Changes Introduced to the OHIP Schedule of Benefits based on Evidence, Best Practices and Expert Opinion

Courtney Marie L.
November 8, 2019

After 4 long years, the Ontario Schedule of Benefits for physician services (commonly referred to as just ‘the Schedule’) has been amended to reflect recommendations given by Appropriateness Working Group (the “AWG”). The last update was in March, 2015.

Haven’t heard of the AWG? The AWG is a physician-led group, which was established back in February 2019 between the Ontario government and the Ontario Medical Association (OMA). Their goal is to use evidence, best practices and expert opinion to improve the quality of patient care and eliminate unnecessary medical services. They do this by recommending changes to the Schedule that will result in shorter wait times and cost savings. The AWG believes that technology and knowledge evolve, and therefore so should the Schedule.

On August 22nd, 2019 the AWG submitted their recommendations based on the current standards of care and the latest available technology. This led to the introduction of new fee codes, revisions on many and the removal of some. In addition to the recommendations of AWG, the OMA also identified 2 additional changes they wanted to see. Currently, all of the new changes are directly related to improving patient care and reducing unnecessary services.

While the new changes were effective as of October 1st, 2019, more revisions and changes are expected. Below is an outline of all of the changes as of date. If you’re still not sure why certain changes were made, or even what recommendations were suggested, below the changes you’ll find the list of recommendations along with descriptions of the changes made.


New Fee Codes

G694, G695, G696: Level 2 Continuous Cardiac Monitoring, 14 or more days recording (e.g., Holter Monitors).

Z292, Z293: Laryngoscopy

R699: Knee Arthroscopy (for non-degenerative disorders or acutely locked knee);

E498: Knee Debridement (debridement of focal, symptomatic post-traumatic cartilage flap); and

J900, J901: Application of Rubidium PET for cardiac perfusion.

Revised Fee Codes/Description

Magnetic Resonance Imaging Commentary

Continuous Cardiac Monitoring services (e.g., Holter Monitors) – descriptions and medical record requirements;

Specialist Consultations (for most specialties);

G005: Urine Pregnancy Test;

G420: Ear Wax Removal;

Laryngoscopy Commentary;

R687: Knee Arthroscopy (now for degenerative disease of the knee only);

E494: Knee Debridement (now for degenerative cartilage);

Special Visit Premiums for Home Visits;

A900: Complex House Call Assessment;

Supervision of Postgraduate Medical Trainees (formerly Team Care in Teaching Units); and

J866, J809: Myocardial Perfusion Scintigraphy with Single-Photon Emission Computerized Tomography (SPECT).

Removed Fee Codes

G660, G661, G690, G692: Cardiac Monitoring – Cardiac Loop Recording;

Z321: Laryngoscopy – with or without biopsy;

A901: House Call Assessment;

  • Physicians visiting patients in their home who are not complex patients (i.e. frail, elderly or housebound as defined under fee code A900) may use the appropriate assessment fee code listed in the Schedule for the service provided.

A903, A904: Pre-Dental/Pre-Operative Assessment;

  • When a medically necessary assessment is required to be performed by the family physician, or a specialist prior to an in-hospital dental or other surgical procedure, that service remains eligible for payment under the appropriate existing assessment fee codes.

X008: Sinus X-Ray; and

G364: Post Coital Mucous Test.


The AWG & OMA Recommendations & the applicable changed to the Schedule


Medical billing in Ontario is confusing and can often be overwhelming. To help out, check out the Ultimate OHIP Billing Guide that walks you through each step of medical billing – from the general submission process to maximizing your claims.


AWG Recommendation: Refer patients to specialized clinics for chronic hip and knee pain to improve arthritic care

Amendments: Magnetic Resonance Imaging Commentary

(found on page 271 of the schedule).

The Canadian Orthopaedic Association, the Canadian Arthroplasty Society and the Arthroscopy Association of Canada do not recommend using knee or hip MRI scans when weight-bearing X-rays demonstrate osteoarthritis. Based on this, a new commentary has been added to the MRI section of the schedule as a reminder. It reads:

“When weight-bearing x-rays demonstrate osteoarthritis and symptoms are suggestive of osteoarthritis, knee MRI scans are not recommended by the Canadian Orthopaedic Association, the Canadian Arthroplasty Society and the Arthroscopy Association of Canada as this investigation rarely adds useful information to guide diagnosis or treatment.”

The goal of adding this is to create greater access to CT and MRI imaging for patients who need it. Adding this section to the schedule aligns it with Choosing Wisely Canada’s recommendations.


AWG Recommendation: Update the use of ambulatory cardiac monitoring devices (Loop and Holter Monitors)

Amendments: New Cardiac Monitoring fee codes G694, G695, G696

In response to AWG’s recommendation to update the use of ambulatory cardiac monitoring devices, 3 new fee codes have been introduced that have minimum technical requirements, as well as a new description/definition of Level 1 and 2 cardiac monitors, plus changes to limits, medical record requirements and payment rules. Similarly, as loop recorders are now considered outdated they are no longer being funded.

The overall aim is that the new fee codes encourage the use of cardiac monitoring devices with new minimum technical requirements for outpatients.

New definition/description for ‘Continuous ECG Monitoring’ (E.G. Holter)

Any Level 1 cardiac monitor now requires a device capable of:

  • recording 3 or more simultaneous channels;
  • receiving a continuous ambulatory electrocardiographic recording of all beats using 3 or more skin electrodes;
  • allowing all parts of the recording to be analyzed;
  • allowing manual review of all parts of the recording; and
  • able to create graphical and quantitative reports of relevant parameters and diagnostic quality tracings for visual review (this includes post-hoc review of any portion) to enable diagnostic rhythm analysis.

You also need to make sure that the level 1 cardiac monitor includes a patient dairy and event marker capability in order to enable symptom-rhythm correlation.

Any Level 2 cardiac monitor now requires a device capable of:

  • one with fewer than 3 skin electrodes; or
  • one that records only portions of the monitoring period, or does not provide trend analysis.

Level 1 and Level 2 Additional Notes

Additional notes have been added to the schedule to clarify:

  • that any cardiac monitoring which uses an external cardiac loop recording device, that relies solely on patient activation to record electrocardiographic data and no real-time rhythm analysis, is not insured.
  • in a 30 day time period, you’re only able to claim one ‘14 day or more’ test, per patient (regardless if it’s level 1 or 2).

Important Guideline Reminders:

As before, in order to get paid, you need to make sure that all cardiac monitoring (level 1 or level 2) records for a minimum of 12 hours.

Your patient’s medical records, for any level of cardiac monitoring, needs to include:

  • the test report(s) with the number of channels recorded;
  • whether the recording was continuous;
  • if it was analyzed in real time, post-hoc or both,
  • the name of the manufacturer and model of
    the device(s).

New Fee Codes for ‘Continuous ECG Monitoring’ (E.G. Holter)

Based on the above information, the following fee codes have been added to the Schedule for Level 2 cardiac monitoring that extends beyond 13 days of recording:

G694: technical component – 14 or more days of recording; ($107.02).
G695: technical component – 14 or more days of scanning; ($78.72).
G696: professional component – 14 or more days of recording; ($86.80).

Removed Fee Codes

Since AWG suggests cardiac loop monitoring is outdated, and since level 1 and 2 monitors now need to include event recording, the following fee codes have been removed from the Schedule:

  • G660 – Event Recorder – professional fee
  • G661 – Event Recorder – technical fee
  • G690 – Cardiac Loop Monitoring – professional fee
  • G692 – Cardiac Loop Monitoring – technical fee


AWG Recommendation: Improve access to primary and specialty care by simplifying referrals to specialists

Amendments: Revised Specialist Consultations (for most specialties)

In order to improve access to primary and specialty care by simplifying referrals to specialists, the schedule has eliminated the requirement for a referral to see a specialist for the same problem within a two year period.

The payment rules for successive Specialist Consultations have been changed to the following:

  • If you have a second consultation in your office with a previous patient for the same diagnosis as the first consultation, then the second consultation will only be eligible for payment once every 24 months.
    • If your patient has an unrelated diagnosis than their original visit you are only eligible to bill for the second consultation once every 12 months.
  • If you have a second consultation with a previous patient for the same diagnosis as the first consultation, but the patient has been admitted to the hospital or you see them in the Emergency Department, then the second consultation will only be eligible for payment once every 12 months.
  • Any additional consultations you provide to the same patient, for the same diagnosis, are payable using the appropriate assessment code.
  • All consultations (including time-based and age-specific) that exceed the limits mentioned above may be eligible for payment if you bill them as a general, medical specific or specific assessment (depending on your specialty).
  • Consultations are not eligible for payment if requested by a Medical Trainee. However, they are eligible for payment at the appropriate assessment fee code amount, depending on your specialty.

Repeat Consultations

A repeat consultation remains eligible for payment in the circumstances defined by the fee code, namely following a consultation where the referring physician provides interval care but refers the patient back to the consultant for additional advice.

Reminders

As before, a consultation prior to a low risk elective surgical procedure (under local anaesthesia and/or I.V. sedation, for example cataract surgery, colonoscopy, cystoscopy, carpal tunnel or arthroscopic surgery) while uncommon; is eligible for payment if you can clearly demonstrate why the consultation was needed (and of course if it’s within the consultation limits).


AWG Recommendation: Ensure Continued Access to Urine Pregnancy Tests when Medically Necessary

Amendments: New Fee Code G005

You only get paid for G005 when you need to immediately determine if your patient is pregnant. For example, your patient comes to the office with abdominal pain and you want to rule out an ectopic pregnancy. If you feel like there is an immediate need, you should also give a blood test, which is often more effective.

G005: Urine Pregnancy Test; $3.88

If there’s no immediate urgency, then use G021 for pregnancy tests ordered through laboratories.


AWG Recommendation: Perform procedure to remove ear wax only when medically necessary

Amendments: New Fee Code for Ear Wax Removal G420

To make sure that ear wax removal is only done when medically necessary (hence when it’s causing hearing loss or is needed to treat/diagnose other issues), a new fee code has been added.

G420: Ear Wax Removal: $11.25

You can only use G420 for ear syringing and/or extensive curetting or debridement unilateral or bilateral.

You can only use G420 when earwax is impacted resulting in hearing loss. It’s only insured when the application of topical cerumenolytics hasn’t worked or if you need to remove the wax for diagnosis and/or therapy.

You cannot use G420 together with the following services:

  • Z906: Removal of drainage tube; under general anaesthetic, unilateral $66.50.
  • Z907: Debridement; unilateral
  • Z908: Debridement; under general anaesthetic, with or without repair of small perforation – when sole ear procedure(s) performed – unilateral $50.90.
  • Z913: Repair; Repair of small perforation under local anaesthesia, with or without debridement, unilateral $39.00.


AWG Recommendation: Conduct larynx examinations during stomach examinations only when medically necessary

Amendments: New Laryngoscopy Fee Codes & Commentary + Revised Fee codes (Z321, Z292, Z293)

You can now only use larynx examinations with stomach examinations if there is evidence of a problem.

Z321 (Laryngoscopy – Direct – with or without biopsy; $61.30) has been removed and replaced with 2 new fee codes – for the primary surgeon and the anaesthetist – one that you can use with biopsy and one that you can use wi
thout biopsy.

  • Z292: Laryngoscopy – without biopsy; $61.30.
  • Z293  Laryngoscopy – with biopsy; $61.30.

Rules

  • If there’s no biopsy, you cannot use Z292 with a gastroscopy, oesophagoscopy, oesophagoscopy-gastroscopy, duodenoscopy or a small bowel push Page 9 of 13 enteroscopy. You can only use Z292 if the laryngoscopy is performed due to suspicion of disease of the larynx.
  • Claims for Z292 in conjunction with upper gastrointestinal tract endoscopy must include a written explanation. Remember to always submit the claim with a manual review indicator and provide the supporting documentation.

Commentary

Commentary has been added to clarify that you don’t need manual review by a ministry medical advisor for Z293 (with biopsy), Z322 (removal of a foreign body) or Z323 (removal of lesion(s), if provided with gastroscopy, oesophagoscopy, oesophagoscopy gastroscopy, duodenoscopy and small bowel push enteroscopy services.


AWG Recommendation: Improve primary care access by streamlining pre-operative assessments

Amendments: Removal of general & operative fee codes (A903, A904)

To help streamline pre-operative assessments the following fee codes are no longer available:

  • A903: Pre-dental/pre-operative general assessment; $65.05
  • A904: Pre-dental/ pre-operative assessment; $33.70

Note: When you (either as the family physician or as a specialist) are required to provide a medical assessment prior to an in-hospital dental or other surgical procedure, the service will be eligible for payment under the appropriate existing assessment fee codes.


AWG Recommendation: Improve access to knee arthroscopies for patients with non-degenerative knee disease

Amendments: Two new fee codes for knee arthroscopy (R699, E498)

Two new fee codes have been added to the Schedule for knee arthroscopy in hopes to provide knee arthroscopies only for degenerative knee disease in special circumstances.

  1. R699: Non-Degenerative Disorders of the Knee or Acutely Locked Knee (knee arthroscopy set-up, non-degenerative disorders of the knee or acutely locked knee. Includes when rendered for synovial biopsy and/or resection or trimming of plica); $97.35If you’re a surgical assistant you can bill this with 6 base units and if you’re an anesthetist for 7 base units.Note: You can use any knee procedure in the Knee section of the Schedule with R699 if that procedure is not described as a component of R699 or described by an E add-on code to R699.
  2. E498: Debridement (trauma). Substantial debridement of 1 or more focal flaps of unstable post-traumatic articular cartilage causing mechanical symptoms, includes when rendered synovectomy, meniscal trimming and/or chondroplasty; $299.00.

R687 Revised with New E-codes

R687 has been revised to clarify that you can only use the service for degenerative disease of the knee only.

Likewise, three E-codes have been revised so that you can now use them with R687.

  • E476 (Removal of symptomatic loose body(ies) and/or screw): You can use this fee code with R687 if there is evidence (prior to surgery) of an intra-articular loose body causing mechanical symptoms or asymptomatic loose screw.
  • You can use E494 (Debridement) and E495 (meniscectomy) with R687 if you have prior approval by a ministry medical consultant (contact your Claims Services Branch office for assistance), or, when there exists:
    • Kellgren-Lawrence knee osteoarthritis (grade of less than 3, as documented on standing knee x-rays) performed within the last 12 months; and
    • Unstable chondral pathology or a meniscal tear causing mechanical symptoms that have not responded to a minimum of six months active non-surgical treatment.

You can now use R687 if your patients with degenerative disease when a diagnostic arthroscopy is required prior to or in conjunction with reconstructive proximal tibial or distal femoral osteotomy.

Additional Payment Rules were created to specify that:

  • You cannot claim E492 (Synovectomy) with E494 or E498 (Debridement – trauma).
  • You cannot claim E498 with codes for degenerative disease R687 and E494; and
  • You cannot claim E494 and E498 for the purpose of surgical visualization alone.

New Commentary has been added to clarify that:

  • You cannot use R687 when performed for lavage only, when the payment criteria are not met or when pre-approval is denied by the medical consultant.
  • You need to get prior approval for Kellgren-Lawrence grade 3 or 4 knee osteoarthritis, based on the documentation of significant functional impairment and ineligibility for more extensive reconstructive surgery.

Additional Reminders

R699 has the same restrictions as R687 in regards to codes from the Knee section and additional arthroscopic knee codes which are not components of the procedure itself or of E-codes associated with R699.

To clarify things further, the description for E494 was revised to outline that:

  • You can only use it for debridement of degenerative cartilage (for substantial debridement of 1 or more focal flaps of unstable degenerative articular cartilage causing mechanical symptoms).


AWG Recommendation: Fund physician premiums for house calls only for frail elderly and housebound patients

Amendments: Home Special Visit Premium Revised (A900) & Descriptions and Payment Requirements

Payment rules for A900 (the complex house call assessment) have been added in hopes to clarify that the service is only eligible for payment if you’re treating a frail elderly patient or a housebound patient.

Furthermore, the current definitions of ‘frail elderly patient’ and ‘housebound patient’ have been revised and now reflect the following:

A frail elderly patient is:

  • 65 years of age or older; and
  • has one or more of the following:
    • complex medical management needs that may include polypharmacy;
    • cognitive impairment (such as dementia or delirium);
    • age-related reduced mobility or falls; or
    • unexplained functional decline (not otherwise described above).

A housebound patient is a person:

  • that has difficulty in accessing office-based primary health care services because of medical, physical, cognitive, or psychosocial needs/conditions;
  • for whom transportation is not available or not appropriate in the person’s circumstances;
  • for whom other strategies to address the access challenges have been considered but are not available or not appropriate in the person’s circumstances; and
  • for whom the care and support requirements can be effectively and appropriately delivered at home.

Special Visit Premiums for Home Visits (Special Visit Premium Table VI):

  • If you travel to a patient’s home for a minor assessment (A001) or an intermediate assessment (A007) you’re not eligible to use travel premiums (B960-B964) and special visit premiums (B990, B992, B993, B994 and B996) as both these services already include travel in their descriptions.

Commentary has been added to clarify that:

  • You can’t use A900 for services in a long-term care home (even though the schedule lists long-term care under home – see definition below).
  • You can only use it for services that are provided in your patient’s home; which is defined in the schedule as:

“a patient’s place of residence including a multiple resident dwelling or single location that shares a common external building entrance or lobby, such as an apartment block, rest or retirement home, commercial hotel, motel or boarding house, university or boarding school residence, hostel, correctional facility, or group home and other than a hospital or LongTerm Care institution.”

  • Home-based assessments for patients who are not frail elderly or housebound are no longer insured as A901 ($45.15) been deleted.
  • You can still see patients in their homes but you’re not able to claim he Special Visit premiums for Travel and First Person Seen (as explained above).

Important notes:

There has been no change to fee codes associated with home-based Palliative Care visits. If you’re offering home visits to patients who do not meet the requirements of the premium, use the appropriate assessment fee code for the service provided.

Removed Fee Code:

A901: House call assessment


AWG Recommendation: Use more accurate diagnostic imaging for sinus problems

Amendments: The removal of X008 sinus fee codes

Based on AWG’s recommendation to use more accurate diagnostic imaging for sinus problems, three sinus fee imaging fee codes have been removed:

  • X008, X008B, X008C : Sinus Radiographs – technical fee, H fee and facility fee.


AWG Recommendation: Use more effective testing to diagnose infertility

Amendments: The removal of G364

Based on AWG’s recommendation to use more effective testing, the Post Coital Mucous Test is no longer insured in hopes to fund more effective infertility testing by offering alternative options based on your judgment and the circumstances of your patient.

G364 – Postcoital test of cervical mucous


OMA Working Group Recommendation: Revised section ‘Supervision of Postgraduate Medical Trainees’

Amendments: Supervision of Postgraduate Medical Trainees (formerly Team Care in Teaching Units)

The OMA established a working group back in 2017 to review the ‘team care in teaching units’ section of the Schedule.

The working group recently recommended modernizing this section to clarify the different types of trainees as well as when the supervising physician can submit a claim for the care trainees have provided.

These changes were made in hopes to strengthen the quality of supervision of medical trainees. The revised section has been renamed Supervision of Postgraduate Medical Trainees, which you can find on page 66 of the schedule.

It now defines terms, clarifies payment rules, and establishes limits and outlining medical record requirements. Here is a list of the new definitions:

  • Procedures: an insured service with anaesthesia base units and includes anaesthesia services
  • Non-Procedure: an insured service that is not a ‘Procedure’ or a ‘Time-Based Service.”
  • Time-Based Service: an insured service listed on pages GP37-42 (psychotherapy, counselling, interviews, hypnotherapy, psychiatric care and primary mental health care).
  • A service provided by a Medical Trainee is not eligible for payment to the Supervising Ph
    ysician:

    • where a Medical Trainee has an OHIP Billing Number, and is providing services outside of the training program;
    • for Special Visit Premiums associated with the Trainee’s service (unless the Supervising Physician personally meets the payment requirements for the Special Visit Premium);
    • for Case Conferences, Multidisciplinary Cancer Conferences, Telephone Consultations, E-Consultations or E-Assessments; or,
    • for Procedures:
      • where the patient is not aware the Medical Trainee is rendering the service;
      • unless the Supervising Physician is physically present in the clinical facility at the time a Resident is rendering the service or is immediately available to personally attend the patient when requested by the Resident or another health care professional; or
      • unless the Supervising Physician is available to personally attend the patient when requested by the Clinical Fellow or another health care professional in a timely manner consistent with the acuity of the clinical scenario (unless the service is procurement of organs or tissues to be used in transplantation). Page 13 of 13.

Important note: If you’re a Clinical Fellow with an OHIP billing number providing a procedure under supervision, you can claim fees for the assistant service if the procedure has basic units listed under the ‘Asst’ column (suffix ‘B’). Then, the supervising physician is eligible for payment as the operating surgeon (suffix ‘A’).


OMA Working Group Recommendation: Ensure the use of Rubidium for cardiac perfusion PET

Amendments: NEW PET Fee Codes (J900 and J901)

To encourage the use of ‘Rubidium for cardiac perfusion PET’ two new fee codes have been added for Myocardial Perfusion Scintigraphy:

  • J900: Application of Rubidium PET for cardiac perfusion (maximum 1 per examination), to J807; ($43.50 Technical, $23.65 Professional)
  • J901: Application of Rubidium PET for cardiac perfusion (maximum 1 per examination), to J808; ($43.50 Technical, $23.65 Professional).

J900 and J901 are ‘add on fee codes’ that you can only use if your patient has:

  • known coronary artery disease; or
  • suspected coronary artery disease and who are at intermediate risk (10%-90%) of significant ischemia where the need for intervention is uncertain.

Similarly, the Schedule was revised to clarify that that J866 and J809 are also ‘add on fee codes.’

  • J866 – application of SPECT (maximum of 1 per examination) is an add on to J807 (resting, immediate post-stress); and
  • J809 – application of SPECT (maximum of 2 per examination) is an add on to J808 (delayed).

If you’re not sure about any of the OHIP changes and how your past billings may be affected, don’t hesitate to write and ask one of our OHIP billing agents.

OHIP has also said that further changes to the Schedule are expected, although when and what those changes are, have yet to be determined.

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