Bulletin 240304 — PSA related Medical Claims Adjustment: Release 8

Payments for E202A, Z844A/C, E175A, E186A/C and E187A/C 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 (FSCs) 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. As described in INFOBulletin 230604, the AWG identified changes to services insured under the Ontario Health Insurance Plan effective July 1, 2023.

The payment rules for the FSCs listed below were implemented on January 1, 2024, with an effective date of April 1, 2023.

• 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

The payment rules for the FSCs listed below were implemented on January 1, 2024, with an effective date of 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
• E175A – Therapeutic paracentesis, to E186A, E187A or E149A

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.

Further information regarding Release 8 can be found in INFOBulletin 240105.

Medical claims adjustment processing

Intravitreal injection codes and other ocular surgery claims assessed between April 1, 2023 and December 31, 2023 with service dates between the same dates are subject to being adjusted by the MADJ. The following FSCs were reprocessed:

• E117A – Keratectomy or relaxing incisions post penetrating keratoplasty or post traumatic corneal scar (non cosmetic)
• E124A – Limbal stem cell transplant
• 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
• E202A – Corneal cross-linking
• Z844A – 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
• E147A – Intravitreal injection of medication for the treatment of wet macular degeneration
• E149A – Vitreous injection or aspiration, posterior with needle for culture and/or injection of medication, other than for macular degeneration
• Z851A – Therapeutic paracentesis

The claims system will reprocess these claims in accordance with the schedule. The adjustments will begin to appear on the March 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.

Claim items that are reprocessed and not eligible for payment in accordance with the schedule will be accompanied with one of the following explanatory codes:

• D7 – Not allowed in addition to other procedure.
• DF – Corresponding fee code was not billed or paid at zero.
• DC – Procedure paid previously not allowed in addition to this procedure
• S3 – Second surgical procedure allowed at 85%

Keywords/Tags

Physician Services Agreement; PSA; E117A; E124A; E202A; Z844A; E175A; E186A/C; E187A/C; E147A; E149A; Z851A; Medical Claims Adjustment; MADJ; Release 8

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.