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OHIP Billing Codes for Medical Oncology: Cheat Sheet

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OHIP Billing Codes for Medical Oncology

Consultation

A445   Consultation

A446   Repeat Consultation

A845   Limited Consultation

A765   Consultation patient 16 years and under

E082   MRP Premium – Add this to Admission consultation/assessment if you are MRP

*Please refer to the SoB page GP 16-19 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.

 

Assessment / Follow-up – Automatic Codes (A44XA/A44VA)

The MDBilling.ca automatic codes allow physicians to bill a single code (A44XA/ A44VA) 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

A44X

  (In-person)

A44VA

(Virtual)

Medical Specific Assessment

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

A443A

K083A x 16

Complex Medical Specific Re-Assessment

Max of 4 per 12 months, or any combination of A443 + A441 to a max of 4 per 12 months

A441A

K083A x 14

Medical Specific Re-Assessment

Max of 2 per 12 months

A444A

K083A x 12

Partial Assessment

Thereafter

A448A

K083A x 8

 

In-Patient Services 

C445   Consultation

C765   Consultation, patient 16 years of age and under

C845   Limited Consultation

C446   Repeat Consultation

C443   Medical Specific Assessment

C444   Medical Specific Re-Assessment

C441   Complex Medical Specific Re-Assessment

C777   Intermediate assessment - Pronouncement of death

C771   Certification of death

 

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.

 

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 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 Holidays

 

Day / Week after admission

IPTMA

(MRP Rounding)

  IPTXA 

 (Non-MRP – covering)

1st Day

C122A + E083A/E084A

C442A

2nd Day 

C123A + E083A/E084A

1 – 5th Week

C442A + E083A/E084A

6 - 13th Week

C447A + E083A/E084A

C447A

13th + Week

C449A + E083A/E084A

C449A

 

Other Subsequent Visit 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

C448   Concurrent Care

C982   Palliative Care

 

Counselling  & Interviews

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

Note: 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

 

Hospital in-patient case conference

K121   Hospital in-patient case conference

Unit calculation chart:

# 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]

 

Chemotherapy

G388  Management of special oral chemotherapy, for malignant disease

G382  Supervision of chemotherapy (pharmacologic therapy of malignancy or autoimmune   disease) by telephone, monthly

G345  Complex single agent or multi-agent therapy – chemotherapy and/or biologic agent(s) that can cause vesicant damage, infusion reactions, cardiac, neurologic, marrow or renal toxicities that may require immediate intervention by the physician

G381  Standard chemotherapy - agents with minor toxicity that require physician monitoring

G281  each additional standard chemotherapy agent(additional to G381), other than the initial agent

G359  Special single agent or multi-agent therapy – chemotherapy and/or biologic agent(s) with major toxicity that require frequent monitoring and prolonged administration periods and may require immediate intervention by the physician

* Please refer to the SoB page J58-J60 for the detailed Chemo payment rules.


E078- Chronic Disease Assessment Premium

E078   Chronic disease assessment premium is payable in addition to the amount payable for an assessment when all of the criteria are met.

Note: E078 is ONLY eligible for payment with outpatient (i.e., A-prefix) assessments when billed under a diagnosis from the below chart:

* Please refer to the SoB page GP26-GP26 for the detailed E078 payment rules.

 

Diagnostic Code Description
42 AIDS
43 AIDS-related complex
44 Other human immunodeficiency virus infection
250 Diabetes mellitus, including complications
286 Coagulation defects (e.g. haemophilia, other factor deficiencies)
287 Purpura, thrombocytopenia, other haemorrhagic conditions
290 Senile dementia, presenile dementia
299 Child psychoses or autism
313 Behavioural disorders of childhood and adolescence
315 Specified delays in development (e.g. dyslexia, dyslalia, motor retardation)
332 Parkinson's Disease
340 Multiple Sclerosis
343 Cerebral Palsy
345 Epilepsy
402 Hypertensive Heart Disease
428 Congestive Heart Failure
491 Chronic Bronchitis
492 Emphysema
493 Asthma, Allergic Bronchitis
515 Pulmonary Fibrosis
555 Regional Enteritis, Crohn's Disease
556 Ulcerative Colitis
571 Cirrhosis of the Liver
585 Chronic Renal Failure, Uremia
710 Disseminated Lupus Erythaematosus, Generalized Scleroderma, Dermatomyositis
714 Rheumatoid Arthritis, Still's Disease
720 Ankylosing Spondylitis
721 Other seronegative spondyloarthropathies
758 Chromosomal Anomalies
765 Prematurity, low-birthweight infant
902 Educational problems

 

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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