Payments for fee schedule codes Z352A, Z363A, K042A and E424A were reprocessed by a MADJ .

To: All Physicians
Category: Physician Services
Written by: Claims Services Branch; Health Programs and Delivery Division
Date issued: July 23, 2024
Bulletin Number: 240702

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.

The payment rules for the following fee service codes were implemented on June 1, 2024, with an effective date of April 1, 2023. See INFOBulletin 240604 for additional information.

  • 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

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.

Medical claims adjustment processing

Claims assessed and with service dates between April 1, 2023 and May 31, 2024 were subject to adjustment.

  • Thoracic Surgery Procedures (Z352A And Z363A)
  • Assessment of Paediatric Patient with Amblyopia (E424A)
  • Extended Specific Neurocognitive Assessment (K042A)

All claims submitted with these FSCs will be corrected to conform with the payment rules. The adjustments will begin to appear on the July 2024 Remittance Advice (RA).

Please note during the MADJ process, the claims processing system selects an entire claim and reprocesses it. A single claim can include multiple FSCs, and all codes will be reprocessed.

Claims reprocessed with no change in payment will appear on the 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 are not eligible for payment in accordance with the schedule will be accompanied with one of the following explanatory codes:

  • D3 – Not allowed in addition to visit fee
  • D7 – Not allowed in addition to other procedure
  • DC – Procedure paid previously not allowed in addition to this procedure – fee adjusted to pay the difference
  • DF – Corresponding fee code was not billed or paid at zero
  • DX – Diagnostic code not eligible with FSC

Keywords/Tags

Thoracic Surgical Procedures; Z352A; Z363A; Physician Services Agreement; PSA; Physician Payment Committee; PPC; K042A; Extended Specific Neurocognitive Assessment; E424A; Assessment of Paediatric Patient with Amblyopia; Medical Claims Adjustment; MADJ; FSC

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.