New payment rules are being applied to Z352A, Z363A, K042A, E424A

To: All Physicians
Category: Physician Services
Written by: Claims Services Branch, Health Programs and Delivery Division
Date issued: June 18, 2024
Bulletin Number: 240604

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 12 changes are being implemented June 1, 2024, with an effective date of April 1, 2023.

The following fee codes will be affected by the change:

  • Z352A - Intrapleural administration of thrombolytic or fibrinolytic agent via thoracostomy tube (chest tube)
  • Z363A - Removal of thoracostomy tube (chest tube)
  • E424A - Assessment of Paediatric Patient with Amblyopia
  • K042A - Extended Specific Neurocognitive Assessment

Claims Submission

The new fee codes are payable as follows:

Thoracic Surgery Procedures

  • Z352A is not eligible for payment with Z339A and/or Z349A by the same provider, for the same patient, on the same date of service. If they are submitted together, the ineligible service will be paid $0 with explanatory code 'D7 – Not allowed in addition to other procedure'.
  • Z363A is not eligible for payment with Z341A by any provider for the same patient and date of service.
    • If both are claimed together or Z341A is already paid, Z363A will be paid $0 and will show explanatory code 'D7 – Not allowed in addition to other procedure'.
    • If Z363A was already paid, Z341A will be reduced by the amount Z363A was paid, with explanatory code 'DC - Procedure paid previously not allowed in addition to this procedure fee adjusted to pay the difference'.

Assessment of Paediatric Patient with Amblyopia

  • E424A is only payable to physicians with a specialty of 23 (Ophthalmology).
  • E424A is only eligible for payment for patients aged 10 and younger and will reject with error code ‘A2A - Patient is underage or overage for this service code’ when submitted for a patient over 10 years old.
  • E424A is only eligible for payment when submitted with A233A or A234A on the same claim or history with diagnostic code ‘368 - Eye: Amblyopia, visual field defects’. Claims for E424A using a diagnostic code other than 368, will reject with error code ‘V16 - Unacceptable Diagnostic Code’.
  • If A233A or A234A is not billed, is paid at $0, or is billed with a diagnostic code other than 368 for the same physician for the same patient and same date of service as E424A, E424A will be paid at $0 with explanatory code ‘DF - Corresponding fee code was not billed or paid at zero’.
  • E424A is eligible for payment virtually with either Telephone Modality (K301A) or Video Modality (K300A).
  • If E424A is submitted for virtual care and A233A or A234A is approved, on history, with a different modality than E424A, E424A will approve at $0 with explanatory code ‘DF - Corresponding fee code was not billed or paid at zero’.

Extended Specific Neurocognitive Assessment

  • K042A will not be eligible for payment for the same date to the same patient by the same physician as a Specific Neurocognitive Assessment K032A.
    • If K042A and K032A are claimed together or K042A is already paid, K042A will pay in full and K032A will approve at zero dollars with explanatory code ‘D3 – Not allowed in addition to visit fee’.
    • If K032A is already paid and K042A is claimed, K042A will be reduced by the value of K032A with explanatory code DC – Procedure paid previously not allowed in addition to this procedure. Fee adjusted to pay the difference’.

Medical Claims Adjustments (MADJ)

Due to staged implementations, Medical Claims Adjustments 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

Thoracic Surgical Procedures; Z352A; Z363A; Z339A; Z349A; Z341A; Physician Services Agreement; PSA; Physician Payment Committee; PPC; K042A; K032A; Extended Specific Neurocognitive Assessment; E424A; A233A; A234A; Assessment of Paediatric Patient with Amblyopia

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.