020 and September 30, 2021 and under the eligibility criteria noted below.

The new temporary modifier for AGMPs outside of hospital is only eligible for payment on AGMPs when the AGMP meets all three criteria:

• Is performed outside of a hospital.
• Is commenced between the hours of 7 am and 5 pm on weekdays.
• Is rendered to a patient who is COVID-19 positive as confirmed by laboratory testing, or at risk of being COVID-19 positive as documented in the medical record.

The ministry currently defines a patient as at risk of being COVID-19 positive if they meet one of these two criteria:

• They have lived in or have recently travelled to public health unit regions defined by Public Health Ontario (PHO) as level Orange-Restrict or higher, as defined in the “COVID-19 Response Framework: Keeping Ontario Safe and Open
• They screen positive based on the criteria in the ministry’s “COVID-19 Patient Screening Guidance Document ”

The list of eligible AGMPs performed outside of a hospital will mirror the list used for the equivalent modifier payment for AGMPs performed in hospitals, which was implemented as part of the larger COVID-19 temporary payments for physician services in-hospital (refer to Related Communications above).

Fee for service claim submissions for E404A

1. E404A is effective October 1, 2020.
2. All the rules that apply to ‘E405A-AGMP Complexity Hospital Modifier’ apply to the new ‘E404A-AGMP Modifier Out of Hospital’ with the exception of Master Number and Admit date which should be blank when submitting a claim for E404A with an eligible AGMP service rendered outside of a hospital setting.
3. If E404A is submitted with an eligible AGMP code with a service date prior to October 1, 2020, the claim will be rejected to the provider’s error report with error code ‘A3E-No such FSC’.
4. A stale-date exemption has been applied until June 30, 2021 for E404A submissions with service dates approaching stale dating.
5. E404A and E405A cannot be submitted together.
6. If an incoming claim contains both E404A and E405A for the same patient and same service date, the 2nd FSC will be paid at $0 with explanatory code ‘D7-Not allowed in addition to other procedure’.
7. E404A is a daytime premium for services commencing between the hours of 7:00 a.m. and 5:00 p.m. on weekdays (not to be used for services on weekends or holidays).

Primary care claim submissions for E404A

Effective October 1, 2020, E404A will pay fee for service for all primary care models.

Appendix A – complete list of eligible AGMPs

NOTE: This list of eligible Aerosol Generating Medical Procedures (AGMP) is currently being expanded to include additional procedures.

AGMPs added to the eligible list

The following procedures, when requiring the use of a high-speed device in the respiratory tract, are eligible for the AGMP premium when performed on patients who are COVID-19 positive or who are treated as at risk of COVID-19 positive:

Additional eligible procedures when requiring open suctioning of the airway:

Keywords/tags

E405A; E404A; AGMP; Aerosol Generating Medical Procedures; COVID-19

Contact information

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

Schedule of Benefits for physician services

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.

Please review the Health Insurance Act

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.