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Primary Health Care Services InfoBulletins

To:  Comprehensive Care Model (CCM)
Family Health Group (FHG)
Family Health Network (FHN)
Family Health Organization (FHO)
Blended Salary Model (BSM)
Group Health Centre (GHC)
St. Joseph's Health Centre (SJHC)
Weeneebayko Health Ahtuskaywin (WHA)
South Eastern Ontario Academic Medical Organization (SEAMO)
Rural and Northern Physician Group Agreement (RNPGA)
GP Focus HIV (HIV)

Published by:   Primary Health Care Branch

Date Issued:  September 26, 2016

Bulletin Number:  11157

Re:   Preventive Care Bonus Projected Reports – September 2016

PDF Version Portable Document Format


The purpose of this INFOBulletin is to remind physicians of the upcoming Preventive Care Bonus Projected report used to determine what patients within the target population still requiring a preventive care service.

The Ministry of Health and Long-Term Care (Ministry) provides eligible physicians in Patient Enrolment Models (PEMs) with a Projected Preventive Care Target Population/Service Report (TPSR) semi-annually, in April and September, to assist them in determining their Target Population and the delivery of preventive care services.

  • Specifically this report identifies:
    • A physician's Target Population including enrolled patients who meet the age and sex criteria for each of the five (5) preventive care categories;
    • Eligible services provided to enrolled patients who have provided consent for each of the five (5) preventive care categories, according to Ministry records;
    • Enrolled patients who have provided consent for whom any physician in the group has submitted a Tracking Code; and
    • Enrolled patients for whom the enrolling physician has submitted an Exclusion Code.

The TPSR – Projected Report allows physicians to focus on providing any preventive care services not yet received by their target population for the remainder of the fiscal year. Submission of the Cumulative Preventive Care Bonus claims does not occur until April and at that time instructions for submissions are provided.

Note: The Influenza Vaccine is an annual service and is neither available nor administered to patients until late fall of each year. As no services have been provided it only provides the patients in the target population.

Physician Eligibility

  • All signatory physicians who are active with an eligible PEM on March 31st of each fiscal year are eligible for the Preventive Care Bonuses for that fiscal year.
  • FHG and CCM physicians must meet the minimum roster size as of March 31st of the fiscal year in order to be eligible for the bonuses.

The requirements for FHG and CCM minimum roster sizes are as follows:

  • Eligibility is based on a physician's roster size on March 31st of the current bonus year.
  • In each bonus year, a physician must have a minimum roster size of 650 enrolled patients on March 31st of the bonus year being claimed.
  • New Graduates in their first year of practice with a FHG or CCM will be required to have a minimum roster size of 450 enrolled patients on March 31st of the bonus year being claimed.

Note: Minimum roster size is calculated based on the physician's enrolled patient roster on March 31st of each year. Physicians must ensure they promptly submit the Per Patient Rostering fee code to enroll their patients.

Each April and September FHG and CCM physicians are provided their Projected TPSR regardless of their roster size at that time.

Target Populations and Services categories

Influenza Vaccine

Target population: consists of enrolled patients who are 65 years or older as of December 31st of the fiscal year for which the bonus is being claimed.

Service Period: is the current flu season up to January 31st of the year for which the bonus in being claimed.

Service Codes reported: G590A, G591A, Q690A, Q691A, and tracking code Q130A

Pap Smear

Target population: consists of enrolled female patients who are between 21 and 69 years of age, inclusive, as of March 31st of the fiscal year for which the bonus is being claimed.

Note: only patients who are sexually active should be used in the calculation for the bonus.

Service Period: by 42 months prior to March 31st of the fiscal year for which the bonus is being claimed.

Service Codes reported: G365A, L713A, L643A, E430A, E431A, Q678A, tracking code Q011A and exclusion code Q140A.

Mammography

Target population: consists of enrolled female patients who are between 50 and 74 years of age, inclusive, as of March 31st of the fiscal year for which the bonus is being claimed.

Service Period: by 30 months prior to March 31st of the fiscal year for which the bonus is being claimed.

Service Codes reported: X178A, X178B, X178C, X185A, X185B, X185C, tracking code Q131A and exclusion code Q141A.

Childhood Immunizations

Target population: consists of enrolled patients who are aged 30 to 42 months of age, inclusive as of March 31st of the fiscal year for which the bonus is being claimed.

Service Period: by their 30th month of age.

Service Codes reported: G538A, G539A, G688A, G689A, G840A, G841A, G844A, G845A, G846A, and G848A and tracking code Q132A.

Colorectal Cancer Screening

Target population: consists of enrolled patients who are between 50 and 74 years of age, inclusive; on March 31st of the fiscal year for which the bonus is being claimed.

Service Period: is 30 months prior to March 31st of the fiscal year for which the bonus is being claimed.

Service Codes reported: G004A, L179A, L181A, Q700A, tracking codes Q133A and exclusion codes Q142A.

Tracking and Exclusion Codes

  • To better assist physicians in monitoring patient status and determining service levels achieved, tracking and exclusion codes have been introduced. When submitted, these codes will identify the patient as having received the preventive care service or identify the patient as having met the criteria for being excluded from the target population for a specific preventive care service. For example, if your patient informs you that they received their influenza vaccination at a flu clinic at work, then the tracking code can be submitted.
  • Tracking and Exclusion codes may be submitted using the normal billing practices used to submit Fee for Service claims and premium codes applicable to their agreement. As with other tracking codes, the fee billed should be zero dollars, and the fee paid on the Remittance Advice (RA) will be zero dollars with explanatory code 30 – "This service is not a benefit of OHIP". Exclusion codes may be submitted if the patient meets the exclusion criteria listed below.
Category Tracking Code Exclusion Code and Criteria
Influenza Vaccine Q130A Not applicable
Pap Smear Q011A Q140A
Exclusions apply for women who have had a hysterectomy, or who are being tested for cervical diseases that preclude regular screening Pap tests and also any female who is not sexually active
Mammography Q131A Q141A
Exclusions apply for women who have had a mastectomy, or who are being treated for clinical breast disease.
Childhood Immunizations Q132A Not applicable
Colorectal Cancer Screening Q133A Q142A
Exclusions apply for patients with known cancer being followed by a physician; with known inflammatory bowel disease; who have had a colonoscopy within the last 10 years; with a history of malignant bowel disease; or with any disease requiring regular colonoscopies for surveillance purposes.

If you have changed your Electronic Medical Record (EMR) and are now with a different vendor, please ensure that the new EMR will accept claim submissions without a health number, date of birth and version code in preparation for submitting for the next preventive care bonus.

For any inquiries please contact the Service Support Contact Centre: 1-800-262-6524 or ServiceSupportContactCentre@moh.gov.on.ca


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