OHIP billing how-to for Cardiologists

This blog is intended to teach the basics of OHIP billing for cardiologists working in a hospital setting. Generally, as a cardiologist, a patient will be referred to you for a consult. To bill for this first initial consult, you need to determine the following for your initial consult:
 
Location (where did your initial consult take place?): ER; Ward
Type (the type of consult): General; Comprehensive; Limited; Repeat
Time (time of day you did the consult): Weekday 7:00-17:00; Weekday 7:00-17:00 during Office Hours; Evening Weekday 17:00-24:00; Weekend/Holidays 7:00-24:00; Nights 00:00-7:00
Travel (did you have to travel to go see the patient): Yes; No

Depending on your answers from above we can determine which fee codes to bill to the Ministry of Health for the initial consult. Using your answers follow the breakdown below to find out which codes you need to bill. The first half is for ER visits while the second half covers Ward visits.  

If ER is chosen as location and…

·Type is:            

o   General = A605A

o   Comprehensive= A600A

o   Limited= A675A

o   Repeat= A606A

· Time is: 

o if Travel=YES (if you had to travel then no matter the time of day you can bill for your travel and first person seen premiums shown below, known as your special visit premiums)

§  Weekday 7:00-17:00 = K960A, K990A

§   Weekday 7:00-17:00 during Office Hours = K961A, K992A

§  Evening Weekday 17:00-24:00 = K962A, K994A

§  Weekend/Holidays 7:00-24:00 = K963A, K998A

§   Nights 00:00-7:00 = K964A, K996A

o   if Travel=NO (if you did  not travel then you can only bill for your first person seen premium shown below; however if you saw the patient during the week from 7:00-17:00 you can't bill for the first person seen premium)

§  Weekday 7:00-17:00: nothing

§   Weekday 7:00-17:00 during Office Hours: K992A

§  Evening Weekday 17:00-24:00: K994A

§  Weekend/Holidays 7:00-24:00: K998A

§   Nights 00:00-7:00: K996A

· If you admitted the patient add: E082A

 
If Ward is chosen and…
 

·Type is: (Use these codes, but if both Travel=NO and Time=Weekday 7:00-17:00, use the codes listed after this)            

o   General = A605A

o   Comprehensive= A600A

o   Limited= A675A

o   Repeat= A606A
 

·Type if Travel=NO and Time=Weekday 7:00-17:00: (Essentially all your codes listed above now start with 'C' instead of 'A')

o   General = C605A

o   Comprehensive= C600A

o   Limited= C675A

o   Repeat= C606A

·Time is:

o   if Travel=YES (if you had to travel then no matter the time of day you can bill for your travel and first person seen premiums shown below, known as your special visit premiums)

§  Weekday 7:00-17:00: C960A, C990A

§   Weekday 7:00-17:00 during Office Hours: C961A, C992A

§  Evening Weekday 17:00-24:00: C962A, C994A

§  Weekend/Holidays 7:00-24:00: C963A, C986A

§   Nights 00:00-7:00: C964A, C996A

o   if Travel=NO (if you did  not travel then you can only bill for your first person seen premium shown below; however if you saw the patient during the week from 7:00-17:00 you can't bill for the first person seen premium)

§  Weekday 7:00-17:00: nothing

§   Weekday 7:00-17:00 during Office Hours: C992A

§  Evening Weekday 17:00-24:00: C994A

§  Weekend/Holidays 7:00-24:00: C986A

§   Nights 00:00-7:00: C996A

That covers your fee codes for the initial visit with the patient. Now what happens if you continue to visit the patient daily until they are discharged?

You can use the following fee codes scheme:

Initial visit: determined using the logic above

Day after admission: C122A + E083A (The E083A is the premium if you are the most responsible physician for the patient)

Day 2 after admission: C123A +E083A

From Day 3 after admission to discharge: (Note that you use a different code for these subsequent visits, depending on when you are seeing the patient relative to their admission date. There are restrictions on how many times you can use C607A and C609A).

-          C602A (if 5 weeks from admission) +E083A

-          C607A (if 6-13 weeks from admission) + E083A

-          C609A (if past 13 weeks from admission) + E083A

Discharge: C124A + E083A

Our Mo-Billing app actually auto-generates all these codes for you given you provide the admission date, the first day you saw the patient, the last day you saw the patient and whether this was the day of discharge and the location, type, time and travel of the initial consult.To help with the understanding here are 3 examples right from our Mo-Billing app:

Example 1

 

Admission Date: Feb 15 2014

First Seen Date: Feb 15 2014 (Day of initial consult, the first day you saw the patient)

Last Seen Date: Feb 20 2014 (Last date you saw the patient, it is also the discharge date)

Enable autogeneration of codes: activated

Location: ER

Type: General

Time: Weekday 07:00-17:00

Travel:Yes

 

 

Feb 15 2014 : A605A (ER and General), K960A, K990A (ER, Weekday 07:00-17:00, Travel=YES), E082A

Feb 16 2014: C122A , E083A (day1 after admission)

Feb 17 2014: C123A, E083A (day2 after admission)

Feb 18 2014: C602A, E083A (I know to use the code for within 5 weeks from admission code since Feb 18 2014 is only 3 days after the date of admission so it falls within this category. If the date was  April 5 2014 then I would use the code C607A, E083A since this date falls within 6-13 weeks after the admission date)

Feb 19 2014: C602A, E083A

Feb 20 2014: C124A, E083A (since the last seen date is the same as discharge otherwise I would use C602A again)

 

Claim Example 2

 

Admission Date: Feb 15 2014

First Seen Date: April 15 2014 (first day you saw the patient, not the same as admission date)

Last Seen Date: April 20 2014 (last day you saw the patient, not the discharge date)

Enable autogeneration of codes: activated

Location: Ward

Type: Comprehensive

Time: Nights 00:00-07:00

Travel: No

 

 

April 15 2014 : A600A (Ward, Comprehensive, Travel=NO), C996A (Ward, Nights 00:00-07:00, Travel=NO)

April 16 2014: C607A , E083A (I know to use the code for within 6-13 weeks from admission since April 16 2014 is 8 weeks and 3 days after the date of admission so it falls within this category. If the date was  Sept 5 2014 then I would use the code C609A, E083A since this date falls after 13 weeks from the admission date)

April 17 2014: C607A, E083A 

April 18 2014: C607A, E083A

April 19 2014: C607A, E083A

April 20 2014: C607A, E083A (since the last seen date is not the same as discharge)

 

Claim Example 3

 

Admission Date: Feb 15 2014

First Seen Date: Feb 15 2014 (first day you saw the patient, the same as admission date)

Last Seen Date: Feb 15 2014 (last day you saw the patient, the same as discharge date)

Enable autogeneration of codes: activated

Location: Ward

Type: Repeat

Time: Weekday 7:00-17:00

Travel: No

 

 

Feb 15 2014 : C606A (Ward, Repeat, Travel=NO),

Note: All this information was obtained from documents made publicly available by the MOHLTC. We are not to be held liable for any occurrences that arise from following our understanding of  medical billing.