Bulletin 231102 — PSA related Medical Claims Adjustment: Release 5
Claim submissions for fee codes R102A, R158A, R159A, E829A, E827A, S079A and associated codes 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: November 1, 2023
Bulletin Number: 231102
Background
The Ministry of Health and the Ontario Medical Association have been working together to implement the 2023 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.
The payment rules for the below fee schedule codes were implemented on September 1, 2023, with an effective date of April 1, 2023, with further information in INFOBulletin 230901.
- E829A - Repair of defect (5-10 cm) with component separation, to S344 (Hernia fascial defect (diameter 5cm or greater) repaired with mesh closure)
- E827A - Repair of defect (greater than 10 cm) with component separation, to S344
- S079A - Repair of massive paraesophageal oesophageal hiatus hernia
- R102A - Level 1 oncoplastic breast conserving lumpectomy or partial mastectomy for malignancy
- R158A - Level 2 oncoplastic breast conserving lumpectomy or partial mastectomy for malignancy
- R159A - Level 3 oncoplastic breast conserving lumpectomy or partial mastectomy for malignancy
As a result, a Medical Claims Adjustment (MADJ) is required to reprocess related claims.
No action is required on the part of the physician.
Medical Claims Adjustments (MADJ)
Claims processed before September 1, 2023, for oncoplastic breast surgery (fee codes R102A, R158A, R159A) and hernia repair (fee codes E829A, E827A and S079A) with service dates between April 1, 2023, and August 31, 2023, are subject to being adjusted by the MADJ. These claims will be adjusted in accordance with the Schedule.
The adjustments will begin to appear on the November 2023 Remittance Advice.
Any procedures billed as fee codes E827A or E829A submitted together or alone and with or without a S344A have been corrected to conform with the payment rules.
Fee code S079A submitted with fee codes S091A, S092A, E793A, E744A, E847A or E742A have been corrected to conform with the payment rules.
Procedures billed as fee codes R102A, R158A or R159A along with R143A, E505A, E525A or E546A have been corrected to conform with the payment rules.
Please note during the MADJ process, the OHIP claims payment system selects an entire claim and reprocesses it. A single claim can include multiple fee 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 to zero with no payment impact but will report on the RA for reconciliation purposes.
Those that are reprocessed and not eligible for payment in accordance with the Schedule will be accompanied with one of the following explanatory codes:
- DF - Corresponding fee code was not billed or paid at zero
- D7 - Not allowed in addition to other procedure
- DC - Procedure paid previously not allowed in addition to this procedure fee adjusted to pay the difference
Keywords/Tags
Physician Services Agreement; PSA; Physicians; Payments; R102A; R158A; R159A; R143A; E505A; E525A; E546A; Hernia; E829A; E827A; S079A; E793A, E744A, E847A; E742A; PPC; Medical Claims Adjustment; Physician Payment Committee
Contact information
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