1. The Principles of Billing March 21, 2014 Queens Family Medicine Tom Faloon MD CCFP FCFP
This presentation is the one offered for Ontario FM residents
The Presenter is to:
Review this complete presentation and customize it to meet their provincial specific fees schedules
The presenter is encouraged to edit to meet their personal presentation style.
Ensure that all fees, codes and provincially specific info is up to date
Ensure that all answers to the billing examples workshop are correct
Ensure that the latest provincially specific info re alternate payment models for GPs in included
Disclaimer:
The physician presenters for Practice Solutions have made all efforts to ensure that the billing information provided meets all the requirements of the MOHLTC. However, it is the responsibility of the reader to read the MOH schedule of benefits and preamble to verify that their billing submissions are appropriate.

2. Educational materials
cma.ca
Module 8 – Physician Remuneration Options - Appendix 1
– Health System Programs – practice management
Un-insured service guidelines 2014 at oma.org
Ontario SGFP
Fall 2013 Billing & Practice Guide is fabulous
January 2013 Common Family Practice Codes
Latest updates available at wwwsgfp.net.ca
OHIP schedule of fees:
Now must pay for hard copy ~ $27
Electronic copy was sent to your program to distribute
Billing questions:
Tom, I changed “member services” to “Health System Programs” to reflect the department name change

3. Obtaining Your Billing Number?
health.gov.on.ca
MOHLTC – Info Line –
HealthForce Ontario – “Practice U”
One stop resource when looking to work in Ontario –
– search Practice U
Cma.ca/pmc has a wealth of resource information for you. For residents the new Resident timeline tool will automatically cue medical students and residents by to address all of the significant personal and professional/academic issues that all residents must address during the residency.
For graduating residents entering practice, doing locums or sessional work Practice solutions has developed an excellent billing service that is very competitive with the existing billing agent services in Ontario. This is a one- stop comprehensive service for registering with OHIP, WSIB and third party billing. The charge is 3% of receivables.
The following slides will illustrate the on-line educational resources available.

4. Golden Rules of Billing
Be accountable
Be honest
Be able to defend with accurate documentation
Be knowledgeable
Be meticulous
Be effective
Be efficient
Always close the loop
The above attributes are essential.
Bottom Line : Close the loop
You will only be paid for what you do if: you know you can be paid for it, you bill for it, you verify you get paid for it. Close the loop
Above all – be honest and accountable.

5. Residents - Are You Billing Now?
What process?
Encounter sheets or billing day sheet?
Written diagnosis or specific code?
Service and procedural codes?
Billing for all on-call & hospital at handover rounds?
Tracking & capturing Chronic disease management & Preventative Care Management bonuses
Are these discussed and reviewed?
With whom?
Do you know what $$ you would be generating per day if you were practicing now?
Presenter:
Poll the attendees to discover how much exposure they have had so far with billing. Ask if their faculty supervisor includes billing with chart reviews. Clarify if the attendees preceptors are working in variety of payment models.
Residents:
It is very important for you to practice billing now during your residency. Billing skills, like clinical skills, improve with practice.

6. Understanding FFS Billing is Vital
90% of GPs still have a significant % of their income based directly or indirectly on FFS billings
FHGs, FHNs, FHTs, FHOs all require shadow FFS billing
Salaried Docs have a vested interest in staying up to date with FFS billing
e.g. academic, hospitalist, gov’t sponsored salary
Institution must collect data re equivalent FFS billing to justify global funding
Salaries depend on “bottom line”
Slide objective is to drive the message home that all attendees will be best served by a comprehensive understanding of billing. Many residents feel that billing is overwhelming and thus aspire to a ‘salaried’ payment format. They don’t realize that there are very few solely salaried positions. They also don’t realize that APPs, capitated models etc still oblige them to shadow bill. In fact there is a vested interest to capture all shadow bills because significant bonuses can be realized.

7. “Is This Code In The Basket or Out?”
Providing appropriate services to patients …
SHOULD NOT BE INFLUENCED BY WHETHER THEY ARE IN OR OUT OF THE BASKET

8. Honesty & Accountability
All physicians billing the MOH are responsible and liable to bill honestly and accountably
Failure to do so is unprofessional and illegal
Ignorance of the rules and regulations is not a defense
Random audits
Red Flags
When a physician is given a billing number they are obliged to adhere to all rules and meet all requirements for submitting fees to the ministry of health.
It is essential to read the rules and regulations that are detailed in the preamble and schedule of benefits.
The MOH can audit a physician at any time
The medical record must stand alone to justify all billings without the interpretation of the physician.
Red Flag is a term that indicates a individual physicians billings for certain services are disproportionately different form the averages of their peers. Such discrepancies will cue the MOH computers to flag the submissions for ‘manual review” . The MOH may then request documentation to verify that all such billings were appropriate. They will request copies of your office notes and use the documentation to decide. Therefore your records must justify your billings without your input. Good records are essential.

9. To be paid… Complete all Components of a Bill
Doctor identification (automatic)
Patient identification (automatic)
Date of service
Place of service (location code for hosp, OPD,ER)
Responsible party (HCP, WCB, 3rd party or patient)
Service code (visit)
Diagnostic code (dx)
Procedural code (if done)
Premiums and modifiers
1. Patient identification = HCP # with correct version code, name, date of birth (address is not required)
2. Doctor identification = doctor’s name and billing number
3. Date of service = the date the patient is examined
4. Diagnostic code = numerical code designating the diagnosis (see HCP manual of diagnostic codes)
5. Service codes= alpha/numerical code designating the service rendered. The number of services, if repeated, must be designated.
6. Procedural code = the alpha/numerical code designating the procedures rendered.
7. Place of service = the office, hospital, emergency, home
8. Premiums if any = special visits allow extra payment
9. Responsible party = HCP, WCB, reciprocal provincial plan, third-party or the patient
A summary of the common service, procedural, premium and diagnostic codes for your province will ideally be supplied to you in your appendices by your local Practice Management Faculty presenters.

10. General Definitions Billing Professional services & Diagnostic codes
Technical services & tray fees
Premiums or Modifiers
Bonuses
Responsible party
Reciprocal Billing **** Quebec
Remittance
Remittance Review and Reconciliation
Billing Period
Detailed explanations are available on cma.ca/pmcmodules – module 6 – physician remuneration options

11. The “Anatomy of a Bill “ SOAP format for Billing
“Fee for Service” Billing requires the following:
Every clinical encounter can be broken down into the following billing components
Diagnostic code
Service code
Procedure code(s) – Professional, Technical & additional office based (tray) fee codes
Special premiums, modifiers and /or bonuses
CCM, CDM, PCM & PEM bonuses
Most residents think their preceptors are on ‘salary’ and don’t have to bill. In fact the resident’s staff person will be obliged to bill, either directly or indirectly for the services they render to patients. The resident should ask their preceptor how , what and why they are using the specific service, diagnostic and procedural codes they do. Review this with the staff-person, their billing agent or responsible administrative staff.
To bill for patient encounters the following components have to be analyzed at all times to make sure you bill for all aspects of the service rendered:
Diagnostic code - indicates the medical reason for the service or procedure
Service code - indicates what service you provided when you were asked to see the patient. A different service code will apply based on the following:
Consultation, repeat consultation, regular visit, follow-up visit etc
Location of the service; office, hospital, OPD, ER, home etc
Procedure code - indicates the procedure you did or delegated and supervised or interpreted. There may be 2 components: the professional fee ( your interpretation) and the technical fee (the actual procedure)
Special Premiums, Modifiers - These indicate that the service or procedure was delivered under special circumstances which result in a different or additional fee. Examples include on-call or after hours premiums - Special visit premiums when you are called to re-evaluate a patient by the nursing staff or attending - Premiums for going to the ER
All patient encounters can be broken down into these elements. Once done the physician references the fee schedule to assign the corresponding fee. If payment is via an APP (alternate payment plan), “shadow billing” is obligatory. That means fee for service billing is done in parallel. The institution has a vested interest in doing accurate shadow billing because the fee for service billings are used as a guide to what global funding will be offered.
Bonus – additional incentive payments added to many regular fees when physicians participate in a patient enrolled model (PEM). Bonuses can increase gross income by 20% or more.
PEM bonuses – refer to the many bonuses and preventative management bonuses that are available for doctors who work in Patient Enrolled Models such as FHG, FHN,FHT etc
CCM = comprehensive care management; CDM = chronic disease management ( DM , CHF )

12. Premiums, Modifiers, Bonus”
A Premium or Modifier is an additional fee that reimburses the physician for:
traveling to provide the service
making special visits
providing after-hours, weekend or holiday services.
The premium or modifier fee will have a specific code and fee
CCMs & FHGs are given bonuses of % of FFS fee for many comprehensive services as well as for comprehensive & preventative care
Preventative Care Management Bonuses, Comprehensive Care Management, and Chronic Disease management
The OMA website has an excellent concise summary of the differences between the varied PEMs. Visit OMA.org

13. Worker’s Compensation WSIB in Ontario
WCB/WSIB should be billed for most work related medical complaints.
Knowingly billing the Provincial HCP for WCB/WSIB services is…fraudulent
Patient refusal makes the service non-insured
WCB/WSIB pays for form completion
Form 8 & progress forms
Latest WSIB fee schedule is December 10, 2012
Before you complete your residency make sure you familiarize yourself with the WSIB forms as well as the fee submissions.

14. Common WSIB Forms and Fees December 2012
Form 8 – First Report
8M – paper submission - $65
8ME - electronic submission - $85
Form 26 – progress report – ‘
26M – paper - $45
26ME - Electronic - $60
Complex Report – M649
Written or dictated $ – no electronic
This is a narrative report
Verify with WSIB by fax first

15. Billing Documentation
Patient record must be able to stand alone as an indicator of what services and procedures were provided without your interpretation!!!
Random audits occur
Dictation / typed notes are recommended for both traditional and electronic medical records
The Ministry of health can randomly request copies of the patient record to verify that what you billed was justifiable. Your record must stand alone to verify appropriate billing (without your interpretation) just as it must as an indicator of good record keeping and patient care if reviewed by the college of physicians and surgeons.

16. Billing Day Sheet - Example * Date:________ Dr. ______________
Time:
Name
Age
$ Prompt
Reason 4 Visit
Payer
Diag Code
Service Code
Procedur
Code
PCM/CDM
Track
8:00 am
8:10 am
8:20 am

17. Doctor’s #1 Complaint = $750,000 over your career !!!!!!!!
‘I am underpaid for the services I provide’
Who should they blame?
First & foremost - themselves
Majority fail to capture and submit bills for > 5% of services rendered
Plus - majority fail to collect on > 3% of unpaid services submitted
Failure = >8% reduction in gross income = >12% reduction
in net income
Easily can = $25,000 insured / year!!!
= $750,000 over your career !!!!!!!!
The number one practice management mistake made by physicians is failure to bill for services rendered. The consequences can be profound. Many physicians fail to bill or collect on $20-30,000 per year or more due to poor practice management. Imagine the lost income over 20 years!
Ignorance leads to Lost Income
There is a 6 month limit to submit your bill for an insured service. After that it is voided and you can’t bill the patient either!

18. Know Your Fee Schedule
Provincial HCP’s “Schedule of Benefits” dictate the fees you receive
Fees change - Read all Bulletins & Fact Sheets from MOH, OMA, SGFP
Have these automatically sent to your inbox!!
Don’t assume “what you have seen or heard” during residency is best practice billing
Stay up-to-date
review the Fee Schedule and the explanatory preamble
IGNORANCE leads to LOST INCOME
The HCP Schedule of Fees/Benefits may not be printed on a yearly basis. However, the Ministry/Department will regularly send out bulletins updating doctors on changes and new restrictions. It is imperative that you always read these bulletins.
Ignorance leads to lost income and / or inappropriate billing for which you will be liable.
Note: The MOH fee schedule is available to the public and can be accessed via your provincial MOH website
Have your staff put all MOH bulletins in your ‘in-basket” so you are automatically cued to review them.

19. Your new bible…

21. What our patients think we get….
For regular office visit
For complete checkup
For a delivery
As part of a research project a resident in Ottawa surveyed 300 people on the street in 1996 and found that the lowest guess for these questions were:
$50 for a regular office visit
$150 for a checkup
$1500 for a delivery
The point of this slide is to educate attendees that patients rarely know how or what a GP is remunerated for their services. Posting the provincial specific fees for common services in waiting rooms and exam rooms educates patients.
Note.
In 2008 the MOH pays $32 for an intermediate visit, $~60 for a complete assessment and ~$400 for a delivery before bonuses.

22. The “Bread & Butter” of Billing
In general, most specialties use 5-6 service codes more often than any others
Family Docs must be aware of many, many more!
Learn what criteria must be met before using these billing service codes
Each code is explained in the preamble of the HCP “Schedule of Benefits”

23. A001 & A007 Definition/required elements of service
A001 = minor visit includes one or both of the following;
A. a brief history and examination of the affected part or region or related to a mental or emotional disorder….or
B. brief advice or information regarding health maintenance, diagnosis, treatment and or prognosis
The above text is taken from the Ontario Ministry of Health Schedule of benefits preamble April 2006

24. A007 = The Foundation of GP Billing Definition/required elements of service
A007 = An intermediate assessment is a primary care GP or pediatric service that requires a more extensive examination than a minor assessment. It requires a history of the presenting complaint(s), inquiry concerning, and examination of the affected part(s), region(s), system(s) or mental or emotional disorder as needed to make a diagnosis, exclude disease, and/or assess function
The above text is taken from the Ontario Ministry of Health Schedule of benefits preamble April 2006

25. Latest MOH Contract = December 2012 PSA Physician Services Agreement
Present contract ends soon. OMA & MOH are in negotiations.
In 2012 the MOH obliged reductions and no fee increases to the 2011 fee schedule. Some new services / fees were addes
0.5% reduction on all physician payments across the board
3% reduction on A007 remains
Impacts bonuses for FHG and seniors
Changes will be highlighted in red!
For example purposes we will use the 2011 fees and not factor in the 0.5% reduction but the 3% reduction in A007 is factored in

26. Bread and Butter GP Codes: Ontario Fees as of December, 2013
Code / service description FFS FHG
A007A - intermediate exam $ $37.07
15% premium to A007 if >65 yo $42.12
A001A - minor exam $ $23.97
A003A - general assessment $ $84.92
15% premium to A003 if > 65 yo $96.50
K017 – child annual health exam $ $47.96
K005A - primary mental health $ $69.02
K013A - counseling $ $69.02
P003 – 1st prenatal visit $ $84.92
P004 – routine prenatal visit $ $38.17
Refer to the MOH preamble for specific explanations:

27. Geriatric Premiums Geriatric premiums also apply to:
A004 general reassessment - $38.35
FHG = 10% + geriatric 15% = $47.94
A901 house call - $45.15
FHG = 10% + geriatric 15% = $56.44

28. Periodic Health Visit Replaces ‘Annual Check-up’ A003 Dx 917
Criteria: Patient presents and reveals no apparent physical or mental illness
Includes an intermediate assessment focusing on age/gender appropriate Hx / OE / health screening & relevant counselling
K017 – child – 2-15 $43.60
K103 – adolescent $77.20
K131 – adult $50.00
K adult 65+ $77.20
If you do a complete history and exam and have a legitimate dx the A003 and Dx code – e.g 412 still applies

29. Periodic Health Visit What Criteria is Recommended
CFPC Website
Preventative Care Checklist Form
Male and Female (2010)
CFPC and Canadian Pediatric Society
The Greig Health Record: Ages 14, 15, 16, 17 (2010)

30. Immunization Codes Have Changed To Allow MOH to Track Delivery
G840 = Quad (DTaP-IPV) = $4.50 for all
G841 = Penta (DTaT-IPV-Hib)
G842 = Hep B
G843 = HPV
G844 = Conj meningococcus C
G845 = MMR
G846 = Conjugated Pneumococcus
Add G700 ($5.10) if sole reason for visit

31. Immunization Codes Have Changed To Allow MOH to Track Delivery
G847 = TdaP
G848 = Varicella
G538 = “other
G590 = Flu
Add G700 ($5.10) if sole reason for visit

32. The Most Commonly Missed Procedural Codes
Examples
Chemical Treatment of Minor Skin Lesions Z117 $11.65
Ear syringing G420 $11.25
Urinalysis G010 $2.07
Strep tests G014 $5.50
Pregnancy tests `` - G005 $3.88
Immunizations Gxxx $4.50
Supervision of Anti-Coagulation - G271 $12.75
Tray Fees for procedures - E542 $11.15
All procedures performed by support staff!
REVIEW ALL procedure codes for applicable tray fees

33. Important (frequently forgotten) codes
K028 - STD management (2/yr) $62.75
K030 - diabetic management (4/yr) $39.20
K037 – chronic fatigue / fibromyalgia (795) $62.75
K023 – palliative care support $62.75
G512 – telephone support in pal care $62.75 weekly (!!)

34. Frequently Forgotten Codes
P005 - antenatal prevent health $45.15
may be billed with P004 and P003
E430 - Pap tray fee (regardless of service) $11.55
NB only if pap is done – not apply for speculum exam only
E542 – procedural tray fee $11.15
K070 – homecare application $31.75
K071/072 – homecare supervision $21.40

35. Forgotten codes.. K035 – MTO Reporting $36.25
Ontario Ministry of Transportation home page
Vehicles>Driver Licensing>Driver Improvement>Medical Review>Physician Reporting Requirements
Download – Medical Condition Report (PDF – 376KB)
Or –
Also Download latest CMA “Physician’s Guide to Driver Examination”
Cma.ca>cma publications>cma books. CMA Drivers Guide

36. Forgotten codes..
B998 – (7h-24h hours) special home visit premium to see palliative care patient $ 82.50
Plus new travel premium B $36.40
W010 –Monthly management fee of nursing home patients $108.85

37. Hospital Care Now Rewarded
C122 day one hospital visit, C123 day two hospital visit, C124 discharge day hospital visit - $58.80 – this is a significant increase for offering in-patient care
If MRP, add 30% ($17.64) (E082, E083) = $76.44
C002 regular visit = $31.00 if MRP = $40.30
E080 – first visit premium within 2 weeks of discharge from acute care hospital (not OB or newborn) - $25.00 in addition to regular service fee (A001, A007, A003, A888, A901, K013, K023, K030, P003, P004, P008 – see preamble for other codes)

38. Special Visit Premiums

39. Enhanced Annual Bonuses For House-calls to Frail and Elderly
Introduced in 2010 – apply to and are captured with:
A901, A902, B990, B992, B994, B996, B910, B914, B916
Bonus payments increased in latest PSA
# patients # encounters bonus
Min 3 min 12 $1500
Min 6 min 24 $3000
Min 17 min 68 $5000
Min 32 min 128 $8000
Palliative Care Bonus is different

40. Diabetic Care Management Fee – Q040
$60 – may bill once per 365 days starting April 1 – Mar 31st
Must complete and meet all examination criteria of Diabetes Patient Care Flow Sheet
Suggestion:
Search and cross reference Dx code 250, tracking code Q040 & last billing date every 3 months
Track & cue yourself to bill Q040, E079 along with the other PCM bonuses on front of chart / EMR
Suggest have copies of the flow sheets in the handouts
Suggest give an anecdotal example of how using the flow sheets has helped you to offer more proactive management and monitoring of your diabetic patients. IE The sheet cues you to prompt the patient to see their eye doctor yearly and to return in the fall for a flu shot. IE how the prompts on the flow sheet reminded me to stress test all my diabetics over 50 resulting in 2 patients captured early before they had any significant anginal symptoms or damage ( Pfizer will appreciate this)
IE how the flow sheet makes it so much easier for your colleagues when they are covering your patients.

41. Smoking Cessation
For all docs offering smoking cessation counseling (FFS,CCM,FHG,FHN etc)
E079 - $15.40 bonus 1/yr – billable with several service codes e.g. A007, K013, P003, P005, W001 etc
K039 - $33.45 – 2 / yr – must document on flow sheets meeting Clinical Tobacco Intervention (CTI) guidelines
For FHG, FHN - Q $7.50 – 2 / yr is added to K039
Suggestion:
Review the billing and the criteria for billing but also endorse the use of the flow sheets with their correct billing guidance right on the sheets.
Note the sheet does not have champix as an option

42. Congestive Heart Failure Management
Q050 = $125 per 365 days
Form completion twice yearly
Suggest - Search diagnostic codes 428 to establish your list. If 428 not used cross reference 412, 427 to see if criteria met.
Excellent clinical tool of latest CHF Rx Guidelines
Suggest offering personal anecdote that you appreciate how this flow sheet is also a comprehensive summary of the latest guidelines for treatment of CHF. Therefore it is a patient aid, CME aid and billing aid

43. Palliative Care G512 – Palliative care management fee - $62.75
billable once per week / patient
includes K070 (home care application), K071, K072 (acute & chronic home care supervision)
Includes G511 (phone care for palliative care patients 2 calls per week - $17.75)
Document in chart!

44. Hospital Case Conferences
K121 Hospital case conference - for inpatient (acute, chronic, rehab hospital)
Participation in person or by phone with 2 or more allied health care givers for a pre-booked case conference
Eligible for each doc participating
Document & individually initial summary and attendance time in chart.
$31.35 per time unit, maximum 4 conferences per 12 months
1unit - 10 minutes, 2units - 16 minutes, 3units minutes, 4units minutes, 5units minutes, 6units minutes, 7units minutes, 8units minutes

45. LTC Case Conferences K124 long term care / CCAC case conference
For LTC institution patient or CCAC patient
Prebooked 20 minute minimum attendance in person with 2 or more caregivers and if available patient and relatives
Same billing criteria as K121
2 per year / physician/patient

46. New Codes!!!
K700 = Palliative care out patient case conference – new fee = $31.35 / 10 minute with 2 or more care givers directing out patient palliative care

47. New Codes Telephone consultation fees
K730 – Physician to Physician – referring doc = $31.35
K “ “ consultant = $40.45
K732 – CritiCall – tele-consult - referring doc = $31.35
K “ “ consultant = $40.45
If ER duty doc
K734 – physician to physician – referring doc = $31.35
K “ “ “ consultant = $40.45
K036 , K037 = CritiCall
Minimum of 10 minutes
NB. These codes are in the basket for FHN and FHOs but
qualify for shadow billing

48. New Incentives to Provide More Timely Skin Biopsies
Simple excision of pre-malignant lesions
dysplastic nevi, actinic keratosis
Face or neck
R lesion $53.20
R161 2 lesions $87.40
R162 3 or more $174.75
Other areas
R163 1 lesion $43.30
R164 2 lesions $71.80
R or more $143.55
Don’t forget the tray fee E542 - $11.15
To date most attendees were not aware of these new codes. Suggest clarify that they do not apply to biopsy by shave and curretage and that pathology reports must support the billing

49. Third-Party Billing & Uninsured Services
Services not covered by provincial HCP or WCB/WSIB
Physician bills the responsible party (insurance company, employer, lawyer, or directly to the patient)
OMA recommended fee schedule = guideline for uninsured service fees – 2013 on web now
% of a physicians gross billings can be generated by discretionary billing for uninsured services.
Historically, physicians have been very poor at billing for uninsured services due to an discomfort of giving the patient a “bill”.
Physicians can no longer afford to ignore billing for these services.

50. Self Audit
Is your preceptor comfortable and consistent in billing for non-insured services?
How comfortable will you be?
Presenter: polling the attendees will offer you insight as to the varied and often limited exposure the residents have had to billing un-insured services. Some may even feel it is unethical based on the attitudes of the faculty they have worked with. Since most FM faculty are institution based they will not have control over teaching clinic policies or staffing. Residents should take advantage of the community based rotations to learn as much as possible about the issues of billing for uninsured services.

51. Billing for Un-insured Services
Be proactive - start from day one!
Always use discretion and be considerate
Be aware of individual patients ability to pay
Inform patients of their responsibility for payment prior to the delivery of the service
Don’t feel guilty for billing appropriately for uninsured services
Issuing “no charge” invoices
The patient must always be informed in advance that the service they have requested is not covered by the HCP. They should be advised of the fee in advance. Payment upon completion of the service is an appropriate expectation of the physician.
The use of patient information sheets will educate patients of your office policies. Well trained staff can proactively inform patients when they request services that are un-insured thus preventing patient discontent and arguments. Uninsured service fee schedules should be posted in the waiting room and exam rooms.
Always use discretion and be aware of individuals ability to pay. Reducing rates or issuing no charge invoices can be very effective. Educating patients that you have reduced or decided to not charge them for a un-insured service should always be done in a manner so that they do not “loose face”
Many patient complaints received by provincial regulatory colleges are a consequence of poor communication between the doctor and the patient. This holds true especially when it applies to the billing of uninsured services. Many patients assume that ALL services are covered. It is therefore very important to proactively educate the patient.
Finally - don’t leave the “dirty work” to your staff. The physician should take ownership for all office policies and personally deal with patients who challenge staff about the billing of uninsured services.

52. Common Uninsured Services
Sick notes and medical certificates
Phone call prescription renewals
Chart transfer charges
Missed appointments
Insurance reports
Un-insured examinations
Cosmetic procedures

53. OMA Non-insured Service Rates 2013 - www.oma.org
General assessment (A003) $152.10
Intermediate assessment (A007) $66.40
Minor assessment (A001 $42.75
Periodic health visit – child (K017) $85.90
Periodic health visit – adult (K131) $98.50
Counseling (K013/K033) – per unit $ / $75.20
Psychotherapy – per unit $123.65
Refer to the OMA Schedule of Fees for a complete listing of suggested uninsured fees for clinical services (e.g. assessments, counseling, procedural and surgical codes).
Refer to the OMA Physician’s Guide to Uninsured Services for suggested fees for forms, notes, insurance-related services, etc.
Refer to the OMA Schedule of Fees for suggested fees for uninsured clinical services (e.g. assessments, counselling, procedures). The OMA Schedule of Fees is a mirror of the OHIP Schedule of Benefits in terms of codes, descriptions, payment rules. The only difference is the fee assigned to each code. Physicians don’t have to look up the uninsured fees if they do not have the OMA Schedule of Fees handy, they can easily calculate the fee if they know the OHIP fee. OMA fees are 1.97 x the September 1, 2011 OHIP fee. Come November 2013 (following Council approval), OMA fees will be 1.97 x the current (October 1, 2013) OHIP fee. Going forward (pending Council approval), the OMA fee will always be calculated against the current OHIP Fee Schedule. As of January 2014 (pending Council approval), the multiplier will increase from 1.97 to 2.04.
Note: if anyone questions my calculated rates in this slide – they are off by a few cents here and there b/c the policy is to round the fee up to the nearest nickel. So, a calculated rate of $ will actually be published as $

54. OMA Non-insured Service Rates 2013 - billed in addition to assessment if done
Form Completion
Sick note $17.35
School/Camp form $25.30
Day care note $25.30
MTO Driver’s Medical form $51.85
EI / Maternity / federal employee form $25.95
Fitness Clubs / Fitness to work $33.75
APS Insurance Form $129.45
MVA Insurance form OCF-3 $129.50

55. Transfer of Medical Records
OMA recommended minimum fees
$30.00 for pages 1 – 20
$0.25 for each page thereafter
Independent Consideration for:
physician review time or summary at hourly rate
Postage
Staff preparation time for transfer
Rates can be altered at the physician’s discretion

56. Transfer of Medical Records
Patient can be charged only when the patient requests transfer of their medical records to a specific practice of their choice or a copy for themselves
Physician relocation or leaving practice
No charge to patients when physician transfers patient records to a new practice
CPSO Policy # 4-12

57. Transfer of Medical Records
CPSO Medical Records, section on “Patient Requests Transfer”
CPSO Policy # 4 – 12, CPSO Policy #
Patients must be informed, in advance, that this is an uninsured service
Cannot delay without reasonable cause and within reasonable time
Reports to be provided with 60 days unless other arrangements are made
Prepayment of a transfer fee may be requested but not demanded

58. Transfer of EMR Medical Records
OMA does not have an official policy as yet
OMA Uninsured Services Committee will address this in the near future
OMA Legal’s present advice is:
Transfer fee is about cost recovery so charges of copying paper chart do not apply
If vendor charges host doc for electronic transfer then yes
Cost for physician review still apply

59. Establishing an Hourly Rate Example
A: Annual Gross Earnings
OHIP = $366,200
WSIB, Stipends, APPP bonuses = ,000
Uninsured services = ,000
Total = $406,200
B: Working days per year
52 weeks * 5 days less 30 days holiday /stats = 230
C: Income generating hours ( paid hours /day)
9 hours minus 2 hours of unpaid clinical = 7 hours
D: Annual Paid hours: = B*C= 230*7 = = 1,610
E: Hourly Rate = A/D
(406,200 / 1,610 ) = = $252.30
Any fee from OHIP can be converted to uninsured amount by multiplying by 1.97

60. Block Fees Objective Issues Outsourcing Optional to all patients
Establish individual and family rates
What will you include in the “basket”
Can you exclude some patients
Dealing with confrontation
Accounting and collection
Outsourcing
Block fees are in effect an insurance premium that the physician annually offers to their patients to cover a basket of un-insured services instead of paying for each service as they incur it.
Issues to consider are:
What services will you include in the basket?
Will you offer different plans such as a basic plan or a premium plan that offers coverage for more services?
You can’t oblige patients to enroll
As with any insurer you don’t have to offer this insurance to all patients especially heavy users
Administrating block fees requires ongoing monitoring of who is enrolled, who has paid, individual renewal dates etc.
You must avoid issuing a bill to a patient who is insured
Companies are offering ability for docs to outsource this to hopefully reduce staff work
For example - The CMA’s Practice Solutions is now offering such a service with the assurance that their program will meet all of the strict ethical codes of the CMA

61. HST & Uninsured Services Excellent review in 2013 OMA uninsured Service Guideline
Any physician who generates $30,000 from all HST applicable services must register, collect and submit HST
HST Applies to:
Block and annual Fees charged to patients
Cosmetic surgical /medical procedures
Expert opinion & medico-legal reports
Disability Certificates
CPP Disability Reports
Review of medical documentation for a third party
Management Fees paid by physicians e.g. locum split to host doc!
Expert Witness fees – e.g. CPSO
Consulting Services

62. **** However – HST Rules May Change
CRA is revisiting this so stay up to date with your accountant

63. Remember!
Billing appropriately for 1 sick note at $15 for every office day generates ~ $3,540 / year... office medical supplies cost < $2,500 per year for a full time equivalent GP
Can you afford not to bill for these services?
If you undervalue your services, so will your patients
This slide is a case example of the value of billing for non-insured services

64. What are Q Codes?
Typically Q Codes are codes that fall outside of the Schedule of Benefits that are paid full Fee for Service value to Primary Care PEM ( Patient Enrolled Model) Physicians
Various incentives including – but not limited to – rostering patients, preventative care, management fees and others.
Not all Q codes are applicable to all PEM Physicians

65. Family Health Group modifiers and Bonuses
These apply to FHN and FHO also

66. FHG Fees & Bonuses
10% added to enrolled and virtual roster for A001, A003, A007, A008 A888, G365, G590,G591, K005, K013, K017, K023, K030, K022, A901, A902, C010, A008, C882, G539
Additional 15% A007, A003, A004, A901 if 65+
Q012 (30%) after hours premium – A001, A003, A004, A007, A008, A888, K005, K013, K017, K030

67. FHG Fees & Bonuses
1st year in practice -New Patient Code Q033 ($100, $120 (65-74), $180 (75+) – 300 in 1st year
Thereafter - New Patient code Q per year
Unattached patient code Q023 ($150, $170, $230) discharged within 3 months from hospital without GP – no limit
Health Care Connect/ Vulnerable Patient code Q053 ($350) and for new mom & baby

68. FHG Fees & Bonuses
Registration Code – Q $5 for first year of enrolling patients in practice – even after 1st year NB for beginning enrollment related payments
What % of your patients are rostered?
How do you cue yourself to verify and enroll?
e.g.: stamp front of chart / EMR
16 year olds must re-enroll in their name
Consider regular computer search for 16+ and non-enrolled patients
Include column on day sheet to prompt enrolled vs NR (not registered)

69. Additional Q Codes
Page 4 of SGFP Common Family Practice Codes has great summary

70. Comprehensive Care Management Monthly Fee For Enrolled Patients
Average ~ $2.45 per person per month age and gender adjusted
# patients ( need minimum of ~ 550 rostered for FHG)
$22,464
$33,396
$44,928
$56,160
If individual Doc has more than 2400 rostered patients the additional are paid at 50%
NB – 1 Primary Care giver can not manage that many patients!!!!

71. FHG Fees & Bonuses Also apply to FHN and FHOs
Q020
Serious mental illness – Q020 billed for bipolar patients (296) and diagnostic code 295 for schizophrenics
must re-bill every fiscal year; $1000 for 1st 5 patients, $2000 for 10+
Palliative Care Premium – 4 or more K023 codes per fiscal year - $2000

72. Preventative Care Tracking Codes
Bonuses for reaching service levels for identified target populations in prevention, using:
Mammography
Pap smears
Fecal Occult Blood screening
Flu shots
Childhood immunizations
Target population within enrolled patients
MOH will track and report service levels biannually
Tracking can be tedious UNLESS YOU HAVE EMR!
Reconciliation can be very difficult unless…..

73. Preventative Care Tracking Codes
Inclusion Code
Pap Q011
Mam Q131
Flu Q130
Imm Q132
O.B. Q133
Note pap cycle now – one every 36 months (by any MD) >20 and <71 yrs
Exclusion Code
Pap Q140
Mam Q141
OB Q142
Review the meaning of inclusion codes and exclusion codes. Note that exclusion codes must be resubmitted each cycle. Point out which inclusion codes are automatically captured with the MOH cross reference of the procedure code and one’s billing number. Point out those that are not: ie mammograms offered at OBSP or Flu shots given at a pharmacy or regional health office clinic
Offer an anecdote to illustrate value of preventative screening. Ie I encouraged a 53 yr old physician colleague (cardiologist) to have his stool for OB done. He initially resisted but then did it. 1 of 3 samples were positive. Colonoscopy revealed a 3 cm hyperplastic polyp at the splenic flexure. Good value. Example for Paps and mammograms can also be offered.

74. Keeping Track of Tracking Codes
Important to capture & submit tracking exclusion codes
MOHLTD should capture inclusion codes by cross referencing with your billing #
Exception
Q131 for mammograms done by OBSP
Q130 Flu shots given at work, pharmacy, PH clinic document
Q132 Immunizations given elsewhere, out of province
No cross reference with your billing #

75. Did You Know?
The Ontario Breast Screening Program will provide up to date list of your patient’s last screening date as well as who is overdue
Provided in alpha format to easily reconcile with MOHLTD printout
Therefore tracking Q131 may be optional
In future similar will hopefully occur with FOBT and PAP testing
The Ontario Breast Screening Program will provide up to date list of your patient’s last screening date as well as who is overdue
Provided in alpha format to easily reconcile with MOHLTD printout
Therefore tracking Q131 may be optional

76. Keeping Track of Tracking Codes
Consider tracking on front of chart / EMR
automatically cues the preventative care service regardless of reason for visit
stamps are very useful
Example provided
Consider formatting flow sheets to document patient name & tracking code when reviewing daily in-box
Staff can input with billing on monthly basis when inputting G271 INR
Incorporate into EMR auto prompt function

77. Tracking Code Stamp Date q30/12 Pp Q011 Pp Q140 Mm Q131 Mm Q141
Flu Q130
Ob Q133
Ob Q142
Ob Q005
Ob Q150
Ob Q152*
This is an example of a stamp that can be put right on the front of the chart. When the service is done – ie pap test you note date. You also note that the last date for the FOBT was 3 years ago so you pull out the kit , encourage the patient to go and then bill Q150

78. Cueing & Tracking Chronic Disease Management
Date
Q040
E079
Q050
Example of stamp for front of chart curing you to remember to bill again the next cycle as well as to cue you to inquire as to present status re these 3 conditions.

79. Preventative Care Tracking Code Sheet
Name
Date
Pap Ex Q140
Mm Tr
Q131
Mm Ex
Q141
IMM
TrQ132
OB Ex
Q142
Flu Tr
Q130
This is an example o a flow sheet that can be used when doing one’s inbox. IE. You receive a culposcopy report on a patient 45 with CIN 2 – This patient is excluded this cycle for Pap teat – Therefore mark down there name date and tick off Q140. You also receive a report of the follow-up colonoscopy report done q2 yrs by GI – You enter name date and Q142. Each week your staff input these codes or at least monthly when they submit your INR billing

80. FHN & FHO Shadow Billing Increase!
N.B. as of October 2010 FHN and FHO receive 50% more for shadow billing
Therefore 15% instead of 10% of FFS for services in the basket
E.G. $200,000 services provided within the basket are shadow billed
Result – additional $30,000
NB. MOH AUDITS OF SHADOW BILLING WILL INCREASE !!

81. New FHG Initiatives for FOBT
Q005A – Colorectal cancer screening management fee
$6.86 for documented contact of patient
Cancelled …. but
Q150A –FOBT distribution & counseling fee
$7.00 to educate & provide FOBT kit & requisition during an office visit
Both are billable every 730 days per patient, not doctor
Clarify that Q005 and Q150 apply to FHG, FHN already has “Q005”

82. Submitting Preventative Care Codes
MOHLTC printed summary sent each September to cue those missed & in April to reconcile
Billing date = March 31, 200X
# of inclusion coded patients = % of target
target (rostered) patients minus exclusion coded patients
Submit appropriate code matching % reached dated Mar 31st
Have until September to reconcile and submit preventative care enhancement fee
oma.org/PC/documents/trackingandbonusesJan06.pdf
The submission confuses many. Explain in detail with examples and consider bringing in your printout that you received in April. Then give them the example of the billing code you submitted April 1st for ie maximum capture of FOBT.

83. New Payment Thresholds Levels for FOBT October 2010 (PEM only)
Enrolled Population Screening Threshold
Bonus
Fee Code
15%
$220
Q118A
20%
$440
Q119A
40%
$1,100
Q120A
50%
$2,200
Q121A
60%
$3,300
Q122A
70%
$4,000
Q123A

84. Summary Never Forget To!!! Stay up-to-date with the fee schedule
Complete all components of the bill!
Always verify who is the responsible party!
Bill for daily minor procedures
Bill WCB whenever appropriate
Never bill the HCP for uninsured services
Bill for uninsured services when appropriate
Action plan

85. Common Billing Examples An Interactive Workshop
Common Billing Examples An Interactive Workshop March 21, 2014 Hard copy will be provided at the workshop
The presenter is to ensure that this workshop is updated to the latest provincially specific codes and fees. Ontario examples have been used in this version.
Offer the attendees a detailed explanation of the ‘best practice’ way to bill for all of the examples.
We strongly recommend that the presenter provides their presentation and answers to the appropriate experts at the ministry of health