Bulletin 230904 — Update: PSA related Medical Claims Adjustment — Z851, G550 and G869
Claim submissions for Z851, G550 and G869 will be reprocessed through a Medical Claims Adjustment
To: All Physicians
Category: Physician Services
Written by: Claims Services Branch; Health Programs and Delivery Division
Date issued: September 8, 2023
Bulletin Number: 230904
Background
The Ministry of Health and the Ontario Medical Association have been working together to implement the 2021 Physician Services Agreement.
As described in INFOBulletin 230310, permanent adjustments to fee schedule codes within the Schedule of Benefits for Physician Services (the Schedule) have been made effective April 1, 2023.
A Medical Claims Adjustment was required to reprocess claims for ‘Z851 – Therapeutic paracentesis’. The payment rules for this were implemented June 1, 2023, with an effective date of April 1, 2023, with further information in INFOBulletin 230601.
Another Medical Claims Adjustment was required to reprocess the following codes:
- G550 – Pessary Care
- G869 – Botulinum toxin injection(s) of bladder detrusor muscle
The payment rules for these were implemented July 1, 2023, with an effective date of April 1, 2023. Further information is available in INFOBulletin 230705.
No action is required on the part of the physician.
Medical Claims Adjustments
Claims for therapeutic paracentesis (fee code Z851), pessary care (fee code G550) and botulinum toxin injection(s) of bladder detrusor muscle (G869) that may have appeared on the May, June or July 2023 Remittance Advices were subject to adjustment. These claims have been adjusted in accordance with the Schedule.
The following adjustments will begin to appear on the September 2023 Remittance Advice:
- As per INFOBulletin 230601, claims for therapeutic paracentesis (fee code Z851) processed before the implementation date of June 1, 2023 with service dates between April 1, 2023 and May 26, 2023 have been reprocessed. Any procedure billed as fee code Z851 that was paid on a claim that included E147 or E149 has been corrected to conform to the payment rules.
- As per INFOBulletin 230705, pessary care (fee code G550) assessed between April 1, 2023 and June 30, 2023 have been reprocessed, and any claims using fee code G550 in excess of 6 times per 12-month period, as well as any payment using fee code G550 on the same service date, to the same patient, by any physician as fee code G398 have been corrected to conform to the payment rules.
- Any bladder detrusor muscle (fee code G869) assessed between April 1, 2023 and June 30, 2023 have been reprocessed, and any claims for fee code G869 in excess of the once per 12-week period limit, as well as any payment for fee code G869 paid on the same date, by the same physician, for the same patient as other Botulinum Toxin injections have been corrected to conform to the payment rules.
While these procedural fee codes are not limited by specialty, the majority of providers within these scenarios are Ophthalmologists (23), Obstetrics and Gynaecologists (26) and Urologists (35) respectively.
Please note during the medical claims adjustments process, the claims processing system selects an entire claim and reprocesses it. A single claim can include multiple fee codes and all codes will be reprocessed.
Please note that claims reprocessed with no change in payment will appear on the Remittance Advice 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 be reported on Remittance Advice for reconciliation purposes.
Keywords/Tags
Z851; G550; G869; Physician Services Agreement; PSA; Physician Payment Committee; MADJ; medical claims adjustments; Adjustments
Contact Information
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