Virtual Care 1: Comprehensive and Limited Virtual Care Services

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.

An introduction to new OHIP Virtual Care Services and fee codes

Category: All physicians 
Date of publication: November 24, 2022
Date updated: April 6, 2023 - Updates made to Schedule of Benefits page references

New insured Virtual Care Services are effective December 1, 2022

As part of the 2021-2024 Physician Services Agreement, the Ministry of Health (MOH) and the Ontario Medical Association (OMA) agreed to a new virtual care funding framework that adds certain services provided by video and telephone as insured services under OHIP.

This new framework replaces the temporary virtual care codes introduced in March 2020. However, it is not intended to replace existing Schedule fee codes that were in place prior to March 2020 for services that were eligible for payment if provided virtually.

Insured physician services that can be provided virtually can be found in Appendix J of the Schedule of Benefits (the Schedule) and are also listed at the end of this EPC Billing Brief.

Important Note: Virtual care codes that were introduced in March 2020 (K080, K081, K082, K083, K092, K093, K094, K095) may not be submitted for payment for insured services provided on or after December 1, 2022.

As of December 1, 2022, video visits will no longer be funded under the Ontario Virtual Care Program (OVCP). Video visits funded under OVCP will transition to the new OHIP Virtual Care funding model. Physicians will no longer be able to bill the modifiers (B203, B204 or B209) or location indicator (SLI=OTN) previously used for OVCP.

Definition of Limited and Comprehensive Virtual Care Services

Limited Virtual Care Service means a Virtual Care Service rendered where no Existing/Ongoing Patient-Physician Relationship exists, and in the physicians’ professional opinion in accordance with accepted professional standards and practice, the person's care and support requirements can be effectively and appropriately delivered by Video or Telephone.

A Limited Virtual Care Service is defined in the Schedule as an assessment which includes, at a minimum, history- taking and medically appropriate exam to arrive at a diagnosis and provide an appropriate management plan and/or management, and when provided, the other specific elements of assessments.

Comprehensive Virtual Care Service means a Virtual Care Service rendered where an Existing/Ongoing Patient-Physician Relationship exists, and in the physicians’ professional opinion in accordance with accepted professional standards and practice, the person's care and support requirements can be effectively and appropriately delivered by Video or Telephone.

Establishing an Existing/Ongoing Patient-Physician Relationship

Any of the following is considered to establish an Existing/Ongoing Patient-Physician Relationship for the purpose of defining which type of virtual care services may be claimed:

1. Where a physician is providing a Virtual Care Service to a patient where there has been at least one insured service with a direct physical encounter between the patient and that physician (Family and General Practice Physician or specialist) in the preceding 24-months (the in-person service establishes the relationship);
2. Where a physician is providing a Virtual Care Service to a patient who has signed the MOH’s Patient Enrollment and Consent to Release Personal Health Information form and is enrolled to that physician or another physician within the same primary care enrollment group (who is signatory/locum to a MOH alternate funding plan agreement);
3. Where a specialist or GP Focused Practice Physician* is providing a consultation by Video set out in Appendix J-Section 1 of the Schedule, or has provided any such consultation in the preceding 24-months to that patient (any consultation billed as an insured service under K083 or as an uninsured service funded under the Ontario Virtual Care Program and rendered prior to December 1, 2022, is considered evidence of an Existing/Ongoing Patient-Physician Relationship); or
4. Where a physician provides any of the following services, or has provided any of the following services in the preceding 24-months:
   1. A920-Medical management of early pregnancy - initial service by Video or Telephone,
   2. A945/C945-Special palliative care consultation by Video,
   3. A680/C680-Initial assessment - substance abuse by Video,
   4. A814, A817, A818-Midwife or Aboriginal Midwife-Requested Assessments (MRAs) by Video,
   5. A802-Extended midwife or Aboriginal Midwife-requested genetic assessment by Video,
   6. A801-Comprehensive midwife or Aboriginal Midwife-requested genetic assessment by Video,
   7. A800-Midwife or Aboriginal Midwife-requested genetic assessment by Video,
   8. A253-Optometrist-Requested Assessment (ORA) by Video,
   9. A256-Special optometrist-requested assessment by Video,A957-Addiction medicine FPA by Video,
   10. K680-Substance abuse-extended assessment by Video.

* GP Focused Practice Physician means, for the purpose of eligibility to provide a focused practice consultation by Video (A010, A011, A906, A913, A914), a physician who has been designated by the bi-lateral MOH-OMA GP Focused Practice Review Committee or a physician who is eligible for the focused practice psychotherapy premium.

Maintaining an Existing/Ongoing Patient-Physician Relationship

Other than for Family Physicians providing virtual services to patients who are enrolled to their primary care practice as defined in #2 above, once an Existing/Ongoing Patient-Physician Relationship has been established, Comprehensive Virtual Care Services are payable for any necessary virtual follow-up care for the next 24-months. Depending on which services are medically necessary for a given patient based on their unique clinical circumstances, a patient-physician relationship may either continue or end after 24-months.

For Specialists, GP Focused Practice or Family Physicians who do not practice in an enrollment primary care practice as defined in #2 above, an Existing/Ongoing Patient-Physician Relationship with a patient (and eligibility for payment of Comprehensive Virtual Care Services) after 24-months of exclusively virtual visits with a patient is maintained if at least one of the following is medically necessary and provided by the physician to the patient:

• For any physician - At least one in-person insured service
• For any physician - Any of the services listed in #4 above
• For GP Focused Practice Physicians-a GP Focused Practice video consultation
• For Specialists-any video consultation (see Example 3b below)

Alternatively, Limited Virtual Care Services would be payable for any virtual follow-up care provided after 24-months, provided that the Limited Virtual Care Services are medically necessary for the patient.

Services that can be provided virtually if clinically appropriate

Please review the College of Physicians and Surgeons of Ontario Virtual Care Policy which specifies that “virtual care is not appropriate in every instance as not all conditions can be effectively treated virtually and not every patient has access to or will be comfortable using virtual care technology” and that physicians must use professional judgment in determining whether a virtual visit is appropriate for a particular patient and/or medical concern.

Other than a direct physical encounter, for payment purposes, all other requirements and conditions for the service as described in the Schedule must be met, including, for example, any physical examination elements that are required as specific elements of assessments (see General Preamble page GP15). This point is addressed in more detail in EPC Billing Brief Virtual Care #2: Terms and Conditions.

Virtual Care Services provided to hospital inpatients or patients in a long-term care institution are not eligible for payment unless all of the following requirements are met:

• The physician providing the service is not the patient's Most Responsible Physician (MRP).
• The hospital/long-term care institution does not have a physician on staff and present in the community with the expertise to render the necessary service, as documented by the referring physician in the patient’s medical record.
• An assessment with a direct physical encounter by the referring physician must have been completed within 30 days preceding a virtual inpatient specialist consultation to confirm the need for a consultation.

Location of patient and physician when Virtual Care Services are performed

Both the patient and physician must be located in Ontario for the services to be insured and payable under OHIP (see section 37.1 of Regulation 552 under the Health Insurance Act).

Virtual Care Fee Codes that pre-date March 2020 continue to be available for use

The new Virtual Care Services are not intended to replace existing Schedule fee codes for services that were eligible for payment if provided virtually prior to March 2020, such as those listed below (please note, this list is not comprehensive).

Physicians should continue to claim the most appropriate fee code that describes the insured service provided and should not substitute new Virtual Care Service fee codes for pre-existing telephone and other virtual fee codes.

For example:

• G064 Management and supervision of outpatient continuous nerve block infusion
• G271 Anticoagulant supervision, long-term, telephone advice
• G334 Telephone supervisor fee for ovulation induction with human menopausal gonadotropins or gonadotropin-releasing hormone
• G382 Supervision of chemotherapy (pharmacologic therapy of malignancy or autoimmune disease) by telephone, monthly
• G388 Management of special oral chemotherapy, for malignant disease
• G511 Telephone management regarding a patient receiving palliative care at home
• K077 Geriatric telephone support

Additionally, physicians claiming management fees that include phone management (e.g., G500; G512; K090; K091; K682; K683; K684; W010; etc.) should continue to claim these fee codes for virtual communication with patients/families/other professionals using the existing management fees rather than the new Virtual Care fee codes.

Examples of Comprehensive and Limited Virtual Care Services

Example 1: Providing virtual primary care to an enrolled patient

On December 1, 2022, Dr. Fisher (a Family Physician) provides a virtual assessment for Ms. Wu (a patient enrolled to Dr. Fisher’s practice which is part of a Family Health Organization) who has booked an appointment to review her response to a new medication for hypertension, including review of her home blood pressure readings. The virtual visit is conducted using a video solution found on Ontario Health’s Verified Solution List and Dr. Fisher documents the modality of the visit on the patient’s medical record. How should this insured service be claimed?

Explanation:

• The described service is a Comprehensive Virtual Care Service as Ms. Wu has signed the MOH’s Patient Enrollment and Consent to Release Personal Health Information form and is enrolled to Dr. Fisher (who is signatory/locum to a MOH alternate funding plan agreement).
• Dr. Fisher should determine whether the service provided is most consistent with the Schedule description of an intermediate (A007) or a minor (A001) assessment, other than a direct physical encounter. Both A001 and A007 are listed in Section 1 of Appendix J of the Schedule as an Eligible Comprehensive Virtual Care Services, and the most appropriate of these fee codes may be claimed. See the definition of these assessments in the General Preamble page GP27. Physicians may also consult the EPC educational resource Assessments and Consultations for more information on how to select the appropriate assessment fee code.
• As the visit was conducted using a verified video solution, Dr. Fisher should submit the appropriate modality indicator to identify the modality used, in this case K300A.

Example 2: Providing virtual care to a patient who does not meet the Schedule criteria for an Existing/Ongoing Patient-Physician Relationship with the physician

Mr. Bass is on holiday at a rented cottage and notices an engorged tick attached to his leg. He is concerned about contracting Lyme disease and wonders if he needs antibiotics to prevent it and has a telephone appointment that day with a Virtual Medical Clinic that he has seen advertised on the subway in his hometown.

How should the insured service be claimed by the physician who conducts the telephone assessment and has never previously provided care to Mr. Bass?

Explanation:

• The described service is a Limited Virtual Care Service as none of the criteria to establish an Existing/Ongoing Patient-Physician Relationship have been met. The appropriate fee code for a Limited Virtual Care service provided by telephone is A102A.

Example 3a: Providing a specialist consultation by video

Mr. Verde is referred to a dermatologist by his Family Physician because of an unusual chronic skin eruption. The Dermatology consultation is conducted by Video using a verified video solution.

How should this insured service be claimed by the Dermatologist?

Explanation:

• The described service is a Comprehensive Virtual Care Service as it is a Specialist Video Consultation and could be claimed as A025A (with the K300A modality indicator) provided that the Schedule specifications for Consultations have been met.

Example 3b: Continuing virtual care after 24-months in a specialist practice

Mr. Verde continues to have regular follow up with the Dermatologist over the next 24-months. All visits to date have been virtual. At this time (>24-months since the initial video consultation), what should the specialist do if ongoing care and maintenance of an Existing/Ongoing Patient-Physician relationship is required?

Explanation: There are several options.

1. The specialist may send the patient back to the family physician for consideration of a repeat referral for the same diagnosis from the family physician for ongoing specialist monitoring and/or management. If the referring physician agrees that ongoing specialist virtual care is medically necessary due to the complexity, seriousness or obscurity of the case and all other payment rules associated with consultations are met, a new consultation is eligible for payment and the subsequent 24-months of virtual assessments are payable as Comprehensive Virtual Care Services. Note that this is only applicable to virtual consultations. Where a physician who has been paid for an in-person consultation for the patient for the same diagnosis makes a request for a referral for ongoing management of the patient, the service rendered following the referral is not payable as a consultation.
2. Alternatively, the specialist may determine that the patient would benefit from a medically necessary in person visit. When provided, this in person visit would maintain the ability to claim Comprehensive Virtual Care Services for another 24-month period.
3. If the specialist continues to provide Virtual Care at this time in the absence of either an in person visit (within the preceding 24 months) or a new referral for a video consultation, these visits are eligible for payment as Limited Virtual Care (See Appendix J, Section 2 of the Schedule).
4. In some cases, ongoing specialist follow-up will no longer be required (in person or virtual) as the family physician will take over the ongoing care of the patient for the concern.

Example 3c: Fee codes that pre-dated the new Virtual Care Services should continue to be used if appropriate

Consider the scenario outlined in Example 3a.

If the Family Physician had requested an opinion and/or recommendations from the specialist for management of Mr. Verde’s skin eruption by providing information electronically through a secure server (rather than a consultation involving an interaction between the Specialist and Mr. Verde), how should the insured service be claimed by the Dermatologist?

Explanation:

The described service is most appropriately claimed as an Initial E-Assessment, U025A (which is a fee code that pre-dates March 2020). This is not a Comprehensive or Limited Virtual Care Service.

Example 4: Providing virtual specialist follow-up care after in-person visit

Bella is a 2-year-old female who was treated for a clubfoot as an infant by an Orthopaedic Surgeon. Her last appointment (in person) was 6 months ago. The Orthopaedic Surgeon agrees to conduct a follow-up visit virtually using a verified video solution to avoid travel as the parent indicates that she has no new concerns.

How should the insured service be claimed by the Orthopaedic Surgeon?

Explanation:

The described service is a Comprehensive Virtual Care Service as the Orthopaedic Surgeon saw the patient in person within the preceding 24-months. The service provided by Video is payable at the same rate as an in-person assessment. While the Orthopaedic Surgeon considered providing a Comprehensive Virtual Care Service by Telephone (payable at 85% of the equivalent in-person assessment), in this situation a facilitated visual examination of the foot was required, and the Orthopaedic Surgeon determined that conducting the service by telephone was not clinically appropriate.

Example 5: Providing virtual specialist follow-up care after a video consultation

Dr. Gomez is a Geneticist who provided a Telephone assessment on December 1, 2022 to Mrs. Farid in follow-up of a Video Consultation provided 12 months previously (and billed using K083A).

How should the insured service be claimed by Dr. Gomez?

Explanation:

The described service is a Comprehensive Virtual Care Service (see Appendix J, Section 1 of the Schedule) as the physician has provided a Video Consultation to the patient within the preceding 24-months. As the service was provided by telephone it should be submitted with the K301A modality indicator and would be paid at 85% of the in-person rate.

Eligible Comprehensive Virtual Care Services

Video or Telephone

A001A, A007A, A008A, A013A, A014A, A020A, A023A, A024A, A033A, A034A, A043A, A044A, A051A, A053A, A054A, A058A, A063A, A064A, A071A, A073A, A074A, A078A, A083A, A084A, A093A, A094A, A113A, A131A, A133A, A134A, A138A, A151A, A153A, A154A, A158A, A161A, A163A, A164A, A168A, A173A, A174A, A181A, A183A, A184A, A188A, A193A, A194A, A203A, A204A, A221A, A233A, A234A, A243A, A244A, A261A, A262A, A263A, A264A, A283A, A284A, A310A, A311A, A313A, A318A, A338A, A340A, A341A, A343A, A348A, A353A, A354A, A411A, A413A, A414A, A418A, A441A, A443A, A444A, A448A, A461A, A463A, A464A, A468A, A471A, A473A, A474A, A478A, A480A, A481A, A483A, A484A, A488A, A510A, A511A, A570A, A601A, A603A, A604A, A608A, A611A, A613A, A614A, A618A, A621A, A623A, A624A, A628A, A632A, A633A, A638A, A643A, A644A, A661A, A760A, A917A, A920A, A927A, A937A, A947A, A957A, A967A, H313A, K002A, K003A, K004A, K005A, K007A, K008A, K010A, K012A, K013A, K014A, K015A, K016A, K019A, K020A, K022A, K023A, K024A, K025A, K028A, K029A, K030A, K033A, K037A, K039A, K040A, K041A, K044A, K122A, K123A, K140A, K141A, K142A, K143A, K144A, K195A, K196A, K197A, K198A, K203A, K204A, K205A, K206A, K208A, K209A, K222A, K623A, K680A, K887A, K888A, K889A, P005A

Video Only

A010A, A011A, A015A, A016A, A025A, A026A, A035A, A036A, A045A, A046A, A050A, A055A, A056A, A065A, A066A, A075A, A076A, A085A, A086A, A095A, A096A, A130A, A135A, A136A, A150A, A155A, A156A, A160A, A165A, A166A, A175A, A176A, A180A, A185A, A186A, A190A, A191A, A192A, A195A, A196A, A197A, A198A, A205A, A206A, A220A, A223A, A225A, A226A, A235A, A236A, A245A, A246A, A253A, A255A, A256A, A260A, A265A, A266A, A275A, A285A, A286A, A315A, A316A, A325A, A335A, A345A, A346A, A355A, A356A, A365A, A375A, A385A, A395A, A400A, A405A, A415A, A416A, A425A, A435A, A445A, A446A, A460A, A465A, A466A, A470A, A475A, A476A, A485A, A486A, A515A, A525A, A545A, A565A, A575A, A586A, A590A, A595A, A600A, A605A, A606A, A615A, A616A, A625A, A626A, A635A, A636A, A645A, A646A, A655A, A662A, A665A, A667A, A675A, A680A, A682A, A695A, A735A, A745A, A765A, A770A, A775A, A795A, A800A, A801A, A802A, A814A, A817A, A818A, A835A, A845A, A865A, A906A, A913A, A914A, A921A, A935A, A945A, C010A, C013A, C014A, C015A, C016A, C020A, C023A, C024A, C025A, C026A, C033A, C034A, C035A, C036A, C043A, C044A, C045A, C046A, C051A, C053A, C054A, C055A, C063A, C064A, C065A, C066A, C071A, C073A, C074A, C075A, C076A, C083A, C084A, C085A, C086A, C093A, C094A, C095A, C096A, C113A, C130A, C131A, C133A, C134A, C135A, C136A, C150A, C151A, C153A, C154A, C155A, C156A, C160A, C161A, C163A, C164A, C165A, C166A, C173A, C174A, C175A, C176A, C180A, C181A, C183A, C184A, C185A, C186A, C190A, C193A, C194A, C196A, C203A, C204A, C205A, C206A, C220A, C223A, C225A, C226A, C233A, C234A, C235A, C236A, C243A, C244A, C245A,C246A, C255A, C260A, C263A, C264A, C265A, C266A, C275A, C283A, C285A, C286A, C311A, C313A, C314A, C315A, C316A, C325A, C335A, C341A, C343A, C344A, C345A, C346A, C353A, C354A, C355A, C356A, C365A, C375A, C385A, C395A, C411A, C413A, C414A, C415A, C416A, C425A, C435A, C441A, C443A, C444A, C445A, C446A, C460A, C461A, C463A, C464A, C465A, C466A, C470A, C471A, C473A, C474A, C475A, C476A, C480A, C481A, C483A, C484A, C485A, C486A, C510A, C511A, C515A, C545A, C565A, C570A, C575A, C585A, C586A, C590A, C595A, C600A, C601A, C603A, C604A, C605A, C606A, C611A, C613A, C614A, C615A, C616A, C623A, C624A, C625A, C626A, C635A, C643A, C644A, C645A, C646A, C655A, C661A, C662A, C665A, C667A, C675A, C680A, C682A, C695A, C735A, C745A, C760A, C765A, C770A, C775A, C795A, C845A, C865A, C895A, C935A, C945A, K630A, W025A, W026A, W075A, W076A, W130A, W150A, W155A, W156A, W165A, W185A, W190A, W196A, W235A, W236A, W275A, W310A, W355A, W356A, W375A, W395A, W425A, W435A, W465A, W466A, W510A, W511A, W515A, W516A, W535A, W770A, W775A, W795A, W895A

Eligible Limited Virtual Care Services

Video-A101A
Telephone-A102A

Modality Indicators

K300A-Video
K301A-Telephone

Keywords/tags

Virtual Care; Comprehensive Virtual Care Service; Limited Virtual Care Service; Existing/Ongoing Patient Physician Relationship

More information

• Virtual Care 2: Terms and Conditions
• Bulletin 221002: New Virtual Care Funding Framework - Updated Schedule of Benefits
• Bulletin 221102: Ontario Virtual Care Program: Video Visit Payment Option End
• Bulletin 221203: Virtual Health Care in Ontario

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 MOH/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.

Image

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.