Ontario Health Insurance Plan

INFOBulletin

COVID-19 Temporary Modifier Payment for AGMPs

Reactivation of the E405A in-hospital AGMP modifier, creation of new E404A out-of-hospital AGMP modifier, and expansion of list of eligible AGMPs


To: All Providers
Category: Physician Services
Written by: Claims Services Branch, Ontario Health Insurance Plan Division
Date issued: March 8, 2021
Bulletin Number: 210302



Background

To further support the government’s efforts to stop the spread of COVID-19 in Ontario, the Ministry of Health (ministry) and the Ontario Medical Association (OMA) have reached an agreement to implement temporary 30% modifier payments for eligible Aerosol-Generating Medical Procedures (AGMPs) performed both in and outside of hospitals, for the period of October 1, 2020 to September 30, 2021.

On March 1, 2021, the ministry has implemented the following changes with an effective date retroactive to October 1, 2020:

  • Reactivation of the E405A fee code-Hospital Complexity Modifier
  • Creation of a new E404A fee code-Modifier payment for AGMPs performed outside of hospital
  • Expanded the list of eligible AGMP services

Related Communications

Please refer to the additional communications listed below regarding AGMP services for further information.

  • INFOBulletin 4758 titled ‘Temporary Fees for Identified AGMP Procedures-COVID-19-Hospital Physician Compensation’
  • INFOBulletin 201105 titled ‘COVID-19 Hospital Physician Compensation: E405A Changes’
  • INFOBulletin 201108 titled ‘Temporary Fees for Identified AGMPs in Community Settings’
  • INFOBulletin 201202 titled ‘System solution for E405A effective December 1, 2020’

Reactivation of E405A Hospital Complexity Modifier

The ministry has reactivated fee schedule code (FSC) ‘E405A-Hospital Complexity Modifier’ with an effective date of October 1, 2020. E405A will be eligible for payment for eligible services between October 1, 2020 and September 30, 2021.

E405A should only be billed for patients who are COVID-19 positive or who are treated as at risk of being COVID-19 positive under local hospital policy. This FSC can only be billed for providing general anesthesia and for performing certain procedures which are listed in ‘Appendix A-Complete List of Eligible AGMPs’.

The eligible AGMP list has also been expanded effective October 1, 2020. E405A will be paid at 30% of the fee paid value (fee approved for shadow billed claims) of the applicable services for the same patient, same physician on the same day.

Fee for Service Claim Submissions for E405A

  • A Master Number is required to be submitted with FSC E405A.
  • E405A does not require a diagnostic code.
  • When E405A is billed with a Northern Specialist Hospital-based group number (group numbers 64AA-64DZ) the 30% premium will be calculated on the pre-reduction amount.
  • E405A is payable on the sum of fee paid (fee approved for shadow billed claims) for all eligible claims, submitted on the same claim or previously paid claims with same service date, same physician, and same patient.
  • E405A is a daytime premium for services that commence between 7:00 a.m. and 5:00 p.m. on weekdays (not to be used for services on weekends or holidays).
  • E405A is not payable with E400C, E401C, E409A, E410A, E412A, E413A, Q012A, Q016A, Q017A and Q018A (after-hours premiums).
  • Travel, first and additional persons seen premiums are eligible for payment with E405A for the same patient, same physician, same service date.
  • E405A is not eligible to be billed with virtual care claims.
  • Additional fee schedule codes E173A, E174A, E839A, F138A, F139A, F140A, F142A, F143A, F144A, M027A, M063A, M144A, R788A, R789A, Z313A, Z314A and Z317A are eligible to be billed with E405A.
  • If a claim is submitted with a service date of October 1, 2020 onwards for E405A, and an eligible AGMP code from Appendix A has been paid for same patient, same service date, same provider on the same claim or on a previous claim, the E405A will be paid at 30% of the fee paid (fee approved for shadow billed claims) on the AGMP service.
  • E405A is not eligible for payment for service dates between August 1, 2020 and September 30, 2020. If E405A is submitted with a service date between August 1, 2020 and September 30, 2020, the claim will be rejected to the provider’s error report with error code ‘A3E-No such FSC’.
  • If E405A is submitted and there is no AGMP service on the claim or previously paid for same patient, same service date, same physician, the E405A will pay at $0.00 with error code ‘DF-Corresponding fee code has not been claimed or was approved at zero’.
  • A stale-date exemption on E405A has been extended until June 30, 2021 for E405A submissions with service dates approaching stale-dating.

New E404A Modifier for AGMPs Outside of Hospital

The ministry has implemented a new temporary 30% modifier payment for eligible AGMPs performed outside of hospitals, which will be applicable for eligible AGMPs rendered outside of a hospital on or between October 1, 2020 and September 30, 2021 and under the eligibility criteria noted below.

The new temporary modifier for AGMPs outside of hospital is only eligible for payment on AGMPs when the AGMP meets all three criteria:

  • Is performed outside of a hospital.
  • Is commenced between the hours of 7 am and 5 pm on weekdays.
  • Is rendered to a patient who is COVID-19 positive as confirmed by laboratory testing, or at risk of being COVID-19 positive as documented in the medical record.

The ministry currently defines a patient as at risk of being COVID-19 positive if they meet one of these two criteria:

The list of eligible AGMPs performed outside of a hospital will mirror the list used for the equivalent modifier payment for AGMPs performed in hospitals, which was implemented as part of the larger COVID-19 temporary payments for physician services in-hospital (refer to Related Communications above).

Fee for Service Claim Submissions for E404A

  1. E404A is effective October 1, 2020.
  2. All the rules that apply to ‘E405A-AGMP Complexity Hospital Modifier’ apply to the new ‘E404A-AGMP Modifier Out of Hospital’ with the exception of Master Number and Admit date which should be blank when submitting a claim for E404A with an eligible AGMP service rendered outside of a hospital setting.
  3. If E404A is submitted with an eligible AGMP code with a service date prior to October 1, 2020, the claim will be rejected to the provider’s error report with error code ‘A3E-No such FSC’.
  4. A stale-date exemption has been applied until June 30, 2021 for E404A submissions with service dates approaching stale dating.
  5. E404A and E405A cannot be submitted together.
  6. If an incoming claim contains both E404A and E405A for the same patient and same service date, the 2nd FSC will be paid at $0 with explanatory code ‘D7-Not allowed in addition to other procedure’.
  7. E404A is a daytime premium for services commencing between the hours of 7:00 a.m. and 5:00 p.m. on weekdays (not to be used for services on weekends or holidays).

Primary Care Claim Submissions for E404A

Effective October 1, 2020, E404A will pay fee for service for all primary care models.

Appendix A – Complete List of Eligible AGMPs

NOTE: This list of eligible Aerosol Generating Medical Procedures (AGMP) is currently being expanded to include additional procedures.

Fee Schedule Code Descriptor April 2020 Price
Anaesthesia Anaesthesia unit fee $15.29
E600 Larynx-Endoscopy-Laryngoscopy-Using operating microscope-To charges for laryngoscopy add $33.60
G050 Trachea and Bronchi-Endoscopy-Bronchoscopy-Endobronchial ultrasound (EBUS), for guided biopsy of hilar and/or mediastinal lymph nodes $203.05
G579 Echocardiography-Transoesophageal echocardiography-Saline study (including venipuncture, to G571, G574, G581 or G584 add $11.35
G580 Echocardiography-Transoesophageal echocardiography-Insertion of oesophageal transducer $45.00
G581 Echocardiography-Transoesophageal echocardiography-professional component (P1) $25.00
M012 Nose-Reconstruction-Septoplasty $293.95
M054 Accessory Nasal Sinuses-Endoscopic approach-Intranasal maxillary antrostomy-unilateral-by endoscopic or endonasal approach $123.70
M055 Accessory Nasal Sinuses-External or Endonasal Approach-Maxillary-Caldwell-Luc (includes intranasal antrostomy)-Unilateral $247.35
M056 Accessory Nasal Sinuses-Maxillectomy-Partial or complete $971.75
M061 Accessory Nasal Sinuses-External or Endonasal Approach-Sphenoid-Trans-Septal sphenoidectomy for tumour or radical exenteration of disease $355.65
M081 Larynx-Excision-Laryngectomy-Total $838.90
M083 Accessory Nasal Sinuses-Ethmoidectomy/antrostomy-Intranasal ethmoidectomy including maxillary antrostomy, with endoscope-unilateral (not eligible for payment with M061 or M054) $350.00
M084 Larynx-Excision-Laryngectomy-Segmental, including reconstruction $888.85
M086 Accessory Nasal Sinuses-Ethmoidectomy/antrostomy-Transnasal endoscopic repair of CSF rhinorrhea (includes harvesting of graft material) with or without 3D CT/MRI image guided system $822.45
M105 Chest Wall and Mediastinum-Excision-Chest wall tumour, resection of 2 or 3 ribs or cartilages $650.00
M135 Lungs and Pleura-Incision-Major decortication of lung for empyema or tumour $848.80
M137 Respiratory /Cardiovascular Surgical Procedures-Lungs and pleura-Incision-Multi-Thoracotomy with or without biopsy $390.65
M142 Lungs and Pleura-Excision-Pneumonectomy, may include radical mediastinal node dissection, sampling or pericardial resection requiring repair $1,485.40
M143 Lungs and Pleura-Excision-Lobectomy, may include radical mediastinal node dissection or sampling $1,402.60
M145 Lungs and Pleura-Excision-Wedge resection of lung $843.40
M149 Lungs and Pleura-Excision-Pleurectomy, and/or apical bullectomy for pneumothorax $525.00
M151 Lungs and Pleura-Excision-Bullectomy for major bullous disease $725.00
N111 Cranial-Skull Base Surgery-Resection of lesion(s)-Endonasal Approach-Pituitary lesion(s)-Transsphenoidal microscopic resection of lesion(s) originating in the sella turcica requiring simple closure, repair and/or reconstruction of surgical defect(s) $1,879.00
N112 Cranial-Brain-Skull Base Surgery-Surgical Access-Endonasal Approach-Surgeon not rendering resection of lesion(s)-Endonasal endoscopic or microscopic approach for surgical access to sella turcica-Includes when rendered middle turbinate reductions, maxillary antrostomies, ethmoidotomies, ethmoidectomies, sphenoidotomies, septotomy, septoplasty and septal mucosal flap(s) harvest associated with septotomy or sphenoidal mucosal flap(s) $1,360.00
N114 Cranial-Skull Base Surgery-Resection of lesion(s)-Endonasal Approach-Pituitary lesion(s)-Transsphenoidal endonasal endoscopic resection of lesion(s) originating in the sella turcica requiring simple closure, repair and/or reconstruction of surgical defect(s) $1,742.45
N116 Cranial-Skull Base Surgery-Resection of lesion(s)-Endonasal Approach-Non-Pituitary lesion(s)-Endonasal endoscopic resection of non-Pituitary lesion(s) not originating from pituitary tissue requiring simple closure, repair and/or reconstruction of surgical defect(s) $2,243.45
N150 Cranial-Cerebral Injury-C.S.F. leak-Intracranial repair (to include trans-Sphenoidal approach) $1,065.45
R181 Respiratory Surgical Procedures-Nose-Excision of nasopharyngeal or oropharyngeal lesion-With palatal split $508.20
S018 Oral Cavity and Pharynx-Excision-Glossectomy-Partial $197.45
S043 Salivary Glands and Ducts-Excision-Parotid gland-Total (with preservation of facial nerve) $885.75
S063 Oral Cavity and Pharynx-Excision-Branchial-Tonsillectomy and may include adenoidectomy $178.35
S065 Oral Cavity and Pharynx-Excision-Branchial-Adenoidectomy $101.25
S068 Oral Cavity and Pharynx-Excision-Closure of fistula-Pharyngo-Laryngectomy $1,155.45
S236 Endoscopic Ultrasound-Linear or radial echo-Endoscope-Excluding biliary or pancreatic examination (scope also used for therapeutic procedures) $203.05
S237 Endoscopic Ultrasound-Linear or radial echo-Endoscope-Including biliary and/or pancreatic examination (scope also used for therapeutic procedures) $253.80
Z292 Laryngoscopy Direct without biopsy $61.30
Z293 Laryngoscopy Direct with biopsy $61.30
Z296 Nose-Endoscopy-Fiberoptic endoscopy of upper airway (nose, hypopharynx or larynx) (IOP)-With flexible endoscope-If only operative procedure performed $20.10
Z299 Nose-Endoscopy-Fiberoptic endoscopy of upper airway (nose, hypopharynx or larynx) (IOP)-With rigid endoscope, for Diagnostic evaluation, or to facilitate biopsy or surgical treatment of pathology in the posterior nasal cavity, hypopharynx or larynx $8.55
Z301 Nose-Incision-Drainage of abscess or haematoma $55.60
Z302 Nose-Incision-Turbinate reduction-Unilateral or bilateral (by any method) $55.60
Z305 Nose-Excision-Nasal polyp-Multiple or involving general anaesthetic-Unilateral $55.60
Z311 Nose-Excision-Removal of foreign body-Local anaesthetic $10.55
Z312 Nose-Excision-Removal of foreign body-General anaesthetic $50.90
Z314 Nose-Treatment of epistaxis (nasal Haemorrhage)-Cauterization-Unilateral $11.50
Z315 Nose-Treatment of epistaxis (nasal Haemorrhage)-Anterior packing-Unilateral $15.35
Z316 Nose-Treatment of epistaxis (nasal Haemorrhage)-Posterior packing-Unilateral or bilateral $35.50
Z317 Nose-Endoscopy-Fiberoptic endoscopy of upper airway (nose, hypopharynx or larynx) (IOP)-Examination under anaesthesia (EUA) of nose including suction cautery for posterior epistaxis-Unilateral or bilateral $112.05
Z318 Accessory Nasal Sinuses-Endoscopic approach-Trephine or endoscopic frontal sinusotomy $133.30
Z322 Larynx-Endoscopy-Direct-With removal of foreign body $106.45
Z323 Larynx-Endoscopy-Direct-With removal of lesion(s) $226.35
Z324 Larynx-Endoscopy-Indirect-With biopsy or removal of foreign body $44.70
Z325 Trachea and Bronchi-Incision-Emergency tracheotomy $474.65
Z326 Trachea and Bronchi-Tracheo-Bronchial aspiration-Change of tracheostomy tube $12.50
Z327 Trachea and Bronchi-Endoscopy-Bronchoscopy-Flexible or rigid, with or without bronchial biopsy, suction or injection of contrast material $124.90
Z329 Chest Wall and Mediastinum-Endoscopy-Mediastinoscopy $380.00
Z331 Lungs and Pleura-Introduction-Thoracentesis-Aspiration for Diagnostic sample $32.45
Z332 Lungs and Pleura-Introduction-Thoracentesis-Aspiration with therapeutic drainage with or without Diagnostic sample $59.15
Z334 Lungs and Pleura-Introduction-Thoracentesis-Total unilateral lung lavage with or without bronchoscopy using Double Lumen Tube and single lung anaesthesia $304.60
Z335 Thoracoscopy (pleuroscopy) with or without pleural biopsy, suction, etc. $242.35
Z336 Lungs and Pleura-Incision-Biopsy of pleura, needle-Including Diagnostic aspiration $59.15
Z338 Lungs and Pleura-Excision-Biopsy of pleura or lung-With limited thoracotomy $202.80
Z340 Lungs and Pleura-Incision-biopsy of lung, needle $137.85
Z341 Lungs and Pleura-Incision-Closed drainage effusion or pneumothorax $76.80
Z342 Trachea and Bronchi-Limited bronchoscopy with placement of endobronchial blocker and/or double lumen tube $112.55
Z343 Larynx-Endoscopy-Direct-With dilatation of larynx, to include bronchoscopy if necessary $202.35
Z344 Trachea and Bronchi-Tracheo-Bronchial aspiration-First procedure $45.95
Z345 Trachea and Bronchi-Tracheo-Bronchial aspiration-Subsequent procedures performed by same physician $18.60
Z346 Trachea and Bronchi-Tracheo-Bronchial aspiration-Transtracheal aspiration $22.35
Z350 Accessory Nasal Sinuses-Endoscopic approach-Ethmoidectomy/antrostomy-Endoscopic sphenoidotomy-Unilateral $123.70
Z355 Trachea and Bronchi-Quadroscopy or panendoscopy-With or without biopsy (nasopharyngoscopy, laryngoscopy, bronchoscopy, oesophagoscopy with or without gastro-duodenoscopy) using separate instruments in search of malignant disease $321.45
Z356 Trachea and Bronchi-Tracheo-Bronchial aspiration-Closure of persistent tracheostoma $133.95
Z359 Trachea and Bronchi-Repeat bronchoscopy for tracheobronchial toilet when performed within one week of another bronchoscopic procedure $56.65
Z360 Trachea and Bronchi-Endoscopy-Bronchoscopy-Emergency rigid bronchoscopy for obstructed airway $474.65
Z361 Lungs and Pleura-Incision-Chronic indwelling pleural catheter for palliative management of malignant pleural effusion-Insertion of indwelling catheter $200.00
Z399 Oesophagus-Endoscopy-Oesophagoscopy-Gastroscopy, with or without duodenoscopy-Elective $92.50
Z400 Oesophagus-Endoscopy-Oesophagoscopy-Gastroscopy, with or without duodenoscopy-for active bleeding $125.10
Z515 Oesophagus-Endoscopy-Oesophagoscopy, with or without biopsy(ies) $68.25
Z524 Oral Cavity and Pharynx-Incision-Drainage of haematoma or deep neck abscess (external approach) $271.05
Z527 Stomach-Endoscopy-Gastroscopy-May include biopsies, photography and removal of polyps less than or equal to 1 cm $82.90
Z528 Gastroscopy-subsequent (within three months following previous gastroscopy) $67.85
Z547 Stomach-Endoscopy-Gastroscopy-With removal of foreign body $99.75
Z558 Biliary Tract-Endoscopy-Endoscopic retrograde cholangiopancreatography (ERCP)-Including sphincterotomy and may include removal of one or more bile duct stones $300.25
Z561 Biliary Tract-Endoscopy-Endoscopic retrograde cholangiopancreatography (ERCP)-With cannulation of common bile duct and/or pancreatic duct $213.15
Z584 Intestines (except rectum)-Endoscopy-Small bowel push enteroscopy $185.15
Z738 Trachea and Bronchi-Incision-Insertion of Montgomery “T” Tube or similar laryngeal or tracheal stent $216.10
Z741 Trachea and Bronchi-Incision-Tracheotomy $273.15
Z760 Biliary Tract-Endoscopy-Endoscopic retrograde cholangiopancreatography (ERCP)-Through gastrojejunostomy following previous Billroth II $251.85

AGMPs Added to the Eligible List

The following procedures, when requiring the use of a high-speed device in the respiratory tract, are eligible for the AGMP premium when performed on patients who are COVID-19 positive or who are treated as at risk of COVID-19 positive:

Fee Schedule Code Descriptor April 2020 Price
F138 Mandible-Closed reduction, includes maxillary-mandibular fixation $350.00
F139 Mandible-Open reduction, per fracture, to include intermaxillary fixation $575.00
F140 Mandible-Removal of intermaxillary fixation device(s) $100.00
E173 Orbit-Open reduction rim/wall fracture-Zygomatic fracture dislocation $594.70
E174 Orbit-Blowout fracture of floor $667.00
F143 Midface fractures-Application of craniofacial suspension wires and external fixation devices (not to be billed in addition to maxillary repair)-Middle ¼ facial $577.65
F144 Midface fractures-Application of craniofacial suspension wires and external fixation devices (not to be billed in addition to maxillary repair)-Cranial-facial separation $1,594.90
F142 Orbit with maxilla-With wiring and local fixation $685.20
M063 Maxillectomy-Coronal and/or osteoplastic procedure for frontal sinusectomy, reconstruction or obliteration-Unilateral or bilateral $716.25

Additional eligible procedures when requiring open suctioning of the airway:

Fee Schedule Code Descriptor April 2020 Price
Z317 Endoscopy-Examination under anaesthesia (EUA) of nose including suction cautery for posterior epistaxis-Unilateral or bilateral $112.05
Z314 Treatment of epistaxis (nasal haemorrhage)-Cauterization-Unilateral $11.50
E839 Excision-Nasal polyp-With flexible endoscope, to Z304 $19.20
M027 Treatment of epistaxis (nasal haemorrhage)-Ligation of external carotid artery-Unilateral $297.25
R788 Treatment of epistaxis (nasal haemorrhage)-Ligation of internal maxillary artery-Unilateral $408.10
R789 Treatment of epistaxis (nasal haemorrhage)-Ligation of anterior ethmoidal artery-Unilateral $299.85
Z313 Treatment of epistaxis (nasal haemorrhage)-Endoscopic transnasal ligation of the sphenopalatine artery for posterior epistaxis-Unilateral $123.70
M144 Segmental resection, including segmental bronchus and artery $1,441.75

Keywords/Tags

E405A; E404A; AGMP; Aerosol Generating Medical Procedures; COVID-19

Contact Information

Do you have questions about this INFOBulletin? Email the Service Support Contact Centre or call 1-800-262-6524.

Find INFOBulletins online on the Ministry of Health website.

Schedule of Benefits for Physician Services

The latest version of the Schedule of Benefits for Physician Services is available on the Ministry of Health website. Hard copies of the Schedule of Benefits for Physician Services will not be distributed. If you would like to order a paper copy or compact disk (CD) of the Schedule for a fee, please visit Publications Ontario. Physicians without access to the Internet can contact ServiceOntario at 1-800-668-9938.

Please review the Health Insurance Act

This bulletin is a general summary provided for information purposes only. Physicians are directed to review the Health Insurance Act, Regulation 552, and the schedules under that regulation, for the complete text of the provisions. You can access this information at ontario.ca/laws. In the event of a conflict or inconsistency between this bulletin and the applicable legislation and/or regulations, the legislation and/or regulations prevail.

For More Information

Call ServiceOntario, Infoline at:
1–866–532–3161 (Toll–free)
In Toronto, (416) 314–5518
TTY 1–800–387–5559.
In Toronto, TTY (416)327–4282
Hours of operation: Monday to Friday, 8:30am – 5:00pm

 
  • Connect With Us
Facebook Twitter YouTube RSS