Internal Medicine OHIP Billing Codes ‘Cheat Sheet’

Courtney Marie L.
June 27, 2019

If you’re an internal medicine specialist in Ontario knowing which fee code to use can quickly get confusing. The complexity of submitting claims to OHIP, on top of your already heavy workload, is bound to cause a few headaches.

To help save you time, we’ve put together an internal medicine guide of all the available fee codes and when/how to use them. Knowing which codes are available in your speciality is essential in order to maximize your earning potential.

Internal Medicine OHIP Billing Guideline for Consultations & Assessments

In general most internal medicine 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. 

A repeat consultation is only allowed once per 12-month period if pertaining to the same diagnosis. A second consultation is only payable in a 12-month period if the diagnosis is completely different than the first. A limited consultation is allowed 1 per 12-month period.

What’s the difference between consultation and a limited consultation? Typically a limited consultation would take up much less of your time and wouldn’t require as much, if any, of taking a medical history.

General Assessments are allowed once per 12-month period. A general assessment requires less time spent with the patient than a consultation. Generally, a consultation is requested by another physician where as an assessment could be an appointment the patient booked, or that you saw in an emergency setting. 

If you need to see your patient again (for the same diagnosis) you can use a general reassessment – you can bill 2 of these per a 12-month period. You can also bill partial assessments which are unlimited. 

What’s the difference between a general assessment and a partial assessment? A General Assessment would include full history where as the partial assessment is limited in that you don’t need to take their history. A general assessment is typical when you see a patient for the first time and don’t know their history.

 

Outpatient Internal Medicine OHIP Billing Codes

For outpatients, set the service location code to HOP and the facility number of the hospital to AM. A is the prefix for outpatient.

A135 Consultation

A765 Consultation patient 16 years and under.

A130 Comprehensive Consultation – minimum time spent 75 mins. Stop and start times recorded in patient record.

A435 Limited Consultation

A136 Repeat Consultation

A133 Medical Specific Assessment

A134 Medical Specific Re-Assessment

A120 Colonoscopy Assessment – same day as colonoscopy.

K045 Diabetes Management by a Specialist.

  • Maximum of 1 service per patient per 12 month period, eligible if you’ve previously provided a minimum of 4 of the following – consultations, assessments, K013, K033, K029, K002, K003 in the 12 month period.

K046 Diabetes Team Management

  • Maximum of 1 service per patient per 12 month period, eligible if you’ve previously provided a minimum of 4 of the following – consultations, assessments, K013, K033, K029, K002, K003 in the 12 month period.

 

Visit to Emergence Department for Consultation or Assessment

*Use the A prefix and add a premium for time and travel if you were outside the hospital when called.

Emergency Department: Special Visit 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
Additonal 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

 

In Patient Internal Medicine OHIP Billing Codes

For inpatients, set the service location code to HIP and the facility number of hospital to AT. C is the prefix for inpatient. 

C135  Consultation

C765  Consultation, patient 16 years of age and under

C130  Comprehensive Internal Medicine Consultation – minimum time spent 75 mins. Stop and start times recorded in patient record.

C435  Limited Consultation

C136  Repeat Consultation

C133  Medical Specific Assessment

C134  Medical Specific Re-Assessment

C131  Complex Medical Specific Re-Assessment

E082 MRP Premium – Add this to Admission consultation or admission assessment.

 

In Patient: Special Visit Premium

When using a special visit premium to travel for inpatients make sure the consult/assessment always uses the prefix A.

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
Additonal 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

 

Subsequent Visit Internal Medicine OHIP Billing Codes

C132  First 5 weeks per visit.

C137  6th to 13th week, 3 per week.

C139  After week 13, 6 per month.

E083 MRP Premium – Add to subsequent visits when you are MRP.

Subsequent Visit (by MRP) Internal Medicine OHIP Billing Codes

C122  Day 1 following MRP admission – add E083.

C123  Day 2 following MRP admission – add E083.

C124 Day of discharge – add E083, if the patient in hospital for at least 48 hours.

 

Subsequent Visits by MRP following transfer from Intensive Care Unit

C142 Day 1 after transfer – add E083.

C143 Day 2 after transfer – add E083.

***Note: the patient must be admitted to ICU by a different specialty.

C121  Additional visits due to intercurrent illness.

C138  Concurrent Care.

C982 Palliative Care.

 

Long Term Care In Patient Internal Medicine OHIP Billing Codes

For inpatients, set the service location code to HIP and the facility number of the Long Term Facility. For long term care make sure your patient card has an admission date. Long Term Care facilities are considered an extension of a hospital, they are “inpatients” therefore an admit date is needed.

W235  Consultation

W765  Consultation patient 16 years of age and under.

W130  Comprehensive Consultation – same as A130.

W435  Limited Consultation

W236  Repeat Consultation

 

Admission Assessment

W232  Type 1

W234  Type 2

W237  Type 3

W239  Periodic health visit.

W134 General Re-Assessment.

 

Long Term Care Facility: Special Visit Premium

When using a premium for time and travel for Long Term Patients make sure the consult/assessment is the prefix A.

Weekdays Mon. – Fri. “Sacrifice of Office hours” Evenings Mon. – Fri. Weekends & Holidays Nights
Travel Premium W960 : $36.40 Max. 2 W961 : $36.40 Max. 2 W962 : $36.40 Max. 2 W963 : $36.40 Max. 6 W964 : $36.40 Unlimited
First Person Seen W990 : $20.00 Max. 1 W992 : $40.00 Max. 1 W994 : $60.00 Max. 1 W998 : $75.00 Max. 1 W996 : $100.00 Unlimited
Additonal Person(s) Seen W991: $20.00 Max. 9 W993: $40.00 Max. 9 W995: $60.00 Max. 9 W999: $75.00 Max. 19 W997: $100.00 Unlimited

 

Subsequent Visits

W132 First 4 visits per patient per month

W131 Additional visit (max 6 per patient per month)

W982 Palliative Care

 

Nursing Home or Home for the Aged

W133  First 2 visits per patient per month

W138  Subsequent visits per month (max 3 per patient per month)

W972  Palliative Care

W121 Additional visits due to intercurrent illness.


COMMON BILLING SCENARIOS

Scenario 1:

You’re called in to the ER on a Saturday evening at 7p.m. for a consultation. You head to the hospital and see the patient. Your claim would look like this:

A135 (outpatient consult)
K963 (travel premium)
K998 (first person seen premium)
The Service Location Indicator (SLI): HOP
Facility number: the # for Ambulatory Care

After the consultation – If your patient is then admitted, you would also bill the following:

E082 (Admission Assessment by the MRP)
The Service Location Indicator (SLI): HIP
Facility number: the # for Acute Care

If the patient was already an inpatient when you were called into the hospital then you’d bill the following: 

C135 for inpatient consult or 

A135 for inpatient consult IF claiming Special Visit Premiums. OHIP will only pay Special Visit Premiums on consults and assessments if it’s the A prefix code, even for an inpatient (which is the C prefix code). They will know it is an inpatient by the Special Premium Visits that are used.

 

Scenario 2:

You’re in the hospital and rounding on inpatients, one of your patients has been admitted for less than 5 weeks. Your claim would look like this:

C132 (subsequent visits). 

However – if you’re rounding on inpatients and you’re the MRP you’d bill the following:

C122: day following the hospital admission assessment

C123: second day following the hospital assessment

C124: day of discharge

For subsequent visits with the same patient (as the MRP) you can also add the following premiums)

E083 (adds a 30% premium to the subsequent visit code)
E084 (adds a 45% premium to the subsequent visit code if provided on Saturdays, Sundays and holidays);

Reminder: Special Visit Premiums are NOT eligible with subsequent visits. If the physician was called in to see the patient on an urgent matter, subsequent visits shouldn’t be billed.

 

Scenario 3:

At the hospital, you see a patient for a consult who is 15 years old. Your claim would look like this:

C130 (comprehensive internal medicine consultation inpatient).

However, if you saw the patient outside of the hospital you’d only need to change the prefix:

A130 (comprehensive internal medicine consultation outpatient)


Common Billing Mistake: Getting rejections on Counselling Codes

We often see rejections of counselling codes due to the following reasons:

  1. Billing special visit premiums on counselling codes.
  2. Billing counselling (such as K013) on the same bill as an assessment with the same diagnosis code.

Counselling appointments are technically pre-booked and therefore no special visit premiums apply.

However, counselling codes CAN be billed on the same day as an assessment BUT:

  • They need to be on separate claims.
  • They need to have different and unrelated diagnostic codes.

*** With the exception of the codes listed below, no other services are eligible for payment when rendered by the same physician on the same day as any type of counselling service.

Exceptions: 

E080

G010

G039 

G040 

G041 

G042 

G043 

G202 

G205 

G365 

G372 

G384 

G385 

G394 

G462

K002 

K003 

K008  

K014 

K015 

K031 

K035 

G480 

G489 

G482 

G538 

G590 

G840 

G841 

G842 

G843 

G844 

G845 

G846 

G847 

G848 

H313

K036 

K038 

K682 

K683 

K684 

K730

WCB Claims

You get paid for both the insured insurances you provide and for reports, there are two different ways to submit claims:

  1. Insured Services: Submit a claim to OHIP like you normally would except on the claim you’ll indicate “WCB.” OHIP will then pay you for your services and bill WSIB accordingly. If you’re using Dr. Bill, select WCB at the top of the claim instead of OHIP like this:
  2. WSIB Forms: When you fill out a form, you bill WSIB. You need to upload these claims directly to WSIB through the online portal Telus Health. These claims have different fee codes than OHIP, which outline which form you’re using.

  3. WSIB Physician Fee Schedule

 


 

If you’re interested in other OHIP fee codes, make sure to save a link to our OHIP searchable database below. You can search by speciality, billing code or keyword.

OHIP billing codes Searchable Database

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