OHIP Billing Theory

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OHIP Billing Theory

• Codes accurate as of November 1, 2011

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Ontario Health Insurance Plan (OHIP)

• Operated by the Ministry of Health and Long-Term
  Care (MOH)
• Set fees for services in negotiation with
  professional organizations, such as the Ontario
  Medical Association (OMA)
• Decides which services will be insurable
• Produces the Schedule of Benefits

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Registering with OHIP

• Two requirements for registering with the
  provincial health plan
• Must hold a valid certificate from the College of
  Physicians and Surgeons of Ontario (CPSO)
• Must have an Ontario practice address
• Once registered, the provider will receive a
  permanent Billing Number

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Provider Billing Number

• Identification number used on all billing and
  correspondence with the Ministry
• 0000-123456-00

Group Identification Number
Specialty Identification Number
Unique Billing Number
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Claim Types

• HCP Health Claims Program
• RMB Reciprocal Medical Billing
• WCB Workers Compensation Board
• Payee
• P - Provider
• S - Subscriber (Patient)

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Diagnostic Codes

• Identifies the reason for a service or procedure
  (diagnosis)
• Based on ICD-9 coding
• Examples
• - 460 Common cold
• - 388 Wax in ears
• - 477 Hay fever rhinitis
• - 487 Influenza
• - 009 Diarrhea
• - 787 Gastrointestinal symptoms vague

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Service (Billing) Codes

• Identifies which service has been provided and
  determines fee
• Example
• A 003 A

Alpha Prefix
Numeric Component
Alpha Suffix
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Alpha Prefix

• Indicates
• Type of service
• Where service occurred
• Circumstances of service

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Alpha Prefix
Prefix Meaning
A Office Visit
B Special Visit to Patients Home
C Service to Hospital In-Patient
E Extra Premiums or Procedure Fees
G Diagnostic and Therapeutic Procedures
H ER Visit Newborn Care
K Psychotherapy Counselling
P Obstetrical Care
W Visits to Long-Term Care Facilities
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Numerical Component

• Identifies the type and/or complexity of the
  service
• 001 is a Minor Assessment
• 003 is a General Assessment
• 007 is an Intermediate
  Assessment

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Alpha Suffix

• Identifies who has rendered the service
• Physician Services / Procedures

Suffix Meaning
A Provider or their staff rendered service
B Assistant rendered service
C Anaesthetist rendered service
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Alpha Suffix

• Diagnostic Tests
• Sometimes can be billed in two components
  Professional and Technical

Suffix Meaning
A Provider performed both components
B Provider performed technical component
C Provider performed professional component
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MOH Age Definitions
Definition of Age for Billing Definition of Age for Billing
Newborn From birth up to and including 28 days of age
Infant Aged 29 days up to and less than 2 years old
Child Aged 2 years up to and including 15 years
Adolescent Aged 16 and 17 years
Adult Aged 18 and over
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Commonly Used Codes

• Family Practice

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Consultations / Visits

• A007 Intermediate Assessment/
  Well-Baby Care
• Most frequently used code in family practice
• Well-baby care refers to a periodic visit made by
  an infant before the 2nd birthday
• Indicated by DC 916

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Consultations / Visits

• A003 General Assessment
• A full assessment done in response to a complaint
  or as an adolescent or adult Annual Health Exam
  (DC 917)
• Can only charge for 1 per 12 month period unless
  there is an unrelated diagnosis, or unless a new
  assessment is required for hospital admission
  more than 90 days since the original assessment

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Consultations / Visits

• A004 General Re-assessment
• Performed if a patient returns for another
  assessment of the same problem
• Paid at a lower rate because the provider will
  not need to perform all components of a General
  Assessment
• A001 Minor Assessment
• Brief history, exam and advice

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Consultations / Visits

• A005 Consultation
• Performed by one provider upon written request
  from another referring provider
• Provider performs a general or specific
  assessment and submits findings to the referring
  provider
• May only bill for 1 in a 12 month period, unless
  referred again for an unrelated complaint
• Requires the billing number of the referring
  provider

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Consultations / Visits

• A006 Repeat Consultation
• Primary provider re-refers patient for a
  follow-up on the same complaint as the original
  consultation
• A777 Pronouncement of Death
• In a location other than the patients home
• Includes counselling of relatives and completion
  of the death certificate

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Consultations / Visits

• A901 Housecall Assessment
• An intermediate assessment done at the patients
  residence
• Only billable for the first patient seen at a
  location
• Can charge a premium for evening, night, weekend,
  or office hour visits
• A902 Housecall Pronouncement of
  Death
• In the patients home
• Includes counselling and completion of the death
  certificate

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Consultations / Visits

• A903 - Predental/Preoperative General Assessment
• Evaluation of patients health and to determine
  whether anesthesia or surgery will present risks
• (maximum of 2 per 12-month period)

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Consultations / Visits

• K017 Annual Health Exam
• For a child between 2-15 years
• No complaint (diagnostic code) needed
• Includes primary and secondary school exams
• A008 Mini Assessment
• Used when patient is seen for a WSIB assessment,
  but also seeks care for an unrelated complaint
• WSIB is billed for a minor assessment and OHIP is
  billed for the mini assessment

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Consultations / Visits

• E079 Initial Discussion with Patient
  Re Smoking Cessation
• Limited to 1 per 12 month period
• Documentation must prove the discussion took
  place
• K039 Smoking Cessation Follow up
  Visit
• E079 must occur previously in the 12 month period
• Max 2 per year

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Consultations / Visits

• K013 Individual Care / Counselling
• Billed in ½ hour units
• Used for the first three units per 12-month
  period
• K033 Individual Care / Counselling
• Billed in ½ hour units
• Used for any additional hours of counselling in
  the 12-month period

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Obstetrical Services

• P003 General Assessment
  (Major Prenatal visit)
• first visit once pregnancy is confirmed
• P004 Minor Prenatal Assessment
• P005 Antenatal Preventative Health
  Assessment
• Initial review of antenatal risk including
  psychosocial, genetic and medical issues
• Testing performed - Only 1 per pregnancy

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Obstetrical Services

• P006 Vaginal Delivery
• Includes assessment of the patient on admission,
  attendance at labour, delivery of baby and care
  of mother and baby immediately following delivery
• P009 Attendance at Labour and Delivery
• If the family physician attends the mother but
  another physician performs the delivery

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Obstetrical Services

• P007 Postnatal Care in Hospital
• Flat fee to include all postnatal visits to
  mother in hospital
• P008 Postnatal Care in Office
• Flat fee for the postnatal examination of mother
  in the office
• H001 Newborn Care in Hospital
• Flat fee to cover all care for newborn in the
  hospital for up to 10 days

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Hospital In-Patient Visits

• C003 General Assessment in Hospital
• If first assessment for this patient in the
  12-month period for the diagnosis
• Can add E082 premium (30) if MRP
• Most Responsible Physician (MRP) Visits
• Can be claimed if family physician is most
  responsible physician for the patient while in
  hospital
• C122 second day following admission
• C123 third day following admission
• C124 day of discharge, if patient has been in
  the hospital for 48 hours

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Hospital In-Patient Visits

• Subsequent Visits
• C002 7 visits per week for the first 5
  weeks
• C007 up to 3 visits per week in weeks
  6-13
• C009 up to 6 visits per month from week
  14 on
• E083 premium that can be added to MRP
  and subsequent visits

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Hospital In-Patient Visits

• C008 Concurrent Care
• Claimed for visits by the family physician if a
  surgeon or specialist is also asked to visit
• No more than 4 visits the first week and 2 per
  week thereafter
• C010 Supportive Care
• Minor assessments by the non-MRP for liaison (max
  4 times in first week, 2 thereafter)

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Procedure Codes

• Venipuncture
• G480 - Infant
• G482 - Child
• G489 - Adult
• Hyposensitization (Allergy Injection)
• G202 - if performed with visit
• G212 if sole reason for visit
• Urinalysis
• G010 routine without microscopy (dipstick
  urinalysis)

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Procedure Codes

• Immunization
• G590 Influenza Agent (Flu shot)
• G848 Varicella (VAR) Chicken Pox
• Pap Smear (Papanicolaou)
• G365 periodic 1 per 12-month
  period
• G394 Additional for follow-up of
  abnormal or inadequate smears

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Premiums / Additional Fees

• G700 Basic Fee Sole Reason for Visit
• Claimed when a procedure is the sole reason for a
  visit to a doctors office
• Used with procedure codes marked with if no
  assessment is performed

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Premiums / Additional Fees

• Age Premiums
• Family physicians receive a 15 premium for
  patients 65 and older on general and intermediate
  assessments and housecall assessments
• Special Visit Premiums
• Extra fees if the provider sees a patient outside
  of working hours (after-hours, weekends,
  holidays), or sacrifices office hours to assess a
  patient at another location

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Premiums / Additional Fees

• First Person Seen Premium
• Payable for the first person seen at a
  destination if the service meets specific
  criteria
• Additional Person Premium
• Payable for additional people seen at a
  destination, up to a maximum

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Premiums / Additional Fees

• Travel Premiums
• Payable if the provider had to travel from one
  location to another to assess a patient
• Only payable once, even if multiple patients are
  seen

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Premiums / Additional Fees

• E542 Tray fee
• For procedures performed outside of the hospital
• Ex IUD insertion, suturing, biopsies, etc
• E430 PAP Smear Premium
• Can be added to A005, A006, A003, A004, routine
  postnatal if performed outside the hospital

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Family Health Group

• Q200 New Patient Accepted to
  Practice
• Fee for filling out rostering form
• Applies to forms filled out by new and current
  patients
• Q013 New patient Registration Fee
• Bonus for taking a new patient into an already
  full practice

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Health Claim Form

• Used to submit OHIP and WCB claims
• Used
• For Reciprocal Claims, use the Out of Province
  Claim form

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1. Provider Billing Number
2. Patient Health Card Number
3. Patient Health Card Version Code
4. Patient Date of Birth
5. Optional Account Number
6. Payment Program
7. Payee
8. Referring Provider Number
9. Master Facility Number
10. Inpatient Admission Date
11. Service (Billing) Code
12. Fee Submitted

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Example

• Ursula Hyatt is seen for an annual health exam.
  While she is there, Dr. Newman (0000-652145-00)
  also takes blood, performs a basic dipstick
  urinalysis and a pap smear
• Ursula Hyatt
• OHIP number 9824 556 551 GV
• DOB May 28, 1968

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Answer
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Independent Consideration

• Codes marked with IC require special evaluation
  before a fee can be determined
• - set fee is not listed
• - service isnt listed in schedule
• Must be submitted with supporting documentation
  and reviewed by a consultant at an OHIP office

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Manual Review

• Occurs when a claim is submitted that does not
  match the policies and regulations of the billing
  guidelines
• Physician must submit documentation supporting
  the need for the claim