General Surgery OHIP Billing Cheat Sheet

Courtney Marie L.
April 15, 2021

As a general surgeon submitting claims to OHIP is an important part of your job as not only does it help OHIP keep a record of procedures being done – it’s also how you get paid.

Unfortunately, knowing which codes to use – or what premiums are allowed – is a time-sucking task that creates more admin work on your already busy workload. The best way to know what to bill is to familiarize yourself with the most common codes. We’ve put together an OHIP General Surgery Fee Code guide that will help you understand basic general surgery rules as well as common procedures. 

General Surgery Procedures 

Unlike other specialties, general surgeons bill for a variety of different procedures that fall under different specialties, sub-specialties or surgeries. This means each surgeon’s fee codes will depend on the diagnosis of your patient and why you’re seeing them.

That being said, after you complete a procedure you’d head to the ER to consult or assess your patient. Consultations, assessments and follow-ups are all common procedures that qualify for extra adds on. You should get familiar with these since pre-op and post-op most of your claims will include these fee codes.

If you need help looking up a procedure fee code consult our OHIP database under ‘OHIP Surgical Procedures

Integumentary system surgical procedures

Musculoskeletal system surgical procedures

Respiratory surgical procedures

Cardiovascular surgical procedures

Haematic and lymphatic surgical procedures

Digestive system surgical procedures

Urogenital and urinary surgical procedures

Male genital surgical procedures

Female genital surgical procedures

Endocrine surgical procedures

Neurological surgical procedures

Ocular and aural surgical procedures

Spinal surgical procedures


For the consultations and assessments you’ll do on a daily basis reference the following fee codes and tips: 

Consultations & Assessments

General Surgery consultations are allowed once per 12-month period. All types of consultations (as outlined below) need to have been referred to you by a physician or nurse practitioner. 

Procedure Expectations Allowable Frequency
Consultation Full medical history required, must be referred to you by another physician or nurse practitioner. Once per 12 month period
Repeat Consultation Full medical history required, must pertain to different medical issue than previous consultation. Must be referred to you by another physician or nurse practitioner. Once per 12 month period, but only for a completely different medical issue
Limited Consultation Full medical history not required. Must be referred to you by another physician or nurse practitioner. Once per 12 month period
General Assessment Full medical history required; less time spent with the patient than a consultation. Does not require a referral and can be both a scheduled appointment or emergency visit.  Twice per 12 month period
Partial Assessment Full medical history not required, does not require a referral, can be both a scheduled appointment or emergency visit.  Unlimited


A035 Consultation 

A935 Special surgical consultation

A036 Repeat consultation

A033 Specific assessment

A034 Partial assessment

K013 Individual counselling (Special Visit Premiums are not applicable to counselling codes)

  • Individual and group counselling services are limited to 3 units per patient per physician per year at the higher fee (K013 individual code or K040 group code respectively); the amount payable for services rendered in excess of this limit will be adjusted to a lesser fee (K033 or K041 respectively).

 

General Surgery Premiums 

You can add Special Visit Premiums (SVP) to all Consultations & Assessments that have prefix ‘A’; please see Special Visit Premium tables below for more details. 

Admission Assessment by the Most Responsible Physician (MRP) Premium

E082 Admission assessment by the MRP. It adds 30% to any of the above consultations or assessments with prefix ‘A’.

  • E082 is only eligible for payment once per patient per hospital admission
  • E082 is not applicable for any consultation or assessment related to day surgery

Intensive or Coronary Care Unit Premium 

If you visit a patient in the ICU or CCU you can add the intensive care premium (C101) to your claim. It is a flat fee of $9.10.

C101 For each patient seen on a visit to ICU or CCU

 

  • C101 is not eligible for payment with Supportive Care or with Critical Care, Ventilatory Care, Comprehensive Care, Acquired Brain Injury Management or Neonatal Intensive Care where team fees are claimed.
  • C101 is also payable alone when no other separate fee is payable for the service provided in the ICU or CCU (e.g. post-operative care by surgeon).

Surgical Procedure Premiums

You can apply surgical premiums to your Surgical Procedure codes if your working on weekends or after office hours. 

E409 Evenings (17:00h – 24:00h) Monday to Friday or daytime and evenings on Saturdays, Sundays, Holidays – increase the procedural fee(s) by 50% 

E410 Nights (00:00h – 07:00h) – increase the procedural fee(s) by 75%. 

Physician Office

For physician office visits, leave the service location and facility fields empty. Special Visit Premiums (SVP) usually do not apply to office visits as these visits are pre booked. However, you can still use Special Visit Premiums for office appointments.

 

Premium Weekdays Daytime (07:00- 17:00) 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 A960 (max. 1 per time period) $36.40 

A962 

(max. 1 per time period)

$36.40 A963 (max. 1 per time period) $36.40 A964 

(no max. per time period)

First Person Seen $20.00 A990 (max. 1 per time period)  $60.00 

A994 

(max. 1 per time period)

$75.00 A998 (max. 1 per time period) $100.00 A996 

(no max. per time period)

 

Hospital Out-Patient Department

For outpatient clinic visits at the hospital, set the service location code to HOP and the facility to the hospital Ambulatory Care number.

Use any applicable Special Visit Premiums (SVP) from the Hospital Out-Patient Department Table below. The prefix for Out-Patient SVPs is ‘U’.

 

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 U960 (max. 2 per time period) $36.40 

U961 

(max. 2 per time period) 

$36.40 U962 (max. 2 per time period) $36.40 U963 (max. 6 per time period) $36.40 U964 

(no max. per time period)

First Person Seen $20.00

U990

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

$40.00 

U992

$60.00

U994

$75.00

U998

$100.00

U996

Additional Person(s) Seen $20.00

U991

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

$40.00

U993

$60.00

U995

$75.00

U999

$100.00

U997

 

Emergency Department

For emergency department visits, set the service location code to HED and the facility to the hospital Acute Care number. Use any applicable Special Visit Premiums (SVP) from the Emergency Department Table. The prefix for Emergency Department SVPs is ‘K’.

Premium Weekdays Mon. – Fri. “Sacrifice of Office hours” Evenings M-F Weekends & Holidays Nights
Travel Premium K960 : $36.40 Max. 2 K961 : $36.40 Max. 2 K962 : $36.40 Max. 2 K963 : $36.40 Max. 6 K964 : $36.40 Unlimited
First Person Seen K990 : $20.00 Max. 1 K992 : $40.00 Max. 1 K994 : $60.00 Max. 1 K998 : $75.00 Max. 1 K996 : $100.00 Unlimited
Additional Person(s) Seen K991: $20.00 Max. 9 K993: $40.00 Max. 9 K995: $60.00 Max. 9 K999: $75.00 Max. 19 K997: $100.00 Unlimited

 

Hospital In-Patient

For emergency calls and other special visits to in-patients (Consultation & Assessments), set the service location code to HIP and the facility number to the hospital Acute Care. Use any applicable Special Visit Premiums (SVP) from the Hospital In-Patient Table. The prefix for Hospital In-Patient SVPs is ‘C’. (SVPs cannot be applied to Non-Emergency hospital In-Patient Services such as subsequent visits and prebooked inpatient Consultation & Assessments).

 

Premium Weekdays Mon. – Fri. “Sacrifice of Office hours” Evenings Mon. – Fri. Weekends & Holidays Nights
Travel Premium C960 : $36.40 Max. 2 C961 : $36.40 Max. 2 C962 : $36.40 Max. 2 C963 : $36.40 Max. 6 C964 : $36.40 Unlimited
First Person Seen C990 : $20.00 Max. 1 C992 : $40.00 Max. 1 C994 : $60.00 Max. 1 C986 : $75.00 Max. 1 C996 : $100.00 Unlimited
Additional Person(s) Seen C991: $20.00 Max. 9 C993: $40.00 Max. 9 C995: $60.00 Max. 9 C987: $75.00 Max. 19 U997: $100.00 Unlimited

 

Non-Emergency Hospital in-patient Services

If you see a patient in the hospital, in a non-emergency setting, you can use any of the fee codes below. Since these appointments are pre-booked (as there isn’t an emergency to see the patient) special visit premiums don’t apply. 

C035 Consultation

C935 Special surgical consultation

C036 Repeat consultation

C033 Specific assessment

C034 Specific re-assessment

 

Subsequent Visits

You can use subsequent visit fee codes for any post-op in-patient visits.

C032 First five weeks

C037 Sixth to thirteenth week inclusive (maximum 3 per patient per week) per visit

C039 After the thirteenth week (maximum 6 per patient per month) per visit

 

Subsequent Visits by the Most Responsible Physician (MRP)

If your the MRP for any non-surgical in-patients, or a patient pre-surgery that you have admitted, use the following codes: 

C122 Day following the hospital admission assessment

C123 Second day following the hospital assessment

C124 Day of discharge (day of discharge can be billed with post-op or non-surgical patients post 48 hours of hospital admission). 

 

Subsequent visits by the MRP following transfer from an Intensive Care Area

C142 First subsequent visit by the MRP following transfer from an Intensive Care Area

C143 Second subsequent visit by the MRP following transfer from an Intensive Care Area

C121 Additional visits due to intercurrent illness

C038 Concurrent care

C982 Palliative care

Looking to maximize your billing?

Check out our General Surgery Billing Guide for more tips, tricks and automated features!

 


This article offers general information only and is not intended as legal, financial or other professional advice. A professional advisor should be consulted regarding your specific situation. While information presented is believed to be factual and current, its accuracy is not guaranteed and it should not be regarded as a complete analysis of the subjects discussed. All expressions of opinion reflect the judgment of the author(s) as of the date of publication and are subject to change. No endorsement of any third parties or their advice, opinions, information, products or services is expressly given or implied by RBC Ventures Inc. or its affiliates.