Amendments to the Schedule of Benefits for Physician Services - Effective April 1, 2012

Transcription

1 To: Published By: Physicians and Hospitals Health Services Branch Date Issued: May 7, 2012 Bulletin #: 4561 Re: Amendments to the Schedule of Benefits for Physician Services - Effective April 1, 2012 In recognition of the latest evidence, improvements in technology, and changes in standards of care, a number of changes are being implemented to the Schedule of Benefits for Physician Services (Schedule). This bulletin describes where to access details about these changes including implementation timelines. New Codes New services have been introduced into the Schedule for: Positron Emission Tomography (PET) and Computed Tomography (CT) scans for esophageal cancer Physician to physician e-consultations conducted through secure The referring physician initiates the e-consultation with the intention of continuing the care, treatment and management of the patient. The consultant physician provides opinion/advice/recommendations on patient care, treatment and management to the referring physician within thirty days. Please refer to the corresponding charts for more information on these new fee codes. Deleted Codes: Several fee codes have been deleted from the Schedule. Please refer to the corresponding charts for more information. 1 of 3

2 Revised Codes: Additionally, there are a number of fee code revisions being introduced. Some examples of the changes include, but are not limited to, the following: Referrals for Diagnostic Services Diagnostic services listed in the following sections of the Schedule must be submitted with an eligible referring physician or practitioner number on the claim: Nuclear Medicine Diagnostic Radiology MRI Diagnostic Ultrasound Pulmonary Function Studies Diagnostic and Therapeutic Procedures (where the service is listed with both a Professional and Technical component) Effective July 1, 2012, the absence of a referring physician number on a claim will result in a rejection of the claim and will require resubmission with the referring physician billing number on the claim in order for payment to be made. Self-referral means a situation where the referring physician (i.e., the physician ordering the diagnostic service) and the physician rendering any component of the diagnostic service are the same physician. It also refers to a situation where the referring physician and the physician rendering any component of the diagnostic service are members of the same physician s group or physician s hospital group. Where the physician rendering the diagnostic service is also the referring physician, this physician must insert his/her billing number in the referring physician field. Effective April 1, 2012, the fee paid for self-referrals for the above services will be reduced by 50%. The only exception to this is when services described by X172 and X178 are provided under the Ontario Breast Screening Program. In addition, for ultrasound services, comparison views initiated by the radiologist are no longer eligible for payment. Computed Tomography (CT) and/or Magnetic Resonance Imaging (MRI) for Chronic Low Back Pain - X-ray, CT or MRI studies of the lumbar spine are only eligible for payment when rendered for low back pain without suspected or known pathology. Examples include, but are not limited to: infection, tumour, osteoporosis, ankylosing spondylitis, fracture, inflammatory process, radicular syndrome, and cauda equina syndrome. 2 of 3

3 Pre-operative Echocardiograms - Pre-operative echocardiography for non-cardiac elective surgery is only eligible for payment when the service is medically necessary, and is not payable solely for the pre-operative preparation of the patient. Electrocardiograms (ECGs) and/or Pulmonary Function Tests (PFTs) provided with the annual health visit - Payment for ECGs and PFTs will be included in the annual well person visit and will not be eligible for separate payment except where the patient has symptoms, signs, or an indication supported by current clinical practice guidelines relevant to the individual patient s circumstances. Charts detailing all of the fee code changes referenced within are available as attachments to this bulletin at: tml The new version of the Schedule is available at: Hard copies of the Schedule 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 Physicians without access to the Internet can contact ServiceOntario at This Bulletin is a general summary provided for information purposes only. Physicians, hospitals, and other health care providers 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 In the event of a conflict or inconsistency between this bulletin and the applicable legislation and/or regulations, the legislation and/or regulations prevail. 3 of 3

4 Chart #1: New Codes Effective April 1, 2012 Code Description Schedule Section J710 Pet scan - Esophageal carcinoma P B K738 Physician to physician e-consultation Referring physician A K739 Physician to physician e-consultation Consultant physician A

5 Chart #2: Code Deletions Effective April 1, 2012 Code Description Schedule Section C101 For each patient seen on a visit to ICU or CCU GP E381 Intra-operative electrophysiological monitoring of neural structures SP E806 Intra-operative monitoring of cranial nerves SP G465 Manipulation of major joint(s) or spine by physician - one or more joints J G693 Cardiac Loop Monitoring - technical component, base station functions J J191 Extra-cranial vessel assessment - above the aortic arch - frequency analysis G J192 Extra-cranial vessel assessment - above the aortic arch - frequency analysis with Doppler scan G J194 Peripheral vessel assessment - frequency analysis, unilateral G J195 Peripheral vessel assessment - frequency analysis with Doppler scan, unilateral G J491 Extra-cranial vessel assessment - above the aortic arch - frequency analysis G J492 Extra-cranial vessel assessment - above the aortic arch - frequency analysis with Doppler scan G J494 Peripheral vessel assessment - frequency analysis, unilateral G J495 Peripheral vessel assessment - frequency analysis with Doppler scan, unilateral G

6 Chart #3: Code Revisions Effective April 1, 2012 Code Description Schedule Section Existing April 1, 2012 General Preamble - General Information - Diagnostic Services Rendered by the Referring Physician GP Diagnostic Radiology & MRI preamble (low back pain) D, F Diagnostic ultrasound preamble G General Preamble - Technical s GP Paediatric care in adults A Vein ligation - Preamble Q Surgical preamble - Intraoperative monitoring (#26) SP Surgical Preamble - IOP (#13) SP Echocardiography - Preamble - Preoperative Echocardiogram J Sleep study - Preamble J Counselling (revisions to exception table) GP Cardiac Loop Monitoring - technical component, G692 J recorder A/C215 Limited consult for acute pain management A A003 General assessment - Annual health examination A A020/C020 Complex dermatological assessment A E023C Anaesthesia service for E140, E141, E143, E138, E144, E145, E146, E137, E139 or Z432 GP E785 Colonoscopy screening biopsies (revision to add on list - add Z496, Z497, Z498) S Sophisticated micro-electrode recording during E896 stereotaxis (not billable in conjunction with E381), to X N123

7 G299 Oximetry J G310 Electrocardiogram - twelve lead - technical component (revision to note) J Electrocardiogram - twelve lead - professional G313 component - must include written interpretation J (revision to note) Compression sclerotherapy (includes multiple G536 injections, compression bandaging and one post J injection visit utilizing principles of Fegan) G537 Repeat compression sclerotherapy J G700 Basic fee-per-visit premium for procedures marked(+) J G818 OCT unilateral or bilateral - retinal disease J G820 OCT unilateral or bilateral - glaucoma J G843 Human Papillomavirus (HPV) type 6, 11, 16, 18 J G846 Pneumococcal conjugate (Pneu-C-7) J G847 Diphtheria, Tetanus, acellular Pertussis (DTaP) - adult J H100 Emergency department investigative ultrasound A J021 J022 J190 J193 Cardiac catheterization - insertion of catheter (including cut down, if necessary) and injection, if given Cardiac catheterization - selective catheterization - add to catheter insertion fee (per vessel, to maximum of 4) Extra-cranial vessel assessment - doppler scan or B scan (P1) Peripheral vessel assessment - doppler scan or B scan, unilateral E, J E, J G G Extra-cranial vessel assessment - above the aortic J201 arch - duplex scan i.e. simultaneous real time, B-mode G imaging and spectral analysis Peripheral vessel assessment - duplex scan i.e. J202 simultaneous real time, B-mode imaging and spectral G analysis, unilateral

8 J323 J332 J490 J493 Oxygen saturation - by oximetry at rest, with or without O2 (revision to note) Oxygen saturation - by oximetry at rest and exercise, or during sleep with or without O2 (revision to note) Extra-cranial vessel assessment - doppler scan or B scan (P2) Peripheral vessel assessment - doppler scan or B scan, unilateral H H G G Extra-cranial vessel assessment - above the aortic J501 arch - duplex scan i.e. simultaneous real time, B-mode G imaging and spectral analysis Peripheral vessel assessment - duplex scan i.e. J502 simultaneous real time, B-mode imaging and spectral G analysis, unilateral K017 Annual health examination - child after second birthday* GP, A K077 Geriatric telephone suppoprt A K630 Psychiatric consultation extension A N218 Extracranial intracranial microvascular anastomosis X Z745 Saphenous Q

9 Chart #4: Unit and Percentage Decreases Effective April 1, 2012 Code Description Schedule Section Existing % April 1, 2012 % Surgical Assistants' Services - After hours premium - E400B Evenings (17:00h 24:00h) Monday to Friday or daytime and evenings on Saturdays, Sundays or GP 50% 40% Holidays - increase the total assistant s fee by Anaesthesiology Services - After hours premium - E400C Evenings (17:00h 24:00h) Monday to Friday or daytime and evenings on Saturdays, Sundays or GP 50% 40% Holidays - increase the total anaesthetic fee by Surgical Assistants' Services - After hours premium - E401B Nights (00:00h 07:00h) - increase the total assistant's GP 75% 65% fee by Anaesthesiology Services - After hours premium - E401C Nights (00:00h 07:00h) - increase the total anaesthetic GP 75% 65% fee by After hours special visit premiums - Evenings (17:00h E402 24:00h) Monday to Friday or daytime and evenings on GP 40% 30% Saturday, Sunday or Holidays After hours special visit premiums - Nights (00:00h E403 GP 50% 40% 07:00h) Physician other than an Emergency Department E409 Physician - Evenings (17:00h 24:00h) Monday to Friday or daytime and evenings on Saturdays, Sundays, GP 50% 40% Holidays - increase the procedural fee(s) by Physician other than an Emergency Department E410 Physician - Nights (00:00h 07:00h) - increase the GP 75% 65% procedural fee(s) by Emergency Department Physician - Evenings (17:00h E412 24:00h) Monday to Friday or daytime and evenings on Saturdays, Sundays, Holidays - increase the GP 20% 10% procedural fee(s) by Emergency Department Physician - Nights (00:00h E413 GP 40% 30% 07:00h) - increase the procedural fee(s) by E792 When performed laparoscopically T, U 25% 10% E793 Laparoscopic or laparoscopic assisted R, S, W 25% 10% E862 When performed laparoscopically T, V 25% 10% E863 When performed laparoscopically V 25% 10%

10 Code Description Schedule Section Existing Units April 1, 2012 Units E022C Anaethesiology - Extra Units - ASA III GP 4 2 E147C Intravitreal injection Y 6 4 E149C Vitreous injection Y 6 4 Endoscopy - Cystoscopy - Diagnostic with or without Z606C T 6 4 urethroscopy Z607C Endoscopy - Cystoscopy - Repeat within 30 days T 6 4

11 Chart #5: Code Decreases Effective April 1, 2012 Code Existing April 1, 2012 Code Existing April 1, 2012 Code Existing April 1, 2012 A007A G577A J157C A777A G582A J158B A917A G585A J158C A921A G647A J159B A927A G648A J159C A937A G651A J160B A947A G652A J160C A957A G654A J161B A967A G655A J161C C777A G661A J162B E140A G682A J162C E147A G683A J163B E149A G684A J163C E378A G685A J164B E450B G686A J164C E451B G687A J165B E705A G688A J165C E740A G689A J166B E741A G815A J166C E747A G818A J167B G104A G820A J167C G111A G850A J168B G121A G851A J168C G123A G852A J169B G127A G853A J169C G140A G854A J180B G143A G855A J180C G146A G856A J182B G149A G857A J182C G152A G858A J183B G153A G860A J183C G167A G861A J186C G174A G862A J187C G181A G863A J188C G209A G864A J189C G227A G865A J190B G228A J102B J190C G238A J102C J193B G284A J103B J193C G308A J103C J196B G310A J105B J196C G311A J105C J197B G313A J107B J197C G315A J107C J198B G414A J108B J198C G440A J108C J199B

12 G441A J122B J199C G442A J122C J200B G443A J125B J200C G448A J125C J201B G451A J127B J201C G455A J127C J202B G466A J128B J202C G471A J128C J203B G519A J135B J203C G540A J135C J204B G541A J138B J204C G542A J138C J205B G544A J149B J205C G554A J149C J206B G570A J151C J206C G574A J157B J207B J207C J462C J615B J290C J463B J616B J301B J463C J617B J303B J464B J618B J304B J464C J619B J305B J466B J620B J306B J466C J621B J307B J468B J623B J308B J468C J624B J310B J469B J625B J311B J469C J626B J313B J476B J627B J315B J476C J629B J316B J480B J630B J318B J480C J631B J319B J482B J632B J320B J482C J633B J322B J483B J634B J323B J483C J635B J324B J486C J636B J327B J487C J637B J330B J488C J638B J331B J489C J639B J332B J490B J640B J333B J490C J641B J334B J493B J643B J335B J493C J647B J336B J496B J648B J340B J496C J649B J402B J497B J650B J402C J497C J651B J403B J498B J652B J403C J498C J653B J405B J499B J657B J405C J499C J658B

13 J407B J500B J659B J407C J500C J660B J408B J501B J661B J408C J501C J662B J422B J502B J663B J422C J502C J664B J425B J503B J665B J425C J503C J666B J427B J504B J667B J427C J504C J668B J428B J505B J669B J428C J505C J670B J435B J506B J671B J435C J506C J672B J438B J507B J673B J438C J507C J674B J457B J602B J675B J457C J604B J676B J458B J606B J677B J458C J607B J678B J459B J608B J679B J459C J609B J680B J460B J610B J681B J460C J611B J682B J461B J612B J683B J461C J613B J684B J462B J614B J685B J686B J868B X019B J687B J869B X019C J689B J870B X020B J690B J871B X020C J695B J872B X025B J696B J873B X025C J697B J874B X027B J802B J875B X027C J804B J876B X028B J806B J877B X028C J807B J878B X031B J808B J879B X031C J809B J880B X032B J810B J881B X032C J811B J882B X033B J812B J883B X033C J813B J884B X034B J814B J885B X034C J815B J886B X035B J816B J887B X035C J817B J889B X036B J818B J890B X036C J819B J893B X037B J820B J894B X037C

14 J821B J895B X038B J823B J896B X038C J824B J897B X039B J825B J898B X039C J826B J899B X040B J827B J990B X040C J829B N123A X045B J830B P004A X045C J831B P008A X046B J832B W777A X046C J833B X001B X047B J834B X001C X047C J835B X003B X048B J836B X003C X048C J837B X004B X049B J838B X004C X049C J839B X005B X050B J840B X005C X050C J841B X006B X051B J843B X006C X051C J847B X007B X052B J848B X007C X052C J849B X008B X053B J850B X008C X053C J851B X009B X054B J852B X009C X054C J853B X010B X055B J857B X010C X055C J858B X011B X056B J859B X011C X056C J860B X012B X057B J861B X012C X057C J862B X016B X058B J863B X016C X058C J864B X017B X060B J865B X017C X060C J866B X018B X063B J867B X018C X063C X064B X122C X159B X064C X123B X159C X065B X123C X160B X065C X124C X160C X066B X125C X161B X066C X126C X161C X067B X127C X162B X067C X128C X162C X068B X129B X163B X068C X129C X163C X069B X130B X164B X069C X130C X164C X072B X131B X165C

15 X072C X131C X167B X080B X132B X167C X080C X132C X168C X081B X133B X169B X081C X133C X169C X090B X134B X170B X090C X134C X170C X091B X135B X171B X091C X135C X171C X092B X136B X172C X092C X136C X173B X096B X137B X173C X096C X137C X174B X100B X138B X174C X100C X138C X175B X101B X139B X175C X101C X139C X176B X103B X140B X176C X103C X140C X177B X104B X141B X177C X104C X141C X178C X105B X142B X179B X105C X142C X179C X106B X145B X180B X106C X145C X180C X107B X146B X181B X107C X146C X181C X108B X147B X182B X108C X147C X182C X109B X148B X183B X109C X148C X183C X110B X149B X184B X110C X149C X184C X111B X150B X185B X111C X150C X185C X112B X151B X188C X112C X151C X189B X113B X152B X189C X113C X152C X190B X114B X153B X190C X114C X153C X191B X116B X154B X191C X116C X154C X192B X117B X155B X192C X117C X155C X193B X120B X156B X193C X120C X156C X194B X121C X158B X194C X122B X158C X195B X195C X227C Y613B X196B X228B Y614B

16 X196C X228C Y615B X197B X229B Y616B X197C X229C Y617B X198B X230B Y620B X198C X230C Y623B X199B X231C Y624B X199C X232C Y625B X200B X233C Y626B X200C X234C Y627B X201B X235C Y629B X201C X400C Y630B X202B X401C Y631B X202C X402C Y632B X203B X403C Y633B X203C X404C Y636B X204B X405C Y637B X204C X406C Y638B X205B X407C Y639B X205C X408C Y640B X206B X409C Y641B X206C X410C Y643B X207B X412C Y647B X207C X413C Y648B X208B X415C Y649B X208C X416C Y650B X209B X417C Y651B X209C X421C Y652B X210B X425C Y653B X210C X431C Y657B X211B X435C Y658B X211C X441C Y659B X212B X445C Y660B X212C X446C Y661B X213B X447C Y662B X213C X451C Y664B X214B X455C Y665B X214C X461C Y667B X215B X465C Y668B X215C X471C Y669B X216B X475C Y670B X216C X480C Y671B X217B X481C Y672B X217C X487C Y673B X218B X488C Y674B X218C X489C Y675B X219B X490C Y676B X219C X492C Y677B X220B X493C Y678B X220C X495C Y679B X221B X496C Y681B X221C X498C Y682B

17 X223B X499C Y683B X223C Y602B Y684B X224B Y604B Y685B X224C Y606B Y686B X225B Y607B Y687B X225C Y608B Y802B X226B Y610B Y804B X226C Y611B Y806B X227B Y612B Y807B Y808B Z399A Y810B Z496A Y811B Z497A Y812B Z498A Y813B Z499A Y814B Z527A Y815B Z555A Y816B Y817B Y820B Y823B Y824B Y825B Y826B Y827B Y829B Y830B Y831B Y832B Y833B Y836B Y837B Y838B Y839B Y840B Y841B Y843B Y847B Y848B Y849B Y850B Y851B Y852B Y853B Y857B Y858B Y859B Y860B Y861B Y862B Y864B Y865B

18 Y867B Y868B Y869B Y870B Y871B Y872B Y873B Y874B Y875B Y876B Y877B Y878B Y879B Y881B Y882B Y883B Y884B Y885B Y886B Y887B