Introduction to OHIP Billing for Family Physicians

Welcome & Acknowledgements

Paul Roscoe (OntarioMD)

It's my pleasure to welcome you to our new series, OMD Vendor Spotlights - a collaborative series that highlights companies driving transformative change in healthcare through cutting edge digital tools and technologies.

As a visitor on this land, I would like to begin this afternoon by acknowledging that I am joining from the Greater Toronto Area covered by the Toronto Purchase and Treaty 13 of 1805.

This land is the traditional territory of many nations, including the Mississaugas of the Credit, the Anishnabeg, the Chippewa, the Haudenosaunee, and the Wendat peoples, and is now home to many diverse First Nations, Inuit, and Métis peoples.

We thank all generations of people who have taken care of this land and recognize and deeply appreciate their historic connection to this place.

Before I introduce our hosts, a few housekeeping notes:

Please note, these sessions are sponsored. Sponsored webinars are not affiliated with, endorsed by, or funded by OntarioMD, OMD Educates, the Ontario Medical Association, or any of their affiliates.

This session is being recorded and will be available on the Ontario MD website next week.

Please post any questions you have in the chat throughout the presentation.

And finally, if you are having any technical issues, please monitor the chat where we'll be posting troubleshooting.

And now I'd like to welcome our sponsor, Dr.Bill.

Chris Hanscomb (Dr.Bill)

Thanks very much, Paul. Excited to be here today representing Dr.Bill, and I'm joined by a very special guest who I will introduce shortly.

For those of you who are not familiar with who we are, Dr.Bill is a medical billing platform, and our mission is to streamline the medical billing process, helping physicians get paid and give time back to focus on what matters most, patient care.

Dr.Bill was founded in 2014 in Vancouver, and since inception, Dr.Bill has grown to now service physicians across Ontario, British Columbia, and Alberta. In 2022, Dr.Bill acquired MDbilling.ca to further strengthen and expand the OHIP service offering, effectively bringing Dr.Bill to a total of 25 years’ experience in medical billing.

Today, Doctor. Bill services over ten thousand individual physicians, one hundred and twenty five group practices, and is the largest standalone medical billing provider in Ontario, servicing one in five Ontario physicians.

As of 2024, Dr. Bill has processed over $5,000,000,000 in gross billings for Canadian physicians.

My name is Chris Hanscomb. I'm a senior medical billing consultant here at Dr.Bill. While at Dr.Bill, I've worked directly with hundreds of physicians, hospitals, and clinics across Canada to help drive efficiency in their medical billing practice. I've spent about fifteen years working in the Canadian finance and technology sector. And with Dr.Bill, I really focus on the intersection of financial services and technology within healthcare.

We're seeing more and more groups of physicians, whether it be clinics, hospitals, or health networks, explore the benefits and efficiency derived from having a more unified approach to medical billing. This is really where I spend the majority of my time.

Joining me today and our guest presenter is Dr. Steph Zhou. Dr. Steph practices addictions medicine at Sunnybrook Hospital, family medicine at Don Mills Family Health Team, and is an assistant professor for the financial literacy curriculum at the University of Toronto Faculty of Medicine.

She also serves on the board of directors for Toronto Public Health. Dr. Steph is an advocate for equalizing student knowledge when it comes to personal finance and managing debt. She began by giving affording medical school webinars to the community of support students before expanding these lectures to a four-year curriculum. She also developed the family medicine building lectures currently used at the U of T family medicine residency program.

Outside of her clinical work, she blogs about personal finance on Instagram and YouTube. You can find her channel through the handle at @breakingbaddebt. Doctor Steph also organizes the annual Physician’s Financial Wellness Conference, a national philanthropic conference for physicians on financial education and practice management.

With all the work you do beyond practice, I don't imagine there's a whole lot of spare time in your calendar, so we do thank you for being here today.

Today's webinar is all about understanding the basics of OHIP medical billing. Dr. Steph will be digging into family medicine practice and payment models, various components of billing and diagnostic codes, common billing codes used in family medicine, and billing software and EMRs.

Along with these topics, Dr. Steph will be providing key resources to access information. These will be posted in the chat throughout.

As Paul mentioned, as we go through, please feel free to post your questions in the chat. We're going do our best to answer them directly, within the chat or throughout the presentation.

We will also be holding a live Q&A toward the end. Dr. Steph, I know everyone is here to learn from you. So with that, I will pass the floor over to you.

Family Medicine Billing in Ontario

Dr. Stephanie Zhou

Great. Thank you for the introduction, Chris. This is an update to the previous lectures that I've done for 2025. There's been a lot of changes to billing recently, and so today we're going be giving an overview of some of the basics of billing. Some of the topics we're going cover are:

• Why is it important to learn billing? 
• What are some main billing resources?
• EMRs
• High Yield Codes & Practice Questions

In terms of who this presentation is for, it is geared more towards people in a fee for service and a FHG model, just because in a full model, there's a lot more nuances to the billing codes that it needs a whole other lecture to cover. And I'll reference you that particular lecture that you can watch on your own time. So this lecture is for the individual who is either new to family practice in their first five years of family practice or just graduated and wants to know a little bit more about the billing codes.

If there are any questions, please post them in the chat and Veronica will be answering them in real time as we only have one hour today.

I'm gonna skip this slide just because Chris already gave a very good overview, but briefly, I do both family medicine and addiction medicine. So I do academic addiction medicine at Sunnybrook Hospital, and I practice family medicine at Don Mills Family Health Team in a FHO practice model.

These slides are for education purposes, and if there's any specific advice, please contact the MOHLTC, or you can also email Dr.Bill directly via their website.

So I'm going start with a poll just because I want to know what are people in this audience interested in learning about. And if you have any questions about these topics, feel free to ask them in the chat as well. So, Brooke, I'll let you post this poll in the chat, and I'll let people kind of answer, as they go along.

Okay. And so as people are answering the questions in the chat, there is that poll posted there.

When I teach residents about this particular topic, at about one hundred and fifty eight, Most people want to know about practice efficiency and looking for jobs, contracts, and things like that. There's actually quite a number of items that it's really hard to cover in a one hour session, but throughout the presentation, I'll try to reference resources that can kind of cover some of these topics as well.

How much do Family Physicians make?

Just for fun, out of curiosity, how much do you think family doctors earn per hour? Brooke will post this poll in the chat as well.

So I'll kind of wait a few seconds just to see what people are writing, and it looks like people are clicking on anywhere between, b actually, any of these three items, b to d seems to be, the most common answer. And when I ask this question to residents that I teach, the vast majority say $100 - $150/hour.

So why is that important to keep that number in mind? So you have to first understand what you can bill OHIP for and what you can't bill OHIP for. So things you can bill OHIP for is anything that you spend in the patient's presence. So any sort of, like, face to face time with the patient, travel to their homes, and so on. But what you can't bill OHIP for is the time that you spend charting, the time you spend billing, file review, and so on. So keep that $150 in mind because that may it seems like a high number of what you're earning. But, you know, if you count in terms of all the time that you spend, doing things that you can't bill for, it can really add up.

Not to mention, as of this year, you'll start seeing some compensation increases.

So briefly, in November, you would be you would have received a lump sum of payments from, the year three of 2021, physician services agreement, and that would have been on your RA. And coming up as of this year, January 2025 to April of 2025, you will also see some additional, a 9.95 percent compensation increase on top of the 2.8 percent, bringing it to 13 percent increase on your, billings as well. So now is an opportune time to really maximize your billings so that you can take advantage of this compensation increase, which will also be reflected in your May lump sum as well. Following that, then it kind of fluctuates because it's specialty dependent. And so depending on what is negotiated based on each specialty group, you might see differences in compensation reflected moving forward as well.

To learn more information about this, if you log into your Ontario Medical Association account and you search up PSA timeline, you'll be able to see more details and these nice, charts such as where I got this one, about the different compensation increases you're going be seeing coming in the next year. But I thought this was a good visual, way of showing what we're going be seeing soon.

Cost of unpaid work is what I'm trying to get at here. So whenever you look at a gross income of a family physician, it might look high initially, but let's say you're working, 52 weeks a year, your daily work income comes to be about $1,000 a day, which is approximately the typical locum rate. You want to deduct the tax from that as well. And your after-tax hourly value of your time actually starts dropping - it becomes to $76 dollars per hour. And then when you really take into account all of the time that you're spending, not billing for the time, right? So doing the administrative work as family doctors, we all have quite a lot of time spent on admin work, charting, billing, various other admin stuff, filling out forms. And if we do that for about two hours to three hours after work every day, it further drops our per hour income that we earn.

And so the gist of this slide is about, you know, it's important to try to minimize this time here, the two to three hours as much as possible. The other factor is thinking about lifestyle inflation. So a lot of residents or new grads will say, well, I just graduated time to earn staff physician income, and I have all of these purchases I want to make. So that's why people will say live like a resident for two to five years after residency or you'll be living like a resident for the rest of your life.

And yes, they might also include overhead, which is growing, not at pace with how much physicians are getting paid.

Billing Resources

So if you were to remember anything from these slides, it would just be the next five slides. Because I think more important to knowing the exact billing codes is actually just knowing where to look for the answers. So as family doctors, we have to know so much and often we don't know the answers to everything our patients ask us. And so we might uptodate it. So it's more important to know where to look than knowing the actual billing codes or memorizing the billing codes.

So the first link that Chris will post in the chat, and I usually bookmark this particular document on my clinic computer as the SGFP common billing codes. What I usually do to maximize efficiency is every time I finish seeing a patient, I finish the note for that patient when it's right in my head, and I bill for the patient right after finishing the note. I have this particular document, open on a different tab on my computer so that I can control find it. And when we do practice billing questions at the end, if we get enough time for that, it's important to have this open so you control-find very efficient.

I don't usually do my billing or do my charting until the end of the day, because by the end of seeing thirty patients, it's hard to remember what you talked about with the patient, and you might end up under billing if you don't remember everything that you talked about, including what was the billing code you should have used.

The second main resource you should have bookmarked is called the schedule of benefits. This is a nine hundred page document. I don't recommend you reading it. The only purpose I have for this document is if I reference the SGFP document, the first one, and it's not really clear what I should be billing, then I might control-find billing codes on here where it provides a little bit more of a descriptor on the billing.

The third resource is some of my lectures that I have given to the U of T students and other schools' students about billing. Because like I said before, these lectures that I'm going to cover today is focused on fee for service because it's important to learn how to do fee for service billing before you take it a step further and becomes more complicated. However, if you're specifically looking for FHO billing, which is another level all on its own, there is a lecture that I gave specific to that. And if you're looking for billing in, let's say emergency medicine, if you are a new grad, and you're looking for lectures about, the new grad entry program, for example, they're all in this playlist, which, Chris can link in the chat as well.

And then the OMA, there is no link for this because you need to actually log in to your member profile for this, but the OMA also has billing webinars as well. And, these can be a bit long to go through.

However, if you're in a hospitalist model or you do palliative care or something that might be more sub specialized within family medicine, a focused practice, they have some good resources for that. Just because in my lectures, I tend to cover stuff for general family doctors.

And then finally, the first five years in a family practice Facebook groups and for Ontario and for Canada.

If you're on Facebook, if you just search up these two titles, you'll find it. So that's why there's no link on it specifically because it's a private group. You have to join the group.

What I really like about these resources is if after exhausting all of previous resources I talked about and you still don't know what to bill for something, or you might have this sticky ethical scenario you're not sure about. What if you got like a CPSO complaint and you don't know what to do? You can post in this group and your colleagues who a lot of them are no longer in the first five years of practice. Some of them are in the first ten years of practice, they provide a lot of excellent advice. What I also like about these Facebook groups is that, if you're looking for something somewhere to refer to and you're struggling finding a specialist with an open spot, like a rheumatologist, for instance, your colleagues can help make recommendations for you as to where to refer in your specific areas.

So within just these five resources, you should be able to do 99% of all of your billings. And that's pretty much the main thing you have to know from my presentation.

EMR & Billing Software

But let's go over some of the more details. So the first thing you need to bill is having an EMR system. And when you're locuming, you get used to so many different types of EMR systems, and I've listed them out all here.

However, if you work in a hospital, you'll start realizing that a hospital EMR may not actually have billing software built in, and that was a surprise for me when I started working in a hospital. So I had to get, my own billing software.

And, while this, talk is sponsored by Dr.Bill, what I would actually recommend you do is that there are many different billing softwares out there. Some of them have free trials, and you can kind of just go through all of their free trials for as long as possible until you find a billing software that actually works for you.

So whatever you feel might be the best user interface, easiest to use, helps you understand how to get your claims back. Like, it's very clear about rejection codes. That should be the billing software you pick. So I encourage you to try to go through several of these. And how I ended up, listing all of these here is I went on a Facebook group similar to first five years. I polled individuals in the group - What billing software do you guys use? And then these were some of the ones that were recommended.

Next in order to bill on an EMR, you have to understand what are the different components of your EMR and the components of billing. So of course you need an OHIP number from your patient to bill.

Plus you need the actual code itself. So a billing code usually has a prefix, which is a letter. It could be a, it could be k, it could be c, various letters. And some billing softwares, need a suffix as well. So it might be something like k 0 8 8 a or b or c. And often people don't realize that they have to put in a suffix on some billing softwares, and hit the bill billing just doesn't go through. So for most family doctors, that would be a as the suffix.

Then you need a diagnostic code and this kind of tells, the ministry or the computer system, what types of patients you're seeing. Particularly in a FHO, it is more important to have a diagnostic code because of the complexity modifier, which uses the diagnostic code to determine how complex the disease you're billing for is. But for the purpose of fee for service or FHGs, you may not necessarily need this diagnostic code unless it is more so for getting a bonus where you might have five, schizophrenia codes, for example, and it gives you a bonus, at the around April, that time.

Then you need quantity. So for some time-based billing codes, which we’ll go into, you'll might you might need to know, what is the quantity to bill. So if it's one unit or two units, you might want to check if your billing's been submitted, especially if you have a billing manager submitting it for you so that you get paid, generally around the 10th or the 15th of the month, but, you should try to get it submitted around the 18th of every month.

And then around the 18th, around the, 10th to 15th of the month, you'll also start seeing something called your RA, your remittance advice. And, this is basically like a receipt that you get from the ministry telling you how much you got paid.

How do you access the remittance advice? So most people will tell you to access it from the medical claims, electronic data transfer or the MCEDT through a GoSecure account. So a lot of you would have had a GoSecure account. However, it can be very confusing for a lot of folks because once you access your GoSecure account, the format of your RA has some weird extension to it. So what I would recommend doing instead, which is much easier, is going on any third party billing software.

So any billing software that I listed before in the second column, you can access your remittance advice or through your EMR system. You can click your claims, you can click your payment period, and then you can see directly your remittance advice. If you're not sure how to do it on your EMR system, speak to your clinic's, IT manager, and they can actually show you how to pull it up. And why it's important to see your RA is more so that you can see your sources of compensation and, sometimes, you know, are you getting paid your bonuses, how much you're getting paid basically.

Practice Models

So briefly, I've been using some of these short terms. Right? I've been talking about fee for service. I've been using the word FHG, the word FHO.

And what do all of these mean? What they refer to is different practice models in family medicine. So fee for service, you might see this in like a walk in clinic setting. You might see this if you're like a, a, enhanced skills, individual.

And it's, it's a very simple, it's the simplest level of billing. So simply what your bills, what you get in a fee for service model, and you get some age premiums that you'll see on your RA as well. Then billing gets a little a step more complex once you move into a FHG or a family health group model or a comprehensive care model. The FHG model is kind of like a blend of the fee for service model and the FHO model.

So the majority of what you get paid is fee for service. However, you get a certain amount of capitation as well. Capitation meaning kind of like a per head fee, like a subscription fee, for every patient on your roster.

Now that your patients are rostered to you, this decreases the flexibility compared to a fee for service. So if you're practicing in a walk in clinic, it's very flexible.

You can take a whole month or two months off if you need to pick up shifts here or there. But once you start having a roster like these patient enrollment models, FHG and FHO, that's when the billing gets a bit more complex and it makes it a bit harder for clinicians to take mat leave, for example, or to take a long extended vacation. You might need to find some sort of coverage in that case. And so as you can see here, the further to the right you go to the chart, the different type practice models, the more components to your billing there is. And so I've just listed it out here just because I won't go through all of it. There is a whole another, forty minutes talk on YouTube just on FHO billing and clarifying what all of these different things mean. And I also have a talk on how to read your RA and how to find what each of these components are on your RA as well.

For more details on, you know, how much you actually get paid in each type of practice model, because each type of practice model dictates how much, you pay, but how much, you have to tend to your rostered patients, I have another lecture there called how doctors get paid, and this goes into more detail on the pros and cons of practicing in each model should you are deciding what type of model you want to practice in. As well, I've kind of done an income comparison based on a roster size for each, payment model as well.

High Yield Billing Codes

So next, we're based on a transition slide. And, before I move on to the next slide, I'm just going to quickly, ensure that, if there's any questions, feel free to post it in the chat. And, if there are and just to make sure, yes, it is recorded. 

Okay. Sounds good. So I'll move on since there doesn't seem to be any questions related to the previous section. So let's talk a bit about some high yield billing codes, and these might be familiar to you already.

So just remember when it comes to billing, be honest. Your documentation is proof of your billing, if you have the audit.

And you can always email economics@oma.org if you're not sure about certain billing as well.

So this is the very basics. Right? So some people might know this, some people might not, but A001 is basically, anything that's quick, like under ten minutes, like a refill or sick note.

I remember my preceptor saying it's like, the patient is in and out, like a one simple issue.

Then A007 is the gist of what most family doctors bill. Most family doctors will bill this particular building code, and it's basically like when you do a history and a physical for a patient, typically like a 15 minute, regular doctor's appointment.

Then the A003. And this part, this A003, it can be a bit contentious because based on the schedule of benefits, technically, it should be, like, a very full and extensive history and physical. So, supposedly, it's supposed to be, like, all your systems except for, like, breast or genital rectal systems. However, you know, generally, I might if you're doing like an A003, I usually bill this for, newborn exams where you are actually doing a head to toe, examination and it's documented.

But some people might actually ask, oh, but what if the patient comes in with a very complex issue like headache or chest pain, and you actually do spend much longer than your typical doctor's appointment with that issue. You're examining, you know, the cardiac system, the respiratory system, sometimes the GI system if they're having chest pain. You're examining multiple systems, but not all the systems. Like you're not doing, an MSK exam for chest pain. Can you still bill this? Personally, I do because you're spending because your time is worth money. Right? And you are spending a lot more time with the patient. It doesn't necessarily make a lot of sense for you to be billing, like, say an MSK exam for a chest pain, but you are spending a lot of the time. So that's why sometimes I will actually bill an A003 if the issue with medical issue itself is quite complex and you do have to kind of take a pretty thorough history on them.

Then the other one to know about is the K013, which is a counseling code. And this is any visit that is more than around 20 minutes long, at a pre booked visit. And it could be counseling about any medical issue, not necessarily, mental health issue because there's a different billing code for that. So this might be, for example, discussing obesity, for instance.

Then if you're, doing virtual care, then you have the K301, which is a tracking code. It doesn't really pay anything, but it reduces how much you get paid to 85% of the full amount.

And this is a phone visit. And a K300, is if you're doing a video visit, you get paid the full amount only if you have EOPPR with the patient. So what is EOPPR? And let's discuss this, in a later slide.

So, the other thing I want to point out is there are some symbols, so these plus signs and these, caret symbols on your SGFP document and what do they mean. They're just a visual reminder for you to, for example, if you bill, let's say for a Pap smear, and they only come in for that particular issue. Or if you do a vaccine, and they only come in for that issue, you can add G700 for it. So it's just a trigger for you to bill that code as well so you can get paid more.

And then if you have a little caret next to the symbol, it's just a reminder for you to bill a tray fee so that you can get reimbursed for your overhead expenses too.

So, if you are practicing in a fee for service model, which means that you don't have an existing relationship with the patient and you see them, virtually phone or video, then you just bill straight A101 or A102.

You don't bill a K301, K300 that I talked about in the previous slide. And as you can see, you get paid much less, unfortunately.

But let's say if you are in a rostered patient model and you have an EOPPR with the patient, and the patient has signed this patient enrollment form or you've rostered them by billing two Q200, then, you know, then you are allowed to bill that, regular billing code like A007 or A001 plus K301 or K300. Or if you have a focused practice designation and you did a video consult in the last 24 months, then you have EOPPR with the patient. And this is what the form looks like, to have proof that that patient has that existing relationship with you.

Veronica, I do see there are two questions that are popping up in the chat. So feel free to answer those as we go along.

So how do you maintain this existing relationship? You just have to make sure that, you know, a patient is rostered to you and, making sure your billing manager or that you check this regularly.

If you have a focus practice, you just to have you just have to have a virtual visit every 24 months, like a video visit.

Generally, I tell a patient to come in, for an annual physical every year. So that way you have that in person visit to show that, you can, that you have EOPPR.

Okay. So there are some questions popping up in the chat, but Veronica is, having some technical issues.

But, let me just briefly answer some of these quick questions after I get to the next transition slide.

How do you know a code can be a virtual code can be combined with K300 or K301 is if you use this particular link, I think Chris can post that in the chat and just control find if you're ever not sure whether, oh, can I combine K300 with, let's say A007 for instance?

The other thing to note is if you call a patient and you see them in person, later that day, you don't actually get paid for the virtual visit. You only get paid for the in person visit. So a tip might be, if you call someone and you feel like it's important to see them, you can tell them to come the following day, for example.

And then this link, it just tells you which EMRs are compatible for virtual visits.

Okay. So, mental health codes. So this is K005. It is a time-based code.

So it's important in your documentation when you sign off on your note to write what start time you spent with the patient and what's the end time you had with the patient.

Some people might ask, can you so a lot of questions about combination codes. Can you combine K005 with, let's say, A007?

You can. You just have to have a different diagnostic code for each. So, just try to remember to put a different diagnostic code.

There are some screening codes as well, and I know, some of them are preventative care. So for example, K300, it's like a annual checkup for an adolescent, and these can be combined with different codes like vaccines or Pap smears and so on.

And then there's also a diabetes code, a K030, and this is for four times a year, every three months, diabetes counseling.

You just have to remember if you're in a FHO FHG model, for example, that you can bill Q040. It gives you, like, a $60 bonus, if you've billed at least three of these K030 codes. Someone had asked, can you combine K030 with, like, let's say, A007?

I have done that before. Just, again, having to make sure you do a different diagnostic code for each. The one thing I think you can't combine a K030 with is, I think, like, a smoking code, That one may get rejected. It's very unusual why it gets rejected.

And, the other code that I that I can recall from the top of my head is, something like a A003, that full physical code, it can't be combined with, like, a Pap smear code. So it's very those are some of the combination codes you realize that you can't really combine.

Okay. So and then just as a visual trigger, some of the FIT testing has, a Q150. Like, some of the forms that you're completing, like FIT has a visual trigger on the top right form top right of the form. So ODSPs, FIT testing, and so on. Just remember to look there because it tells you what to bill.

Vaccination codes, again, can be combined with any visit code unless, you know, if you're just here for the vaccine alone, then you bill this g seven hundred plus the vaccination code. If you're in a patient enrollment model like a FHG, for example, you might also want to remember some of the some of these cue codes, on your SGFP document that gives you a bonus. It's like a tracking code. It gives you a bonus if you've done a certain number of flu shots for kids, like 80% of the flu shots in your clinic.

Then there are these procedure codes, and it's just the reminder to do the tray fee, and how you know when to add the tray fee. I think someone had asked can you do a tray fee for injection or suture removal? It depends on the code itself. So for example, if you're doing like, injection, you can't build a tray fee because it doesn't have that little symbol next to it for the injection.

And then for suture removal, you just have to check the specific, code itself and see if it has a little symbol next to it. If it does have that symbol next to it, then you can bill a tray fee. So as you can see, for example, injection with visit, it doesn't have any symbol next to it. So that's why you can't bill that, E542 tray fee with it.

What I would recommend, especially if you paying overhead, try to delegate a lot of these, services to your RN or your NP, especially these urine dips, injection and so on. Because some of them, again, you can't bill a tray fee, but at least you can delegate it to someone else to do. So it helps you a little bit with your own time management as well.

Then the other the other thing to note on the first page of the SGP augment are OBGYN codes. So anytime you do an antenatal exam, patient comes in, they're pregnant, you know, you might want to bill any of these codes as well.

The key thing to note is that you can't combine P003 with a P004 because it doesn't make sense to do a major and a minor prenatal assessment, but you can combine a P004 with a P005.

So for example, let's say a patient comes in, they're pregnant and you fill in that antenatal form with all of the little check boxes on there.

Then you can build P005 with it. And if you talk to the, patient, let's say about their pregnancy history, do a thyroid exam, breast exam, so on, then you can bill a P003 in combination with P005. The other thing I was going to point out is you'll see the N and the O next to these, the, red N and the blue O. That's just a visual trigger for people in FHN models and FHO models to tell them what is considered out of basket. But I won't be touching on out of basket too much in this talk, because it's covered in the FHO specific lecture.

Okay. So, the other thing I also want to point out is sometimes the SGFP document has typos. And so if you're doing deliveries, you get a premium for the delivery. It's not at 5AM to 12. It's 5PM to 12AM is what I'm saying here.

Okay.

Then there's smoking cessation codes. And so, smoking cessation codes, generally you always want to remember to bill those because it's fairly easy to get when you're enrolling a patient, when you're doing an annual physical, you're going to ask patients whether they smoke. And so you might as well bill for that. And this is what I mentioned earlier. There are some codes you can't combine and you only realize that when it gets rejected and you were like, why is this rejected? And then you realize, well, oddly enough, if you're talking to someone who's with diabetes and you bill a smoking cessation and you talked about smoking, for some reason, it's rejected. I don't know why.

Then you always want to bill a follow-up appointment. Make sure you bring the patient back for K039 follow-up appointment.

And, this K039 is also one of those codes that have issues with combining.

So it's hard to combine the K039 with, let's say, K013, which is a counseling code. So that's why it's been really important when you do this, it's trying to do it for a dedicated smoking follow-up visit because there has been some rejections in the past. If you're in a patient enrollment model, always remember that you get to bill this Q042. In a walk in clinic setting, you can't really combine this with this code, the K039.

And the minimum requirement for you to be billing the E079 is as long as you ask the patient, do you smoke, do you plan to quit, and when do you plan to quit? As long as you have those things documented in your note, then, you can you're eligible for billing this.

Finally, diagnostic codes. You don't need to remember any of them just because, when you type it into your EMR system, like you type in the diagnosis, it auto populates with the diagnostic code. But if you ever need to search something up, you can control-find it on the SGFP document shared earlier.

If you're in a FHO, like I said before, this is where putting the most complex diagnosis, is more useful, instead of, like, nonspecific or, like, least complex, diagnosis. So if a patient comes in for multiple issues, always try to bill the most complex issue that you discussed about, as the diagnostic code.

Billing Practice Cases

Okay. So we're now going to go on to some a little bit of practice cases because I know we only have twenty minutes left.

And so let me just quickly look through the chat, to see what questions have been asked.

Someone asks, what is the diagnostic code for a book Pap when the patient has no complaints or no symptoms at all? I usually use the diagnostic code 622. It's kind of I think it's like a cervical or cervicitis type of diagnostic code. That's what I usually use, but, you know, if other people in the chat use a different diagnostic code, feel free to let me know. I've never had any issues with that particular diagnostic code.

Someone asks, can A007 plus K301 for CCM if seen patient but not rostered aloud? As long as you've seen that patient in person at least once in the past two years, then you've already established EOPPR with the patient. So, yes, Miriam, you could combine the A007 plus K301 even if they're not rostered because you saw that person in person.

Marwa asks, what if you are working now fee for service until getting the FHO signatory status for billing the K codes?

If you're working fee for service, you can still bill K codes. Oh, I think I guess you mean the, virtual care, K300, K301. Like I said, as long as you saw that patient at least once in person, you can still bill that even if you are in a fee for service model. Until you're waiting for the FHO model, to come through and the forms, those roster forms to be filled out, try to see the patients in person at least once as much as you can.

So when Mariam also asked also for prescription authorization request and refills, Can we bill or only bill if appointment? Yeah. This is this is a part I have some issues with because it takes a long time for you to read through the chart, see why the patient is on this, and then, refill the prescription. But, unfortunately, you can't bill that unless you actually see the patient.

Right? So what some clinics might do is some clinics might charge, like, a $20 private fee for prescription refills, without an appointment. Right? And it helps kinda manage a bit of the paperwork a bit. Other clinics will ensure that patients book either a telephone appointment or an in-person appointment to get all the prescription refills done at once.

Oh, okay. So I do see Gemma is starting to answer some of the questions below.

So I will let her continue answering some of the questions that are building up while I move on to some practice cases.

And then if there are any that are, that have not been answered, then I'll get back to them.

Okay. So let's do a few practice case cases, in the couple of minutes that we have left.

So, Brooke will post this, in the chat.

What do you bill for an assessment of a 32 year old with upper respiratory infection that requires a B12 shot as well? So you'll see, like, a submit vote pop up in the chat, and so you could click which one, you would bill in this case.

And, maybe you also see what your colleagues will bill as well.

So this is just like just like if you are doing this in clinic, you just saw this patient. What I would do after I saw this patient, I would bill right after I saw them. Control-find, the billing codes on your SGFP document, and then you would submit your answer. So it looks like a vast majority of people are clicking b. So you're absolutely right. And so where you're finding this is injection with visit G372, and you can combine that with an A007 because you saw that patient for the resp infection. So you would bill that A007 plus whatever the diagnostic code is for URTI, and you could combine that with your injection visit. No tray fee, unfortunately.

Okay. Billing case two. So Brooke will post that in the post that poll in the chat.

What do you bill for a complete assessment of an 85 year old with chest pain and also a urine dip?

So I'll let people submit their answer.

Yeah. And then someone said my K030 with A007 tends to get rejected.

Just make sure that the diagnostic code is, is different. Because I know that, if you are billing K030, you should use a diagnostic code 250 for diabetes, and then A007, whatever the issue is, you would bill that for a different diagnostic code.

Okay. So it looks like a lot of people are clicking a.

So let's see here. And yes, I would put a. It looks like some people also put c. I mean, c could potentially be right, especially if you counsel the patient. But, sometimes there could be multiple right answers.

But you always want to choose the one that pays the highest amount. So you do a general assessment because you're kind of doing multiple systems, and you're spending a lot of time with the patient, and then you delegate that urine dip to your nurse, or whoever does the urine dip for you, and you can bill for them as well as long as you saw that patient the same day.

Okay. So next billing case, I'll let, Brooke post that in the chat there, and then I'll let you guys click on what you would vote for. So let's say you had a 40 minute appointment. The patient's really anxious, had a lot of questions, and they also wanted a Pap smear.

Sorry. Anxious patient as in anxiety. My bad. Anxiety. Patient with anxiety. What would you bill?

So I'll let people click their answers.

And then I saw a question pop up. Is there a limit on how many A003s? There is there is only a limit of A003s, for I think it's for two different, it has to be different diagnoses. So for example, let's say you saw someone for chest pain the first time, you can bill A003. And then that patient comes in for, headache, which can also be, like, a very general assessment issue or, like, a multiple assessment issue, then you would bill another A003. But let's say the patient comes back for chest pain, then it would be A004, which is the reassessment of your first A003. So that's kind of where the limit is. Okay. So it looks like a lot of people are clicking c, and so, yes, I would put c as the answer, because they came in for a mental health issue, K005. And then you would bill the G365 for the Pap smear that you did. And because the Pap smear had a plus sign next to it sorry. The Pap smear has a tray fee, as well. You just have to remember you bill E430. So I think someone in the chat, I briefly saw it pass by, had asked which tray fee one do you use. I use the E430.

And when do you do the E431? When do I bill that? It's usually when I bill G394. So if the patient comes back, let's say, three months later with, like, ASCUS or something, or some whatever LSIL or HSIL reason, and you have to do a repeat Pap, then I will bill G394 for that repeat Pap done in three months later, plus this E431 tray fee. So that's where that comes from. So, hopefully, I answered your question there.

Okay. So let's say this is a patient of yours and you do, a medication refill where you discuss the prescription over the phone, what do you click?

Sonia asked if the nurse practitioner does a Pap, can a physician bill?

Only if it's the same like, you saw that patient as well. So let's say, for example, and I see this a lot with male doctors. They delegate it. So let's say they saw the patient the same day, and they talked about their vaginal history or so on. Then they said, okay. Next, the nurse practitioner will do the Pap for you, and you delegate that to the nurse practitioner. Because you saw the patient that same day, you can bill for what the nurse practitioner does as a delegated act. However, if the nurse practitioner does the Pap test on their own, they do it, like, the day after and you never saw that patient at all, then you can't bill for what the nurse practitioner does.

So hopefully that clarifies it.

So let's see what people voted for. A lot of people clicked d. And, yeah, any of c or d could be right depending on how complex the medication refill was. Right? So if you discussed it for a long time with the patient, then, yeah, you could bill A007. If it was like, oh, I just need an asthma inhaler.

Okay. Here. Here's your refill.

Then maybe d would be right too.

Okay. Last case. I'll let Brooke post this case in the chat.

31 year old pregnancy test that's positive. She is six weeks gestational age. You do all her antenatal risks. You do the antenatal form, And then you also educate her about the maternal testing options. You order blood work.

You measure her BP and her weight, and then she then books her full prenatal exam at nine weeks. What do you bill here?

So, yes, so I see that Gemma has been answering some of these questions. E079 can bill with A003. Yes. Just have to be careful with the E079 combined with, K030. But with A003, it can be combined.

You just have to you the only thing you can combine with A003 from what I've seen is, like, flu shot and, Pap test. It's very weird. I don't know why you can't combine Pap test.

Okay. So let's see what people voted for.

Yes. So Gemma is writing down the documentation needed for smoking cessation premium.

Okay. So it looks like vast majority of people clicked d, and so you're absolutely right.

So you do the P004, which is kind of like your minor prenatal assessment because you're gonna do the major prenatal assessment at nine weeks. Then you bill P005 because you filled in that form, and then the G005 is because you want to recoup your overhead for that pregnancy urine dip.

Okay. So then the last billing case, I think the last one, number six. So I'll let and then doctor Patel had sorry. The chat just moved.

Can we not bill P003 with P005? I mean, you could, but because the question stem had said you're gonna do your major prenatal assessment at the next appointment at nine weeks, That's why they put P004 as the answer. But if you did the major one and you did a very comprehensive pregnancy history and you also did the antenatal form in that first initial six week visit, totally, you can do P003 plus five plus G005.

Okay. So let's see what people are voting for. They're voting for d.

So K005 to K301. So, yes, you discussed you're assuming this patient is rostered to you. So you bill the K005 plus the phone visit, and you get paid ninety five percent instead of eighty five percent for these billing codes. Now, if you're in a FHO, you might consider billing K013, even though it's not a mental health code only because after three K013s, then all the codes thereafter, the K033s are out of basket, but that will be discussed in that FHO lecture. I just wanted to mention it here for comprehensiveness.

Okay. Last building case.

Brooke will post that in the chat. When you bill for a video visit with a roster child, with sore throat and fever, and then you bring that kid into clinic for a throat swab the same day.

Gemma's answering questions in the chat about cannabis consults, and, she write it would depend on the provided depth of discussion per patient.

Yeah. And if you do the consult with a video, through video, and you have some focus designation, that that means that you could potentially build that, EOPVR code.

But the main thing is doing it video first. Okay?

Let's see. When can you bill A003 with the annual physical?

I usually only bill A003 for a physical with, well baby visits.

But, can you bill A003 with the annual physical? So in the SGFP document, it doesn't seem like you can because it has this thing that says with the exception of, like, 916, next written next to it, and that's that's the fee like, the diagnostic code for annual physical. Generally, for annual physical, I bill that, K130, K132, like, K131 codes is what I usually bill for annual physical just because there's, like, kind of a limit to the A003 billing code.

Gemma wrote the answer to is there a billing code for a well child exam.

Okay. So it looks like most people click d, and you're right.

It would not be c, which is the second most voted answer because they if you saw the patient twice in a day, they only take the in person codes. And don't forget to bill for the rapid strep so that you can recoup some of your overhead costs.

Okay. So this is the FHO, lecture that I'm referencing because as I've mentioned before, FHO billing can be a much more complex than fee for service billing. And some of the rules on billing that apply to fee for service and FHG, may not apply to FHOs. Right? And there are other ways to optimize so for FHOs. So maybe I know there's only four minutes left. Maybe Chris can post that link in the chat.

And then if there are additional questions, you can always email Dr.Bill. You can always reach out to me, and my next talk will be about it's it might be more for the advanced, family doctor on billing who understands the basics, and we'll be looking at some of the more nuances on when two billing codes are valid, which ones to pick, how to pick the one that pays you more.

So I'm just going see in the last four minutes if there are any questions that I wasn't able to get to. Sorry. The chat is moving, like, really quickly.

Gemma, are there any specific questions I should focus on? Yeah. Sonia asks how much time should you spend for K005 plus K301? Minimum 20 minutes. So it's like time based. Right? 20 minutes, then 46 minutes is the next unit.

So if you're gonna see a patient for 40 minutes, you might as well drag it longer by 6 more minutes to build a second unit.

And then Gemma answered a question about palliative care case management fee.

Yes. So she linked the palliative care billing codes for that as well. Subeta is asking which model is better, FHG or FHO? It actually it really depends, for because each model has their own pros and cons, and that's where that YouTube video that I showed earlier, like, there isn't one that's better than the other. It just depends on, what you want to see in your practice. Like, FHOs obviously has a higher capitation than a FHG, but there might be more paperwork that you have to do because you have to try to, you know, sometimes when the patient's roster to you, they're the bigger your roster is, then the bigger your capitation is, right, compared to the in basket versus out of basket codes. So when you watch that full lecture, you'll see what are the benefits of working in a FHO and why you might work in a FHO compared to in a FHG. FHG, it relies more on fee for service billings. You get the full fee for service amount.

Karim asks, when can you bill A003 with the annual physical?

To be honest, I don't usually bill A003 with the annual physical just because it does not work with the annual physical billing code unless you talk about, like, a certain issue that takes up the whole system, that you can bill for that. So you I guess you can if there is, like, one diagnostic code issue that allows you to examine many, systems.

What do you bill for obesity medicine initial visit? If you are like a consultant and someone referred you specifically for obesity visit, you might consider billing A005.

Someone had let me just see if, so we're at one minute left, and there are many other questions down below.

So I'm not sure how we should we should, address all the questions, but I'll try my best to finish some of the questions.

Can I combine K030 with insulation initiation code? I don't see why not, especially if it's related to diabetes.

Recording, I believe will be sent out.

Other than time increments, minimum, other limits on when you can bill K013. The only other limit is it has to be prebooked. It can't just be like a patient shows up and then suddenly it was a counseling for 20 minutes. It has to be a prebooked visit.

G500. I wasn't sure what the oh, that was with the insulin initiation.

Thank you for your talk. Can I bill K132 and A007 if they come with a complaint on top of their annual physical, or K132 or K005? And this is where time management might be important because, you can technically, you can if it's a completely different, issue and it's a different diagnostic code. But how long are you actually ending up spending with this patient, right? You're doing your annual physical. Sometimes that takes 30 minutes, then they have additional issues. And this is where I might have to use my communication with the patient and say like, oh, you know, maybe we'll try to book this second additional issue at another time, because I'm going to be running late for my next patients.

So now that we're at one, just want to double check because I I know that this session ends at one, but, I know that there are still several, questions left over. So if there are additional questions, you can always feel free to post them in the comment section of my videos.

That way it'll be it'll be very clear. I can also answer them there, and anyone who else anyone else watching the lecture recordings can answer can see the answers as well.

And I don't know how to do this, but maybe if there's a way to copy and paste all of the questions that weren't answered in the chat, I can try to answer them and type them out and maybe submit that with the oh, okay. So Gemma's saying, yes. If you have further questions, reach out to Veronica at veronica@dr-bill.ca as well.

So thank you everyone for joining. It was a very rushed session because billing is a very complex topic. That's why I have so many lectures on it.

And I'll maybe I'll see you at the next February 27th, session where we will go through some cases where doctors often underbill and how we can correct that because there might be something else you could bill that is higher paying.

Final Notes

That's great.

Thank you for that session.

So that concludes our presentation for today. As a reminder, the recording will be sent out next week. You can find it on our website under OMD vendor spotlights and also on the Dr.Bill website.

Stay tuned to our OMD Vendor Spotlights page as we continue to post upcoming webinars.

Thank you everyone for joining us.