Education and Prevention Committee Billing Briefs

Education and Prevention Committee (EPC) Billing Briefs are prepared jointly by the Ministry of Health (MOH) and the Ontario Medical Association (OMA) to provide general advice and guidance to physicians on billing matters.

Category: Anaesthesia, Family Practice, Obstetrics
Date Issued: February 17, 2023
Date Updated: February 27, 2023

Attendance at Labour and Delivery (P009)

  • P009 is for use by a family physician who provides obstetrical care to a patient during labour and provides one of three types of services (see below) during the delivery but does not perform the delivery.
  • P009 may only be claimed once per patient per delivery.

Common claims issues

  • P009 being claimed in error by a physician who has not provided attendance at labour services.
  • Multiple P009 claims for the same delivery by different physicians. Only one claim is payable per patient/per delivery.

P009 is eligible for payment when all payment parameters are met

  1. The physician has provided the service defined in the Obstetrics preamble of the Schedule of Benefits-Physician Services (Schedule) as “attendance at labour” and
  2. provided at least one of three additional services listed below:
    • assists at vaginal delivery or surgery
    • gives anaesthetic at a caesarean section or operative delivery
    • resuscitates the newborn

Definition of Attendance at Labour

Paragraph “e” of the Obstetric Preamble defines attendance at labour as being in constant or periodic attendance on a patient, during stages one and two of labour but without completion of the delivery, to provide all aspects of care.

This includes:

  • the initial assessment
  • such subsequent assessments as may be indicated
  • ongoing monitoring of the patient’s conditions; and,
  • intervening except where intervention is a separately billable service.

P009 is not applicable to:

  • services provided by obstetric consultants
  • surgical assisting, anaesthesia or neonatal resuscitation services provided at delivery by physicians who have not provided the attendance at labour service defined in the Obstetrical Preamble and listed above.

Examples

Example 1:

An anaesthesiologist provides anaesthesia for a caesarean section. During labour, the same physician provided epidural analgesia services to the patient.

Is P009 payable?

Explanation:
  • P009 is not applicable as the anaesthesiologist has not provided attendance at labour services.
  • Anaesthetic services during labour including epidurals do not meet the required components of attendance at labour.
  • P009 is not intended for anaesthesiologists providing anaesthetic services for delivery or surgery. The appropriate claim for surgical delivery would be P018C Caesarean section (basic plus time units) plus any applicable anaesthesia extra units and premiums.

Example 2:

An anaesthesiologist is asked to attend at a delivery but is not required to provide anaesthetic or resuscitation services.

Is P009 payable?

Explanation:
  • P009 is not applicable as the anaesthesiologist has not provided attendance at labour services.
  • The appropriate claim would be E100C, attendance at delivery (4 basic plus 1 time unit per .25 hour) plus any applicable anaesthesia extra units and premiums.
  • Note that anaesthesia extra units listed on GP95 are not eligible for payment with E100C.

Example 3:

A family physician provides surgical assistant services during a caesarean section but has not provided services to the patient during labour.

Is P009 payable?

Explanation:
  • P009 is not applicable as the family physician has not provided attendance at labour services.
  • The appropriate claim would be P018B Caesarean section (base plus time units) plus any applicable premiums.

Example 4:

An obstetrician is asked by her obstetrician colleague to assist at a caesarean section.

Is P009 payable?
Explanation:
  • P009 is not applicable to obstetrical consultants.
  • The appropriate claim would be P018B Caesarean section (base plus time units) plus any applicable premiums.

Example 5:

An obstetrician manages all stages of a patient’s labour but then asks an obstetrician colleague to perform the patient’s caesarean section. The first obstetrician participates during the surgery as a surgical assistant.

Explanation:
  • P009 is not applicable to obstetrical consultants.
  • The appropriate claim would be P018B Caesarean section (base plus time units) plus any applicable premiums.

Example 6:

A family physician manages all stages of labour and determines that a caesarean section is required. Care is transferred to an obstetrician. The family physician does not attend the delivery.

Is P009 payable?

Explanation:
  • P009 is not applicable as the family physician has not provided one of the 3 services during delivery identified in the Schedule as payment requirements.

Example 7:

A physician is asked to attend a high-risk delivery in case it is necessary to resuscitate the newborn.

Is P009 payable?

Explanation:
  • P009 is not applicable as the physician has not provided attendance at labour services.
  • The appropriate claim is dependent upon the service rendered, which could include billing the appropriate assessment fee (example, H007 Attendance at maternal delivery for care of high-risk baby/babies) and/or resuscitation (G521, G522, G523).
  • The Obstetrics preamble provides additional guidance on how to appropriately bill for immediate care of the newborn.

Example 8:

A family physician attends the labour of a patient-stage 1 and stage 2. The patient requires an operative delivery due to fetal distress. The family physician is required to assist at the Caesarean section.
What may the physician claim?

Is P009 payable?

Explanation:
  • The family physician may claim P009 which includes attendance at labour and participation in delivery as surgical assistant.
  • The family physician may not claim assistant services in addition (as these are included in P009 in this case).

Example 9:

A physician attends the labour of a patient (stage 1 only). Physician #1 hands over care to their colleague (physician #2) prior to the commencement of the 2nd stage of labour. Physician #2 provides care for the remaining part of stage 1 and stage 2. The patient requires an operative delivery due to fetal distress. Physician #2 is required to assist at the Caesarean section. Physician #1 is called back to assist with the resuscitation of the newborn.

Which physician may claim P009?

Explanation:
  • P009 is only payable to Physician #2 who has both attended labour (stages 1 and 2) and participated in the delivery by providing surgical assistant services.
  • Physician #1 may claim resuscitation of newborn services only.

Example 10:

An obstetrician (day shift OB) follows a patient in labour for most of the day. When her shift ends at 8 pm, care is transferred to a second obstetrician (night shift OB) who is coming on shift. The patient is delivered at 8:10 pm by the night shift obstetrician.

What may each physician claim for these services?

Explanation:
  • The night shift obstetrician may claim P006A for the patient’s delivery.
  • The day shift obstetrician may not claim for monitoring the patient’s labour as labour and delivery services include all necessary assessments and special visits, except for C989 which only applies to obstetrical delivery with sacrifice of office hours for the first patient seen.
  • No assessment or special visit fee may otherwise be claimed for a patient assessed in labour.
  • In addition to the physician’s own patients, this applies to all transferred or non-referred obstetric patients under the physician’s care during the time he/she is on call for deliveries at the hospital, even if he/she has not assessed the patient previously and even if that physician does not go on to deliver the baby.
  • If one physician partially manages a labour/delivery to be completed by another physician, the physicians may apportion payment of the all-inclusive service fee amongst themselves.
  • Note that obstetricians may not claim P009A which is only payable to a physician other than an obstetric consultant for attending labour and delivery when the physician either assists at vaginal delivery or surgery, gives anaesthetic at a caesarean section or operative delivery, or resuscitates the newborn.

The Sole Delivery Premium (E411)

This premium is eligible for payment with specific labour and delivery services (listed below) when one of those services is the only delivery service provided on a specific calendar day.

  • P006A-Vaginal delivery
  • P009A-Attendance at labour and delivery
  • P018A-Caesarean section
  • P020A-Operative delivery i.e., mid-cavity extraction or assisted breech delivery
  • P038A-Attendance at labour when patient transferred to another centre for delivery
  • P041A-Caesarean section including tubal interruption
  • E414A-High risk obstetrical premium

Limits (per physician)

  • One claim per day-if more than one claim for E411 is submitted on the same day, the second claim will pay at zero with an explanatory code of “MD” (daily maximum has been exceeded).
  • A maximum of 25 sole deliveries in a fiscal year (April 1 to March 31 of the following year). When the claims processing system identifies that there have been 25 paid services for E411, any additional claims for E411 in the fiscal year will be paid at zero with an explanatory code of “MY” (yearly maximum has been exceeded).

Common claims issues

  • Claiming E411A on a day when more than one delivery service is rendered.
  • Claiming E411A more than once per day.
  • E411A being claimed in error by a physician who has provided a service to an obstetric patient that is not one of the listed obstetric services (example, anesthesiologist; surgical assistant).

Examples

Example 1a:

Ms. Au arrives at the hospital Tuesday at 05:30, is admitted into the labour and delivery ward and examined. She has dilated to 7 centimetres and the nurse at the hospital contacts her family physician (Dr. Barr), who will be delivering. Dr. Barr arrives at the hospital at 07:00 and delivers Mrs. Au’s baby at 07:35. Following the delivery, Dr. Barr leaves the hospital to attend her usual office practice. Dr. Barr does not perform any other deliveries on Tuesday.

Is Dr. Barr eligible for payment of E411?

Explanation:
  • Yes, Dr. Barr is eligible for payment of P006 (vaginal delivery) and
  • the sole delivery premium (E411) at 100% of the value of P006, because this was the only delivery of that day.

Example 1b:

If Ms. Au delivers twins, is Dr. Barr still eligible for payment of the sole delivery premium?

Explanation: Yes, but only for one of the delivery services.

Example 2a:

Mrs. Cheechoo is admitted to the hospital on Wednesday evening at 20:00 with severe pregnancy-induced hypertension and is immediately scheduled for a caesarean. Dr. Dall initiates a magnesium sulphate IV infusion and shortly afterwards performs a caesarean section. Dr. Dall is eligible for payment of P018, E414 (high risk obstetrical premium), Z775 (pharmacological management of P.I.H. and toxemia by IV) and E409 (evening premium).

Is Dr. Dall eligible for E411 on this day if he does not provide any other eligible obstetrical services?

Explanation:
  • Yes. Dr. Dall is eligible to claim E411 in association with P018 and E414.
  • Note that as E414 is a premium that relates to the same delivery as P018, the combination is considered one eligible obstetrical service.

Example 2b-Alternate scenario:

Dr. Dall also renders a vaginal delivery later that evening.

Is Dr. Dall eligible for E411 on this day?

Explanation:

No, Dr. Dall has rendered more than one delivery service on the calendar day and therefore E411 is not eligible for payment.

Example 3:

Dr. Embury is an anaesthesiologist who provides anesthetic services for Mrs. Cheechoo during the caesarian section. Dr. Embury does not participate in any other deliveries that day.

Is Dr. Embury eligible for the sole delivery premium on this day?

Explanation:

No. The sole delivery premium does not apply to obstetrical anesthesia or surgical assistant services.

Example 4:

Dr. French, a family physician who delivers her own obstetrical patients, attends one of her patients during the first and second stages of labour. Dr. French identifies problems in the second stage of labour and consults Dr. Garcia, an obstetrician. Dr. Garcia delivers the patient and Dr. French assists at the delivery. Dr. French did not attend to any other labour/delivery patients that day.

Is Dr. French, eligible for the E411 premium for the service she rendered to his obstetrical patient?

Explanation:
  • Yes, provided all payment requirements are met, Dr. French is eligible for payment of P009 and E411 for attendance at labour and delivery (as long as she does not deliver or render the service of attendance at the labour and delivery of any other patients in the same calendar day).
  • In this example, if Dr. Garcia does not render any of the other labour/delivery services listed in the Schedule in association with the sole delivery premium on that day, then Dr. Garcia is also eligible for the E411 premium. In other words, more than one physician may be eligible for the premium for the same patient provided it is the only labour/delivery service rendered by each physician on that day, and all other payment requirements are met.

Keywords/tags

Anaesthesia; Attendance; Caesarean section; C-section; Delivery; Family Practice; Labour; Newborn Care; Obstetrics; OHIP Claims; OHIP Payment; P009; Surgical Assist

Contact information

For additional information, please visit the Resources for Physicians and the How to Get Help with Billing Questions pages on the ministry website.

If you have any billing or claims submission inquiries, please contact the Inquiry Services, Service Support Contact Centre (SSCC) by email or by calling 1-800-262-6524.

To provide feedback on EPC Billing Briefs, or to suggest topics for future EPC Billing Briefs, send an email to the attention of the joint MOHMOH/OMA Education and Prevention Committee.

The Ministry of Health (MOH) and the Ontario Medical Association (OMA) have jointly prepared this educational resource to provide general advice and guidance to physicians on specific billing matters.

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Note: This document is technical in nature and is available in English only due to its limited targeted audience. This publication has been exempted from translation under the French Language Services Act. For questions or support regarding this document, please contact the Service Support Contact Centre (SSCC) by email or by calling 1-800-262-6524.

Remarque : Ce document est de nature technique et est disponible en anglais uniquement en raison de son public cible limité. Ce document a été exempté de la traduction en vertu de la Loi sur les services en français. Pour toute question ou de l’aide concernant ce document, veuillez contacter Les Services de renseignements, Centre de contact pour le soutien des services par courriel ou en téléphonant le 1-800-262-6524.