Bulletin 231203 — PSA related adjustments to the Schedule of Benefits: Release 7
New payment rules are being applied to Fee Schedule Codes: E088A, E518A, E519A, E520A, Z516A, Z517A, and Z518A.
To: All physicians
Category: Physician Services
Written by: Claims Services Branch, Health Programs and Delivery Division
Date issued: December 22, 2023
Bulletin Number: 231203
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. Adjustments to the claims payment system related to these Schedule changes are being introduced through staged implementations to ensure correct payment of claims in accordance with the Schedule.
The following Release 7 changes were implemented December 1, 2023, with an effective date of April 1, 2023.
The following fee codes were affected by the change:
- E088A - Congestive heart failure premium
- E518A - Each additional polyp (20 mm to 29 mm)
- E519A - Each additional polyp (10 mm to 19 mm)
- E520A - Each additional polyp (6 mm to 9 mm)
- Z516A - Excision of first polyp (20 mm to 29 mm)
- Z517A - Excision of first polyp (10 mm to 19 mm)
- Z518A - Excision of first polyp (6 mm to 9 mm)
Claims Submission
E088A - Congestive Heart Failure
E088A will pay a 50% premium of the approved value of the Fee Schedule Codes (FSCs) A601A, A603A, A604A, and A608A with diagnostic code 428 - Ischaemic and Other Forms of Heart Disease: Congestive heart failure.
E088A will pay at zero dollars with the explanatory code VX - Complexity premium not applicable to visit fee if it is submitted without one of the above FSCs on the same claim or on history. E088A will also pay at zero dollars with the explanatory code VX if one of these codes is present in the same claim or on history but does not have the diagnostic code 428.
If E088A is submitted with a diagnostic code other than 428, the claim will reject to the physician’s error report with error code V30 - FSC/DX Code Combination Not A Benefit (NAB).
E088A is not eligible for age-based premium payments and after-hours premium (E409A, E410A, E412A and E413A).
Colonoscopic Polypectomy
E720A, E520A, E519A, E518A are eligible for payment when billed with Z571A, Z518A, Z517A, or Z516A by the same physician for the same patient and for the same date of service.
If one of the above E-prefix codes are submitted without Z571A, Z518A, Z517A, or Z516A, the claim will approve at zero dollars with explanatory code DF - Corresponding fee code was not billed or paid at zero.
A maximum of 2 services of any combination of E720A, E520A, E519A, or E518A are eligible for payment per patient per day. Additional services will be approved at zero dollars with explanatory code M1 - Maximum fee allowed or maximum number of service has been reached same/any provider.
Some combinations of E720A, E520A, E519A, E518A can result in underpayment when more than two units of the add-on codes are being billed. One example is the scenario E518A x 1 and E519A x 2. Both units of the smaller polyp will approve at zero dollars with explanatory code M1 - Maximum fee allowed or maximum number of service has been reached same/any provider. Physicians can re-submit one unit of smaller polyp code to be eligible for payment or submit a Remittance Advice Inquiry to change the smaller polyp to one unit.
Only one of Z571A, Z518A, Z517A, Z516A is eligible per patient per day. If a second service of any of these codes is submitted, providers will see the explanatory code M1 - Maximum fee allowed or maximum number of service has been reached same/any provider.
The largest polyp excised should be used to determine the appropriate fee code to claim for the first polyp (Z571A, Z518A, Z517A or Z516A).
Medical Claims Adjustments
Due to staged implementations, 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
E088A; Congestive heart failure premium; A601A; A603A; A604A; A608A; K301A; K300A; E409A, E410A, E412A; E413A; Physician Services Agreement; PSA; Physician Payment Committee; PPC; E720A, E520A, E519A, E518A; Z571A, Z518A, Z517A, Z516A; OHIP; Polyp; Polypectomy; Colonoscopic
Contact information
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