Physician payment

General Preamble of the Schedule of Benefits for Physician Services

The following is intended to be a brief overview of the critical elements within the General Preamble of the Schedule of Benefits for Physician Services (Schedule), and not a substitute for the actual document. In the event of a conflict between this overview and the full text of the General Preamble, the General Preamble prevails. Physicians are responsible for being familiar with all legislation and regulations applicable to the services they provide, including all relevant sections of the Schedule. All claims for payment will be assessed in accordance with the Schedule and not with this overview. Schedule changes may have taken effect since publication and the current version of the Schedule should always be consulted for the applicable payment rules.

Separate fee schedules exist for insured services provided by dental surgeons and optometrists, medical laboratories (licensed under the Laboratory and Specimen Collection Centre Licensing Act) and facility fees for independent health facilities (licensed under the Independent Health Facilities Act).

OHIP schedules of benefits and fees are posted electronically.

The first section of the Schedule is the General Preamble. The General Preamble provides important billing information that applies to services listed in the Schedule, including definitions of key terms used in the Schedule, common and specific elements of insured services, and descriptions of various consultation and assessment types.

It is necessary to review the General Preamble in addition to the service specific sections of the Schedule to have a complete understanding of the requirements for a service.

The following is an overview of the issues and information contained within the General Preamble that may guide you in a more detailed examination of the General Preamble.

Services insured by OHIP

The Ministry of Health (ministry), on behalf of the General Manager of the Ontario Health Insurance Program (OHIP), makes payments for services insured by OHIP in accordance with the legislative requirements of the Health Insurance Act (HIA) and its regulations including the Schedule of Benefits for Physician Services (Schedule).

The Schedule is a document incorporated by reference into Regulation 552 under the HIA and is amended only by regulation change. The Schedule lists approximately 6,000 physician services and the conditions under which each service can be claimed to OHIP. The Schedule is comprised of a General Preamble with rules of general application to all listed services, rules of general application to subsets of listed services separated by medical specialty, and rules and descriptions specific to individual listed services.

The HIA and Regulation 552 provide additional guidelines to help determine when a service is or is not insured and should be read along with the Schedule. For example, subsections 24(1) and (2) of Regulation 552 provide circumstances when a service listed in the Schedule is not insured, unless an exception in subsection 1.0.1, 1.1 or 1.2 applies.

According to the HIA, services are only insured when medically necessary.

Medical records

All insured services must be documented in the medical record. In addition to fulfilling professional requirements, this record is used as evidence of care. It must be clear from the medical record what services were provided, whether the OHIP payment requirements were met and whether the services provided were medically necessary. For example, for services insured only when a specific medical indication is present, the presence of the indication must be clear in the medical record.

For many procedures that may be considered cosmetic, the Schedule requires the physician obtain prior approval from the ministry. This requirement is specifically listed in notes next to applicable fee codes and/or in Appendix D of the Schedule. Download the “Request for Approval of Payment for Proposed Surgery” (0691-84).

Common and specific constituent elements of insured services

Common elements are the components that are included in the payment for all insured physician services. The common elements are listed in the General Preamble. In contrast, specific elements are components that only apply to specific groups of services. The General Preamble lists specific elements that apply to some groups of services (example: assessments). However, specific elements for other groups of services may be listed in the additional preambles throughout the Schedule (for example: the surgical preamble).

Payment for an insured service includes compensation for performing any applicable common and specific elements of the service, as well as the skill, time and responsibility involved in performing the service. All elements taken together are referred to as the constituent elements of a service.

Unless the Schedule specifically states otherwise, the elements that are common to all insured services and not separately payable include:

• being available to provide follow-up insured services to the patient or making arrangements for coverage when you are not available
• making any arrangements for appointment(s) involving the insured service
• obtaining and reviewing information (including taking history) to make the appropriate decisions to perform elements of the service
• obtaining consents or delivering written consents
• keeping and maintaining appropriate medical records
• providing any medical prescriptions, except where the request for this service is initiated by the patient (or their representative) and no related insured service is provided
• preparing or submitting documents, records or information for use in programs administered by the ministry
• conferring with or providing advice, direction, information or records to physicians and other professionals associated with the health and development of the patient
• providing premises, equipment, supplies and personnel for the service
• please refer to the General Preamble for the full text

Please refer to the General Preamble for the full text.

Specific elements of assessments

Specific elements of assessments are included in the payment for all insured assessments and services that include assessments (for example: consultations). A direct physical encounter with the patient, including any appropriate physical examination and ongoing monitoring of the patient’s condition where indicated, is included in the payment for all assessment and services that include assessments. These services cannot be delegated.

Payment for an insured assessment includes compensation for performing any applicable common and specific elements of the service, as well as the skill, time and responsibility involved in performing the service. These specific elements include:

• other inquiry, including patient history, carried out in order to arrive at any opinion as to the nature of the patient’s condition, appropriate procedures, related services and/or follow-up care which may be required
• performing any procedure(s) during the same encounter as the physical examination unless separately listed in the Schedule and payable in addition to the assessment (examples include obtaining specimens, preparing the patient, interpreting results)
• making arrangements for related assessments, procedures, therapy, interpreting results and appropriate follow-up care
• discussion with and providing advice and information, including prescribing therapy to the patient (or their representative) by telephone or otherwise on matters related to the service and when appropriate, to convey the results of a related procedure prior to future patient visit (example: it would not normally be necessary to schedule a second visit with a patient to review the results from a diagnostic test such as a throat swab; however, if an examination such as an exercise stress test was ordered in the first appointment, then it may be necessary to have the patient return for a second appointment to discuss the results and the second appointment would accordingly be an insured service for which a claim for payment could be submitted)
• when medically indicated, monitoring the condition of the patient and intervening until the next insured service is provided
• providing the premises, equipment, supplies and personnel for the specific elements of the service (except for those performed in a hospital or long-term care home)
• annual limits may apply to various codes, including individual consultation and assessment codes

Please refer to the General Preamble for the full text as well as specific elements for other groups of services (example: specific elements of psychotherapy, psychiatric and counselling services).

Assessments

The Assessments section of the General Preamble lists descriptions for various types of assessments listed in the Schedule. The information below is intended to be provided as a summary of frequently claimed assessments. Please see the General Preamble of the Schedule for a full list of assessments and descriptions.

A general assessment (A003) is a family practice service provided somewhere other than the patient’s home and includes a full history (including medical, family and social history) and except for breast, genital or rectal examination where not medically indicated or refused, an examination of all body parts.

A periodic health visit is a general assessment of an individual who has no apparent physical or mental illness and which takes place after the second birthday. It may include instructions to the patient and/or parents regarding health care. A periodic health visit should be claimed using the following codes:

• Family Practice and Practice in General (A periodic health visit is limited to one per patient per year by any one physician):
  • K017 — child after second birthday
  • K130 — adolescent
  • K131 — adult aged 18-64
  • K132 — adult 65 years of age and older
• Paediatrics (A periodic health visit is limited to one per patient per year by any one physician:
  • K267 — child age 2 to 11 years (no diagnostic code required)
  • K269 — adolescent age 12 to 17 years (no diagnostic code required)

A general re-assessment (A004) is a family practice code that includes all of the services included in a general assessment, with the exception of the patient’s history (which need not include all the details already obtained in the original assessment).

A minor assessment (A001) includes a brief history and examination of the affected part, region or disorder and/or brief advice or information regarding health maintenance, diagnosis, treatment, and/or prognosis. For example, seeing a patient with a simple skin rash or conjunctivitis would be billed as a minor assessment. This is a family practice code but should also be billed by specialists practicing outside of their specialty and/or in a primary care practice setting.

An intermediate assessment (A007) is a primary care service that requires a more extensive examination than a minor assessment. It also requires a history of the presenting complaint(s), inquiry concerning and examination of the affected part(s), region(s), system(s) or mental and emotional disorder as needed to make a diagnosis, exclude a disease and or assess function. This is a family practice code but should also be billed by specialists practicing outside of their specialty and/or in a primary care practice setting.

Consultations

The Consultations section of the General Preamble defines a consultation according to the Schedule and lists descriptions for various types of consultations. The information below is intended to be a summary of this section. Please see the General Preamble of the Schedule for the full text.

A consultation is an assessment rendered following a written request from a referring physician or nurse practitioner who, in light of their professional knowledge of the patient, requests the opinion of a physician (the “consultant physician”) competent to give advice in this field because of the complexity, seriousness, or obscurity of the case, or because another opinion is requested by the patient or patient’s representative.

The consultant must perform a general, specific or medical specific assessment, including the review of all relevant data. The consultant physician must submit his or her findings, opinions, and recommendations in writing to the referring physician. A copy of the written request must be maintained in the consulting physician’s medical record except in the case of a consultation which occurs in a hospital, or long-term care home where common patient medical records are maintained. In such cases, the written request may be kept in the common medical record.

In the absence of a written request, the amount payable for the consultation shall be reduced to the amount payable for an assessment. A consultation fee code is not to be claimed when either:

• a patient presents him or herself to a consultant’s office without a referral from his or her primary physician
• the patient simply asks his or her primary physician for the name of a specialist and the patient approaches the specialist directly

The information provided above is available.

A repeat consultation is an additional consultation rendered by the same consultant regarding the same problem, following care rendered to the patient by another physician following the initial consultation. If a consultant asks a patient to return for a later examination, this visit is not a repeat consultation.

A limited consultation involves all elements of a full consultation, but requires substantially less of the physician’s time than a full consultation. For example, when a physician sees a patient in consultation for a plantar wart a limited consultation code would be appropriate.

Non-emergency acute care hospital in-patient services

Non-emergency acute care hospital in-patient services include consultations and assessments rendered to admitted patients on a non-emergency basis and utilize the “C” prefix code. This includes, but is not limited to admission assessments, subsequent visits, concurrent care, and supportive care.

Emergency Department — Emergency Physician on Duty

Emergency Department — Emergency Physician on Duty: There are specific “H” prefix listings (H1-codes) for consultations, multiple systems assessments, minor assessments, comprehensive assessments and re-assessments rendered by the physician on duty in the Emergency Room. Any physician on duty or on-call in the emergency department should use these fee codes unless a special visit is required. If a special visit is required to the Emergency Department (example: the physician is called from home to make a special visit to see a patient in the Emergency Department and must travel to the hospital), the appropriate ‘A’ prefix fee code should be claimed for the first patient assessed (in addition to the special visit premium code(s)).

If the Emergency Department physician on call (or off duty) is already in the hospital or hospital environs a special visit premium cannot be billed when the physician is called to the Emergency Department. See the section on ‘Special Visit Premiums’ below for more information.

Psychotherapy and counselling services

Psychotherapy (K007) is treatment for mental illness, behavioral maladaptations or emotional problems, in which a physician deliberately establishes a professional relationship with a patient for the purpose of removing or modifying existing symptoms attributed to the problem.

Individual counselling (K013, K033) is defined as a patient visit dedicated solely to an educational dialogue between the patient and a physician. Advice provided to a patient that would ordinarily constitute part of a consultation, assessment or other treatment, is included as a common or constituent element of such other service, and does not constitute counselling in this context. If the patient does not have a pre-booked appointment, the amount payable for this service will be adjusted to a lesser assessment fee.

Delegated Procedure

A Delegated Procedure is a procedure carried out by a physician’s employee where the service remains insured if certain conditions are met. Procedures in this context do not include such services as assessments, consultations, psychotherapy, counselling, etc. One of the requirements (with few exceptions) is for “direct supervision”, that is, the physician must be physically present in the office or clinic at which the service is rendered. For more information including payment rules for delegated procedures, refer to the ‘Delegated Procedure’ section of the General Preamble.

Special visit premiums

Special visit premiums may be payable when a physician is required to make a medically necessary visit to a patient at a specific location. Special visits are generally non-elective; however, if a special visit is required at the patient’s home, the visit may be non-elective or elective.

A non-elective visit is one that is initiated by a patient or by an individual on behalf of the patient (for example: nurse) for the purpose of rendering a non-elective service.

An elective home visit is a visit to a patient’s home that the physician has determined to be medically necessary, initiated by the physician and carried out at a time convenient to the physician.

The General Preamble contains several tables, each representing a different location for a special visit (for example: long-term care home, patient’s home, hospital in-patient, etc.). Please refer to the table representing the location of the special visit to determine the appropriate fee code(s).

Special visits may have two components:

1. a travel component
2. a person seen component (first person seen and additional person(s) seen)

The travel component of a special visit requires the physician to travel from one location to another to see the patient (for example: from home to the hospital). Travel from one location of a hospital facility/complex to another location within the same facility/complex does not qualify for the travel premium (even if they are separate buildings).

In order for the first person seen premium to be eligible for payment, the physician must meet the requirement for travel. Additional persons seen may also qualify for a premium if there is a need to see other patients on a non-elective basis at the same location as part of the same visit. The travel component is not payable for additional persons seen at the same location.

Full payment rules and requirements, including the medical record requirements, are listed in the General Preamble under ‘Special Visit Premiums’.

Other than a hospital or long-term care facility, special visits do not apply when rendered in a place that is open for patients to attend (such as walk-in clinic). Patients seen during office hours held on nights or Saturdays, Sundays, or holidays do not qualify for any of the special visit premiums.

Surgical Assistants’ services

The Surgical Assistants’ services section of the General Preamble provides a list of specific elements for assistance at surgery as well as information regarding these services.

Appendix H of the Schedule contains a chart to assist in determining the number of assistant time units for billing purposes.

Anesthesiologists’ services

The anesthesiologists’ section of the General Preamble provides a list of specific elements for anesthesiologists’ services as well as information regarding these services.

Appendix H of the Schedule contains a chart to assist in determining the number of anaesthesia time units for billing purposes.

For further details or clarification regarding any of these topics, please refer to the Schedule or contact the Service Support Contact Centre at 1-800-262-6524 between 8:00 a.m. and 5:00 p.m., Monday to Friday (excluding holidays).

Schedule of Benefits appendices

There are several appendices found at the end of the Schedule. With the exception of Appendix D, these appendices do not form part of the Schedule; however, they do contain information that may be helpful. Regulations, such as those excerpted within the appendices are subject to change. Physicians are reminded to acquaint themselves with the current text of these regulations.

Appendix included as part of the Schedule:

Appendix D — This section contains information regarding the criteria for OHIP coverage for surgical procedures that are for the purpose of altering or restoring appearance, including surface pathology and sub-surface pathology.

Appendices as attachments to the Schedule:

• Appendix A — Provides an on-line reference and link to Section 24 of Regulation 552 under the HIA.
• Appendix B — Provides on-line references and links to Regulation 114/94 relating to Conflict of Interest and Records in accordance with the Medicine Act, 1991.
• Appendix C — Information on Benefits Outside Ontario as well as Interprovincial. Reciprocal Billing of Medical Claims.
• Appendix F — Services set out here are not “insured services” within the meaning of the HIA but are paid by the ministry, acting as a paying agent on behalf of the Ministry of Community and Social Services (MCSS), the Ministry of the Attorney General, the Ministry of the Community and Correctional Services, and the Workplace Safety and Insurance Board (WSIB). This appendix includes a list of important forms for physicians relating to the MCSS Ontario Disability Support Program and MCSS Ontario Works Program.
• Appendix G — Provides on-line references and links to medical record requirements as found in the Medicine Act, 1991 and the HIA.
• Appendix H — Table listing the number of units payable based on the duration of time spent rendering anaesthesia or surgical assistant services.
• Appendix Q — Provides descriptions and information for ‘Q’ prefix codes for primary care models.

Contact us

Call the Service Support Contact Centre (SSCC) at: 1-800-262-6524

Hours of operation: 8:00 a.m. – 5:00 p.m. Monday – Friday, except holidays

E-mail: SSContactCentre.MOH@ontario.ca