ER OHIP billing

Here is a simple introduction to ER billing in Ontario.

First let's start with the weekdays

Weekday (8am-5pm)
H101 Minor (14.70)
H102 Comprehensive (36.45)
H103 Multi-system (29.65)
H104 Reassessment (14.70)

For every patient you see, you can use one of these codes. As usual for the ministry there is precious little to guide us what these words really mean. Also peculiar to this system is that there is no "single-system" assessment. So the usual dilemma is when you see a "single-system" disease that is not "minor". So here is my very personal interpretation of these words.

"Minor" assessment applies to very simple service such as refilling a few days worth of anti-hypertensive while the family doctor is away for the weekend. Patient is CTAS 5, there are no acute complaints. Or a patient is referred to ER to insert an IV or a Foley catheter from a family doctor's office. No further assessment is necessary other than your order on the chart. Patient returns to the family doctor's office promptly.

Anything beyond this is "multi-system" more or less. For example, if a person comes in with a cold, you are examining both the lungs and heart. Hopefully you are also checking the head and neck. Maybe an x-ray? Some quick blood work if you are worried about mono? That is multi-system to me.

The next step up is "comprehensive". If you are taking a full history (including family history, social history, systems review) and doing a "full physicial", according to your own definition, then your case is likely comprehensive. An elderly person comes in with pneumonia, has difficulty coping at home, there is some difficult family dynamics, and you are giving fluid and IV antibiotics. This is not a typical "walk-in" type of patient, but rather more of "obs" case as many ERs call them, where you are seeing them over multiple hours to check on the response to the treatment or interpret the on-going diagnostic tests. Personally, I should use this code more often...

"Reassessment" can be used 2 hours after the last assessment. However, you cannot use it if this "reassessment" leads to discharge or a referral. (i.e. a discharge assessment is NOT a "reassessment"!) You can only use 2 "reassessments" per patient per day, and maximum 3 per day between multiple physicians if the patient was already seen by another ER physician. Again, I should use this a bit more often.

Please refer to page A11 in the Schedule of Benefit published by Ontario Ministry of Health for actual wording from the ministry. Yes, it is not clear and yes, it is open to interpretation.

Once you have understood the weekday codes, the rest is easy.

Weekday evenings (5pm - midnight) are coded as H13_.
H131 Minor (16.15)
H132 Comprehensive (40.10)
H133 Multi-system (32.65)
H134 Reassessment (16.15)

Weekend 8am - midnight (no evening codes!) are H15_.
H151 Minor (22.05)
H152 Comprehensive (54.70)
H153 Multi-system (44.50)
H154 Reassessment (22.05)

Night (midnight - 8am) on any day of the week. H12_.
H121 Minor (25.75)
H122 Comprehensive (63.80)
H123 Multi-system (51.90)
H124 Reassessment (25.75)

There we go, these are the most basic ER billing codes. There will be more postings about other billing codes used in the ER soon!

For more information, the teaching group in London, On. has made a very useful website listing common ER codes:
https://emlondon.ca/clinical/ohip-fee-codes