Bulletin 230901 — PSA related adjustments to the Schedule of Benefits: Release 5
Claims payment system changes have been implemented for hernia repair (E829A, E827A and S079A) and oncoplastic breast surgery (R102A, R158A and R159A)
Category: Physician Services
Written by: Claims Service Branch; Health Programs and Delivery Division
Date issued: September 1, 2023
Bulletin Number: 230901
Background
The Ministry of Health and the Ontario Medical Association have been working together to implement the 2021-2024 Physician Services Agreement.
As described in INFOBulletin 230310, permanent adjustments to fee codes within the Schedule of Benefits for Physician Services (the Schedule) have been made effective April 1, 2023. These changes are being implemented in stages to ensure correct payment of claims in accordance with the Schedule.
The following changes are being implemented on September 1, 2023, with an effective date of April 1, 2023.
Claims processing
The new fee codes are payable as follows:
Hernia repair
Fee codes E827A or E829A are eligible for payment when billed with S344A for the same patient, same service date and by the same physician.
If S344A is not on the same claim or on history, E827A or E829A will pay at $0 with explanatory code ‘DF - Corresponding fee code was not billed or paid at zero’.
Only one of E827A or E829A is payable for the same patient, same service date, by the same physician. If both codes are submitted, one will pay at $0 with explanatory code ‘D7 - Not allowed in addition to other procedure’.
If S079A is submitted with S091A and/or S092A on the same claim, for the same service date by the same physician for the same patient, the higher value claim will pay in full and other claims will pay at $0 with explanatory code ‘D7 - Not allowed in addition to other procedure’.
If the lower value claim already exists on history, payment of the higher S079A claim will be reduced by the value of the lower value claim with the explanatory code ‘DC - Procedure paid previously not allowed in addition to this procedure fee adjusted to pay the difference’.
E793A, E744A, E847A and E742A are eligible for payment with S079A.
Oncoplastic breast surgery
Fee code R143A is not eligible for payment to any physician for the same patient on the same service date as R102A.
If R143A or R102A has already been claimed and another physician submits a claim for either code, for the same patient and same service date, the claim will pay at $0 with explanatory code ‘D7 - Not allowed in addition to other procedure’.
If R143A and R102A are submitted on the same claim for the same service date by the same physician for the same patient, R143A will approve at $0 with explanatory code ‘D7 - Not allowed in addition to other procedure’.
E505A, E525A and E546A are eligible for payment with R102A, R158A or R159A.
Medical Claims Adjustments (MADJ)
Medical Claims Adjustments may be required. Further information will be provided in advance of a Medical Claims Adjustment.
Please note: no action is required by the physician.
Keywords/Tags
Physician Services Agreement; PSA; Physicians; Payments; R102; R158; R159; R143; E505; E525; E546; OHIP; Hernia; E829; E827; S079; PPC
Contact information
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