Physician Payment and Policy Ontario Health Insurance Program
Resource Manual for Physicians
 
2.2   General Preamble (Continued)

Special Visit Premiums

A special visit requires the physician to travel from one location to another to see the patient or may involve an emergency call with sacrifice of office hours. The appropriate special visit premium applies when a physician makes a special visit outside of normal office hours or an emergency call with sacrifice of office hours. Special visit premiums are applicable in addition to fees for certain services.

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

Except for those visits rendered to palliative care patients, a physician providing an elective home visit must claim, in addition to the appropriate “A” prefix service, B990, even if the elective visit is rendered at night, on Saturdays, Sundays and holidays (subject to the restriction based on volume of special visits laid out on page GP46).  For example, a pre-booked or pre-planned house call on a weekend or evening would be claimed as B990 and appropriate assessment code, rather than B994 (the special visit premium code for evenings, weekends and holidays) and the appropriate assessment code.

A separate special visit premium – Special visit for the purpose of providing palliative care, elective or non-elective (B998) is payable for special visits rendered to palliative care patients in their home.

NOTE:

In order to claim a special visit premium for a sacrifice of office hours (e.g., K992) a physician must be required to immediately leave his or her office to visit the patient (perform a special visit), and the physician must have had an office visit booked with one or more patients during the affected office hours, but because of the special visit, it was necessary to delay or cancel such visits.

Special visits to the patient’s Home or Equivalent:  if the total amount billed for insured services including special visit premiums to patient’s homes or equivalents and long-term care institutions in any calendar month is more than 20 percent (of the total amount payable on all claims submitted for services rendered in that month) no special visit premium is payable. The physician must submit claim for such services using fee schedule codes B910, B914 or B916 in lieu of a combination of an assessment plus special visit premium.

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