Common OHIP Psychiatry Billing Mistakes and How to Fix Them

Kristen Campbell
March 22, 2021

Billing mistakes can happen in any specialization – forgetting to add a premium, using the wrong diagnosis code, not checking if your patients are insured or incorrectly entering their patient data can end up leaving money on the table or getting your claim rejected. Although billing mistakes are possible in all specializations, psychiatrists especially can benefit from being cautious – unlike specialties where procedures are fairly standardized in both task and duration (such as taking a patient’s blood pressure or preparing them for surgery). Psychiatric assessments are more subjective – how long a consultation lasts will depend on your patient approach, the complexity of their situation, and their willingness to provide you with the information you need. It’s a good idea to familiarize yourself with the most common billing mistakes to make sure you’re avoiding them: 

1. Too Many Visits with a Patient

Within Ontario’s medical billing system, psychiatry has a similar system of fee codes and timeframes to other specializations – consultations are only billable once every twelve months and need to be referred to you by another physician or nurse practitioner. If you work in a hospital and perform a consultation on a patient coming into the ER, this consultation code cannot be billed again for the patient in the next 12 months. If the same patient returns to the ER for another consultation six months later, you’ll need to bill for a repeat consultation (unless it’s a completely different issue) or use a regular time-based billing code. Keep in mind that limited consultations (those where you don’t need to collect a full medical history), general assessments, and repeat general assessments are also limited for how many you can bill.

2. Using the Wrong Code

OHIP will not allow you to bill multiple codes for a single patient in one day, even if you check on that patient multiple times. For example, if a patient comes into the hospital and you bill for a consultation (A190) and then later that day you visit them again for the same issue and try to bill a partial assessment (A194), the higher code in the claim will be rejected (A190). Since A190 has a significantly higher dollar value than A194, this mistake is crucial to avoid – going over the allowable limit for these visits is not allowed under the OHIP rules, so if you need to see a patient more frequently, make sure you’re billing correctly for your time.

For more on psychiatry in Ontario, see our guide on Psychiatry Billing Guide.

3. Double Billing by Multiple Physicians

One of the complexities of billing as a psychiatrist is that in many cases – especially if you work out of a hospital or inpatient practice – your patient will be under the care of many different doctors. OHIP does not allow multiple physicians to use the exact same code for a specific patient, so if this happens, your claim will be rejected. As a psychiatrist, you might be part of a patient medical team that includes more than one physician – in this instance if you’re both working with the same patient you have to make sure your claims aren’t identical – otherwise only one of you will be paid. 

Unlike refusals, OHIP rejections go against their billing rules – so although you can resubmit the claim, it may not be accepted. Getting a clear understanding of the claim you’re submitting is a crucial step to making the most of your billing. 

4. Using the Wrong Diagnostic Code

Be careful to use a diagnostic code that is specific and relevant to the issue that you’re treating. Not being specific enough can sometimes cause your claims to be rejected – for example, if you’re treating a patient with depression caused by substance use and you bill fee code 300 (depression), your claim could be refused. Billing too many generic codes – for example, anxiety disorder – for your patients could potentially be an OHIP red flag. Document your visit well, and make sure the code you choose to use fits the bill based on what you’ve discussed with the patient and written down in their chart. It might take a few extra minutes, but it’s important to make sure you’re using the correct diagnostic code for the fee code you’re planning to use – doing so now can save you a lot of time fixing a claim refusal in the future. 

5. Using Premiums or Incentives Incorrectly

Special visit premiums or billing incentives pay you an additional amount over your normal billing for coming into the hospital at certain times, in certain situations, or for coming in to see a patient from another hospital or clinic. These premiums can add to your monthly income, but they also open you up to potential mistakes – since these premiums are meant to incentivize specialists to assist in urgent medical situations and compensate you for your additional travel time, there are only certain scenarios when they can be used. These are:

    • Emergencies – Special visit codes are meant to be used in urgent and emergent medical situations. They cannot be used in pre-booked appointments. 
    • Travel – Special visit codes are used when you have to travel to the hospital from anywhere else, including another hospital. They cannot be used if you are traveling from another unit. These travel premiums apply only to the first patient (the one you travelled to see) and can’t be used on subsequent patient visits. 
  • First Patient Seen/Additional Patients – When you travel from another hospital or from your home, you can bill for a premium on the first patient you see and on any additional patients you take in the same visit.
  • High Risk Community Care – A 15% bonus for patients seen less than six months following a suicide attempt (code K188)
  • Urgent Community Care – an additional $216.30 for seeing a patient less than 4 weeks post-discharge from a hospital and seeing them as an outpatient for six months (code K189). To be eligible for K189 you need to provide a service that’s described by A190 (Special psychiatric consultation) A195 (consultation), A695 (Neurodevelopmental consultation) or A795 (Geriatric psychiatric consultation) to an out-patient on an urgent basis.

6. Not Checking Patient Information

Details are important, especially when you’re billing. Common reasons for OHIP claim refusal include having incorrect or incomplete patient information (for example, missing their healthcare card number or misspelling their last name), not checking that the patient was insured (uninsured patients and patients from Quebec will need to be billed privately), or forgetting to add details like the hospital admission date or the name of the referring physician. These details are important to double check before you submit, since a refusal (or a rejection) of your claim by OHIP could lead to a delay in getting paid, or earning less than you’d expect. 

Since psychiatrist visits are sometimes more complex and subjective than other specializations, understanding your billing (as well as having a good network of administrative staff and using a good billing software) is crucial to earning for your time and not leaving money on the table. Whether you’re in private practice or you’re rounding on patients in a hospital inpatient setting, taking charge of your billing and developing a knowledge of the core fee codes and premiums now can save you a lot of time in the future – something that’s good for your patients and for your wallet!

 


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