Bulletin 240104 — PSA related Medical Claims Adjustment: Release 7

Payments for E518A, E519A, E520A, Z516A, Z517A and Z518A were reprocessed by a Medical Claims Adjustment.

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.

The payment rules for the below fee schedule codes were implemented on December 1, 2023, with an effective date of April 1, 2023. See INFOBulletin 231203 for additional information.

• 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)

As a result, a Medical Claims Adjustment (MADJ) was required to reprocess related claims.

Note: No action is required on the part of the physician.

Medical claims adjustment processing

Colonoscopic polypectomy claims assessed between April 1, 2023 and November 30, 2023 with service dates between the same dates are subject to being adjusted by the Medical Claims Adjustment (MADJ). This includes fee schedule codes:

• 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)
• E685A – total excision of very large sessile polyp (> 3 cm) through colonoscope, and may include fulguration
• E692A – with laser debulking
• E720A – each additional polyp (3 mm - 5 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)
• Z491A – follow up of incomplete polyp resection
• Z491B – follow up of incomplete polyp resection
• Z491C – follow up of incomplete polyp resection
• Z571A – excision of first polyp (3 mm to 5mm)

The claims system will reprocess these claims in accordance with the Schedule. The adjustments will begin to appear on the January 2024 Remittance Advice.

All claims submitted with these fee schedule codes have been corrected to conform with the payment rules.

Please note during the MADJ process, the claims processing system selects an entire claim and reprocesses it. A single claim can include multiple fee schedule codes and all codes will be reprocessed.

Claims reprocessed with no change in payment will appear on the Remittance Advice (RA) with explanatory codes 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 $0 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
• M1 – maximum fee allowed or maximum number of service has been reached same/any provider

Keywords/Tags

Physician Services Agreement; PSA; Physicians; Payments; E518A; E519A; E520A; E685A; E692A; E720A; Z516A; Z517A; Z518; Z491A; Z491B; Z491C; Z571A; PPC; Colonoscopic Polypectomy; Medical Claims Adjustment; Physician Payment Committee

Contact information

Do you have questions about this INFOBulletin? Email the Service Support Contact Centre or call 1-800-262-6524. Hours of operation: 8:00 a.m. to 5:00 p.m. Eastern Monday to Friday, except holidays.