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OHIP Billing Codes for Geriatrics: Cheat Sheet

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OHIP Billing Codes for Geriatrics

Consultation

A075   Consultation

A070   Consultation in association with special visit to a hospital in-patient, long-term care in-patient or emergency department patient. 

  • Claims submission instructions: Submit claim using A070 and the appropriate special visit premium beginning with "C" prefix for a hospital in-patient, “W” prefix for a long-term care in-patient or “K” prefix for an emergency department patient.

A775   Comprehensive Consultation

  • at least 65 years of age; or when the consultation is for the assessment of dementia; and where the physician spends at least 75 minutes with the patient exclusive of time spent rendering any other service to the patient

A770  Extended comprehensive geriatric consultation

  • at least 65 years of age; or when the consultation is for the assessment of dementia; and where the physician spends at least 90 minutes with the patient exclusive of time spent rendering any other service to the patient

A076   Repeat Consultation

A375   Limited Consultation

E082   MRP Premium – Add this to Admission consultation or admission assessment

*Please refer to the SoB pages GP16-19 and A99-100 for the detailed Consultation payment rules

 

Special Visit Premiums (Emergency Department)

*When billing Special Visit Premiums, use A-prefix consultation or assessment.

Not eligible for payment to Emergency Department Physicians (see definition GP67)

Premium

Weekdays Daytime (07:00- 17:00)

Weekdays Daytime (07:00 - 17:00) with Sacrifice of Office Hours

Evenings (17:00- 24:00) Monday through Friday

Sat., Sun. and Holidays (07:00- 24:00)

Nights (00:00- 07:00)

Travel Premium

$36.40 

K960 (max. 2 per time period)

$36.40 

K961 (max. 2 per time period)

$36.40 

K962 (max. 2 per time period)

$36.40 

K963 (max. 6 per time period)

$36.40 

K964 (no max. per time period)

First Person Seen

$20.00 

K990 (max. 10 (total of first and additional person seen) per time period)

$40.00 

K992 (max. 10 (total of first and additional person seen) per time period)

$60.00 

K994 (max. 10 (total of first and additional person seen) per time period)

$75.00 

K998 (max. 20 (total of first and additional person seen) per time period)

$100.00 

K996 (no max. per time period)

Additional Person(s) seen

$20.00 

K991 (max. 10 (total of first and additional person seen) per time period)

$40.00 

K993 (max. 10 (total of first and additional person seen) per time period)

$60.00 

K995 (max. 10 (total of first and additional person seen) per time period)

$75.00

 K999 (max. 20 (total of first and additional person seen) per time period)

$100.00 

K997 (no max. per time period)

 * Please refer to the SoB page GP 65-68 for the detailed Special Visit Premium payment rules.

 

Special Visit Premiums (In-Patient)

*When billing Special Visit Premiums, use A-prefix consultation or assessment.

 The “C” prefix consult codes are strictly for non-emergency inpatient consults (and therefore no special visits apply).

Premium

Weekdays Daytime (07:00- 17:00)

Weekdays Daytime (07:00 - 17:00) with Sacrifice of Office Hours

Evenings (17:00- 24:00) Monday through Friday

Sat., Sun. and Holidays (07:00- 24:00)

Nights (00:00- 07:00)

Travel Premium

$36.40
C960
(max. 2 per
time period)

$36.40
C961
(max. 2 per
time period)

$36.40
C962
(max. 2 per
time period)

$36.40 

C963 (max. 6 per time period)

$36.40
C964
(no max. per
time period)

First Person Seen

$20.00
C990
(max. 10
(total of first
and additional
person seen)
per time
period)

$40.00
C992
(max. 10
(total of first
and additional
person seen)
per time
period)

$60.00
C994
(max. 10
(total of first
and additional
person seen)
per time
period)

$75.00
C986
(max. 20
(total of first
and additional
person seen)
per time
period)

$100.00
C996
(no max. per
time period)

Additional Person(s) seen

$20.00
C991
(max. 10
(total of first
and additional
person seen)
per time
period)

$40.00
C993
(max. 10
(total of first
and additional
person seen)
per time
period)

$60.00
C995
(max. 10
(total of first
and additional
person seen)
per time
period)

$75.00
C987
(max. 20
(total of first
and additional
person seen)
per time
period)

$100.00
C997
(no max. per
time period)

 * Please refer to the SoB page GP 65-68 for the detailed Special Visit Premium payment rules.

 

Assessment / Follow-up – Automatic Codes (A07XA/A07VA)

The MDBilling.ca automated codes allow a physician to bill a single code (A07XA/A07VA) for a “follow-up”, and our software will automatically choose the highest paying assessment based on existing assessment codes previously billed in our database. The algorithm will choose the highest paying assessment code first, and subsequently bill assessment codes in decreasing fee value per the rules from the OHIP Schedule of Benefits (section GP23-25).

The rules for the automatic re/assessment services (in-patient and virtual) are as follows:

Service

Limits

A07XA    (In-person)

A07VA (Virtual)

Medical Specific Assessment

Max of 1 per 12 months, or 2 if the second visit is an unrelated diagnosis

A073A

K083A x 18

Complex Medical Specific Re-Assessment

Max of 4 per 12 months, or any combination of A073 + A071 to a max of 4 per 12 months

A071A

K083A x 17

Medical Specific Re-Assessment

Max of 2 per 12 months

A074A

K083A x 15

Partial Assessment

Thereafter

A078A

K083A x 9

 

In-Patient Services 

C075   Consultation

C755   Comprehensive geriatric consultation- subject to the same conditions as A775

C770   Extended comprehensive geriatric consultation- subject to the same conditions as A770

C375   Limited Consultation

C076   Repeat Consultation

C073   Medical Specific Assessment

C074   Medical Specific Re-Assessment

C071   Complex Medical Specific Re-Assessment

C777   Intermediate assessment - Pronouncement of death

C771   Certification of death - Note: Certification of death rendered in conjunction with A902 or      A777/C777 is an insured service payable at nil.

 

Hospital Rounding – Automatic Codes (IPTMA, IPTXA)

Service codes for rounding will differ depending on the number of days the patient has been admitted. The MDBilling.ca automatic codes allow a physician to enter one code for rounding. Our software system will automatically choose the correct (and highest paying) inpatient subsequent visit service allowed based on the admission date entered. 

 

HOW TO USE:

IPTMA (MRP Rounding): Our system will choose the correct inpatient subsequent visit code and add the MRP premium (E083/E084) for you.

IPTXA (Non-MRP - covering): Our system will choose the correct inpatient subsequent visit code for you.

MRP Subsequent Visit Premium:

E083   Weekday

E084   Saturday, Sunday or Holiday

 

Day / Week after admission

IPTMA      (MRP Rounding)

IPTXA (Non-MRP – covering)

1st Day

C122A + E083A/E084A

C072A

2nd Day 

C123A + E083A/E084A

1 – 5th Week

C072A + E083A/E084A

6 - 13th Week

C077A + E083A/E084A

C077A

13th + Week

C079A + E083A/E084A

C079A

 

Other Subsequent Visits by MRP

C142 + E083/E084   1st day following transfer from ICU

C143 + E083/E084   Second day following transfer from ICU

C124 + E083/E084   Day of discharge (patient must be in hospital for at least 48 hours)

 

Other Visits

C121   Additional visit due to intercurrent illness

C078   Concurrent Care

C982   Palliative Care


Hospital in-patient case conference

K121   Hospital in-patient case conference

Unit calculation chart:

# Units

Minimum time

1 unit

10 minutes

2 units

16 minutes

3 units

26 minutes

4 units

36 minutes

5 units

46 minutes

6 units

56 minutes

7 units

66 minutes [1h 6m]

8 units

76 minutes [1h 16m]

 

Long Term Care In-Patient Services 

W075   Consultation

W755   Comprehensive geriatric consultation- subject to the same conditions as A775

W770   Extended comprehensive geriatric consultation- subject to the same conditions as A770

W375   Limited Consultation

W076   Repeat Consultation

W272   Admission assessment - Type 1

W274   Admission assessment - Type 2

W277   Admission assessment - Type 3

W279   Periodic health visit

W074   General re-assessment of patient in nursing home*

*May only be claimed 6 months after Periodic health visit (as per the Nursing Homes Act)

W072   Subsequent visits - Chronic care or convalescent hospital - first 4 subsequent visits per patient per month … per visit

W071   Subsequent visits - Chronic care or convalescent hospital - additional subsequent visits (maximum 6 per patient per month) … per visit

W073  Subsequent visits - Nursing home or home for the aged - first 2 subsequent visits per patient per month … per visit

W078   Subsequent visits - Nursing home or home for the aged - subsequent visits per month (maximum 3 per patient per month) … per visit

W972   Subsequent visits - Nursing home or home for the aged - palliative care

W982   Subsequent visits - Chronic care or convalescent hospital - palliative care

W121   Additional visits due to intercurrent illness

W010   Monthly management fee (per patient per month) 

*See General Preamble GP51 to GP53

 

Counselling  & Interview

Automatic Codes (K01XA / K04XA) 

When billing counselling codes, there are limits on the number of units billable before the need to select a different service code (refer to OHIP Schedule of Benefits section A19).

  • Individual Counselling (K01XA): K013 for the first three units of K013 and K040 combined per patient per provider per 12 month period; K033 thereafter.
  • Group Counselling (K04XA): K040 for the first three units of K013 and K040 combined per patient per provider per 12 month period; K041 thereafter.

 HOW TO USE:

Simply bill K01XA (Individual Counselling) or K04XA (Group Counselling), and the system will search for existing counselling codes in our database and choose the appropriate counselling code for you.

Note: 

  • Per unit fee calculated in ½ hour increment

# Units

Minimum time

1 unit:

20 minutes

2 units:

46 minutes

3 units:

76 minutes [1h 16m]

4 units:

106 minutes [1h 46m]

5 units:

136 minutes [2h 16m]

6 units:

166 minutes [2h 46m]

7 units:

196 minutes [3h 16m]

8 units:

226 minutes [3h 46m]

  • With the exception of the codes listed below, no other services are eligible for payment when rendered by the same physician the same day as any type of counselling service: E080, G010, G039, G040, G041, G042, G043, G202, G205, G365, G372, G384, G385, G394, G462, G480, G489, G482, G538, G590, G840, G841, G842, G843, G844, G845, G846, G847, G848, H313, K002, K003, K008, K014, K015, K031, K035, K036, K038, K682, K683, K684, K730
  • Detention (K001) time may be payable following a consultation or assessment when a physician is required to spend considerable extra time in treatment or monitoring of the patient. See OHIP Schedule of Benefits page GP29 for further information.

K005   Primary mental health care

K014   Counselling for transplant recipients, donors or families of recipients and donors

K015   Counselling of relatives - on behalf of catastrophically or terminally ill patient

K002   Interview with relatives

 

 MDBilling.ca Billing Resource

To know more about how to bill virtual services, please refer to Virtual Care Billing Guide during COVID-19

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