New payment rules are being applied to fee schedule codes N291A, N293A, K711A, A772A and C772A.

To: All Physicians
Category: Physician Services
Written by: Claims Services Branch, Health Programs and Delivery Division
Date issued: March 1, 2024
Bulletin Number: 240301

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 9 changes were implemented on March 1, 2024:

  • Effective date of April 1, 2023
    • K711A – Multidisciplinary Cancer Conference (MCC) Nuclear Medicine Participant for patients requiring Positron Emission Tomography (PET) scan, per patient
    • N293A - Minor nerve transfer- (sensory/cutaneous nerve)
    • N291A - Major nerve transfer - (mixed sensory and motor nerve, or pure motor nerve)
  • Effective date of July 1, 2023:
    • A772A - Medical certificate of stillbirth
    • C772A - Medical certificate of stillbirth

Claims submission

The fee codes are payable as follows:

Nerve transfer procedures (N291A, N293A)

  1. N291A and N293A are eligible for payment to the same physician, or different physicians, for the same patient on the same date of service.
  2. When both N291A and N293A are submitted for the same patient, by the same physician, within a 14-day 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%.
  3. E906A will pay a 40% premium of the approved value of FSCs N291A and N293A. E925A will pay a 30% premium of the approved value of FSCs N291A and N293A.

Nuclear medicine participant for case conference (K711A)

  1. K711A can only be billed for up to five services per patient per day by any physician. Excess claims will approve at zero dollars with explanatory code M1 – Maximum fee allowed, or maximum number of service has been reached same/any provider.
  2. If a physician bills K711A in excess of eight services on the same service date for different patients, the excess claims will approve at zero dollars with explanatory code MD – Daily maximum has been exceeded.
  3. K711A is not eligible for payment on the same service date for the same patient by the same physician as K708A, K709A, or K710A.

Medical certificate of stillbirth (A772A, C772A)

  1. Only one of A772A or C772A are eligible for payment for the same date to the same patient by the same, or different physicians.
  2. If A772A or C772A are billed for the same patient and an A772A or C772A has been approved at a fee greater than zero, the new claim will approve at zero dollars with the explanatory code D7 – Not allowed in addition to other procedure.
  3. A772A and C772A must be submitted without a modality indicator of K300A or K301A. If A772A or C772A are submitted with a modality indicator, they will approve at zero dollars with explanatory code B8 – Service Not Eligible for Payment Virtually.

Medical claims adjustments (MADJ)

Due to staged implementations, Medical Claims Adjustments (MADJs) 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

Nerve Transfer Procedures; N291A; N293A; E906A; A772A; C772A; K711A; K300A; K301A; E925A Physician Services Agreement; Physician Services Agreement; PSA; Physician Payment Committee; PPC; Nuclear Medicine; Case Conference; Stillbirth.

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.