New payment rules are being applied to fee schedule codes E202A, Z844A, E175A, E186A and E187A.

To: All Physicians
Category: Physician Services
Written by: Claims Services Branch, Health Programs and Delivery Division
Date issued: January 15, 2024
Bulletin Number: 240105

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.

In addition, the 2021–24 Physician Services Agreement included the continuation of the Appropriateness Working Group (AWG) to satisfy any outstanding AWG requirements as part of the Kaplan Arbitration Award.

The Ministry of Health and the Ontario Medical Association formed the AWG with a mandate to use evidence, best practices and expert opinion to identify and update the delivery of certain services to help ensure the most effective care for Ontario patients.

Overview of changes

As described in INFOBulletin 230310, permanent adjustments to fee schedule codes (FSCs) within the Schedule of Benefits for Physician Services (Schedule) were 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.

As described in INFOBulletin 230604, the AWG identified changes to services insured under the Ontario Health Insurance Plan effective July 1, 2023.

The following changes were implemented January 1, 2024.

  1. Intravitreal injection codes affected by the AWG. E147 is replaced by two new fee codes, effective July 1, 2023:
    • E186A/C – Intravitreal injection of medication for the treatment of wet macular degeneration, left eye
    • E187A/C – Intravitreal injection of medication for the treatment of wet macular degeneration, right eye
  2. Other ocular surgery codes affected by the Physician Services Agreement:
    • E202A – Corneal cross-linking
    • Z844A/C – Diagnostic paracentesis for suspected intraocular infection, intraocular inflammation or uveitis, or suspected cancer involving the intraocular structures or fluids
    • E175A – Therapeutic paracentesis, to E147A or E149A

Claims submission – intravitreal injection codes

  1. Z851A is not eligible for payment with E186A and/or E187A for the same provider, same patient, and same date of service.
    • If Z851A is submitted with E186A and/or E187A on the same claim or E186A/E187A has already been paid, Z851A will pay at $0 with explanatory code ‘D7 – Not allowed in addition to other procedure’.
    • If Z851A has been paid previously, E186A or E187A will be reduced by the amount of Z851A with explanatory code ‘DC – Procedure paid previously not allowed in addition to this procedure – fee adjusted to pay the difference’.
  2. Z844A and E149A are not eligible for payment with E186A and/or E187A for any provider, for the same patient, and same date of service. If these code combinations are claimed for the same patient and service date, the ineligible service will pay at $0 with explanatory code ‘D7 – Not allowed in addition to other procedure’.
  3. When both E186A and E187A are submitted for the same patient, by the same physician, within a 14-day time period, the first claim will pay 100% and the second will be reduced to 85% with explanatory code ‘S3 – Second surgical procedure allowed at 85%’.
  4. E186C/E187C are eligible for the base units listed in the Schedule and have a limit of 5.
  5. E186C and E187C are not allowed to be billed with anaesthesia extra units E010C, E011C, E012C, E016C, E017C, E020C, E021C, E022C, E024C or E025C on the same service date, by any physician. If these codes are claimed together, ineligible service(s) will pay at $0 with explanatory code ‘D7 - Not allowed in addition to other procedure’.
  6. E186C and E187C are not allowed to be billed with E023C on the same service date, by the same physician and for same patient.
    • If E186C or E187C is submitted and E023C has been previously paid, E186C or E187C will pay at zero dollars with explanatory code ‘D7 - Not allowed in addition to other procedure’.
    • If E023C is submitted and E186C or E187C have already been paid, E023C will either be reduced with explanatory code ‘DC – Procedure paid previously not allowed in addition to this procedure’ or paid at zero dollars with explanatory code ‘D7 - Not allowed in addition to other procedure’.
  7. E186A and E187A are not allowed with E003C on the same service date by any physician, for the same patient. If one of these codes has already been paid, the claim will reject with error code ‘ASP – Not allowed with surgical procedure’.

Claims submission – other ocular surgery codes

E202A – Corneal cross-linking

Changes were implemented January 1, 2024, effective April 1, 2023.

E202A is not eligible for payment to any physician, for the same patient and same date of service as E117A. If these codes are claimed together, ineligible service(s) will pay at $0 with explanatory code ‘D7 - Not allowed in addition to other procedure’.

Z844A – Diagnostic paracentesis for suspected intraocular infection, intraocular inflammation or uveitis, or suspected cancer involving the intraocular structures or fluids

Changes were implemented January 1, 2024, effective April 1, 2023.

Z844A is not eligible for payment with Z851A, E147A and/or E149A to the same physician, for the same patient, on the same date of service. If these codes are claimed together, ineligible service(s) will pay at $0 with explanatory code ‘D7 - Not allowed in addition to other procedure’.

Please note, effective July 1, 2023, E147A was replaced with E186A or E187A. See claims submission – intravitreal injection codes above for additional information.

E175A – Therapeutic paracentesis, to E147A or E149A

Changes were implemented January 1, 2024, effective April 1, 2023.

  1. E175A is only eligible for payment when E147A or E149A is billed for the same service date, the same patient, and the same physician. If E175A is submitted without E147A or E149A on the same claim or history, then E175A will pay at zero dollars with explanatory code ‘DF – “Corresponding fee code was not billed or paid at zero’.
  2. E175A is not eligible for payment with Z851A for the same physician, same patient and same service date. If these codes are claimed together, one of the services will pay at zero dollars with explanatory code ‘D7– Not allowed in addition to other procedure’.

Please note, effective July 1, 2023, E147A was replaced with E186A or E187A.

Medical claims adjustment

Due to staged implementations, Medical Claims Adjustments (MADJs) may be required. Further information will be provided in advance of a MADJ.

Please note: No action is required by the physician.

Keywords/Tags

Physician Services Agreement; PSA; Physician Payment Committee; PPC; E202; Z844A; E175A; E186A; E186C; E187A; E187C; E147A; E149A; Appropriateness Working Group; AWG;

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.