Bulletin 240401 — PSA related adjustments to the Schedule of Benefits: Release 10
New payment rules are being applied to fee schedule code E098A.
To: All Physicians
Category: Physician Services
Written by: Claims Services Branch, Health Programs and Delivery Division
Date issued: April 5, 2024
Bulletin Number: 240401
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. 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.
Release 10 changes
The following Release 10 changes were implemented on April 1, 2024 with an effective date of April 1, 2023: E098A - Gastroenterology Chronic Disease Assessment Premium
E098A is only payable to physicians with an OHIP specialty of 41 (Gastroenterology).
Claims processing
E098A will pay a 28% premium on the fee approved value of FSCs A411A, A413A, A414A, and A418A (relevant codes) with the following diagnostic codes only:
- 555 - Other Diseases of Intestine and Peritoneum: Regional enteritis, Crohn's disease
- 556 - Other Diseases of Intestine and Peritoneum: Ulcerative colitis
- 571 - Other Diseases of Digestive System: Cirrhosis of the liver (alcoholic cirrhosis, biliary cirrhosis)
If E098A is submitted with a diagnostic code other than 555, 556, or 571, the claim will reject to the physician’s error report with error code V30 - FSC/DX Code Combination not a benefit.
If one of the relevant codes is missing or approved on the same claim or history, for the same physician, same patient, and same date of service as E098A with a diagnostic code that does not match that of the relevant code the claim will approve at zero dollars with explanatory code VX - Complexity premium not applicable to visit fee.
E098A provided in-person or virtually will not by itself establish the patient/physician relationship.
E098A is not eligible for after-hours premiums (E409A, E410A, E412A and E413A).
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
Gastroenterology Chronic Disease Assessment Premium; Physician Services Agreement; PSA; Physician Payment Committee; E098
Contact information
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