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Ontario Health Insurance Plan

OHIP Bulletins


INFOBulletin

Keeping Health Care Providers informed of payment, policy or program changes

To: Primary Care Physicians

Published by: Negotiations Branch, Ministry of Health

Date Issued: August 22, 2019

Bulletin Number: 11214

Re: Kaplan Board of Arbitration Award - Appropriateness Working Group (AWG):
Changes to the Schedule of Benefits for Physician Services (Schedule) effective October 1, 2019

Posted Electronically Only

PDF Version


As directed by the February 2019 Kaplan Board of Arbitration Award, the ministry and the Ontario Medical Association (OMA) formed the Appropriateness Working Group (AWG) with a mandate to use evidence, best practices and expert opinion to identify and update the delivery of certain services to help ensure the most effective care for Ontario patients.

For details related to the AWG changes to the Schedule of Benefits (the Schedule) effective October 1, 2019, please refer to INFOBulletin # 4726 Kaplan Board of Arbitration Award - Appropriateness Working Group (AWG): Changes to the Schedule of Benefits for Physician Services (Schedule) effective October 1, 2019.

Primary Care Changes

This bulletin outlines the impact of the Schedule changes on primary care payments. The changes involve new fee codes and removed fee codes.

New Fee Codes

The following new codes have been added to the Schedule effective October 1, 2019. Further information regarding the implementation dates for each of these changes will be forthcoming.

G694, G695, G696 - Level 2 Continuous Cardiac Monitoring, 14 or more days recording (e.g., Holter Monitors)

  • The above codes are considered Core Services for the following primary care models:
    • Aboriginal Family Health Team
    • Blended Salary Model
    • Group Health Centre
    • St. Joseph’s Health Centre
    • Sioux Look Out Regional Physician Services
    • Rural and Northern Physicians Services Agreement – Group 1
    • Rural and Northern Physicians Services Agreement – Group 2
    • Weeneebayko Area Health Authority
  • If any of the three new codes are submitted by a physician in any of the above models with a service date equal to or greater than October 1, 2019, the claim will pay $0, with explanatory code I2 – Service is globally funded.

Z292, Z293 – Laryngoscopy

  • The list of Excluded Codes for the Group Health Centre (GHC) has been updated to include the two new fee codes, effective October 1, 2019.
  • If either of the two new codes are submitted by a physician in the GHC with a service date equal to or greater than October 1, 2019, the claim will pay FFS.

R699 - Knee Arthroscopy - (for non-degenerative disorders or acutely locked knee)

  • The Excluded Code lists for the Group Health Centre (GHC) and for St. Joseph`s Health Centre (SJHC) have been updated to include the new fee code, effective October 1, 2019.
  • If this code is submitted by a physician in the GHC or SJHC with a service date equal to or greater than October 1, 2019, the claim will pay FFS.

E498 - Knee Debridement - (debridement of focal, symptomatic post-traumatic cartilage flap)

  • The Excluded Code lists for the Group Health Centre (GHC) and for St. Joseph`s Health Centre (SJHC) have been updated to include the new fee code, effective October 1, 2019.
  • If this code is submitted by a physician in the GHC or SJHC with a service date equal to or greater than October 1, 2019, the claim will pay FFS

Fee Codes Removed

The following codes have been removed from the Schedule effective September 30, 2019. There are no impacts on primary care payments.

  • A904 - Pre-Dental/Pre-Operative Assessment
  • G364 - Post-Coital Mucous Test
  • G690 - (professional fee) Cardiac Loop Monitoring
  • G692 - (technical fee) Cardiac Loop Monitoring
  • G660 - (professional fee) Event Recorder
  • G661 - (technical fee) Event Recorder
  • X008B - (technical fee H-fee and facility fee) Sinus Radiographs
  • X008C - (professional fee) Sinus Radiographs

The following codes have been removed from the Schedule effective September 30, 2019 and will have the following impacts on primary care payments.

  • A901 – House call assessment

House call assessment A901 is an Included Code for the Family Health Organization (FHO), and will be removed from the Included Code list of services for Regular enrolled patients effective September 30, 2019.

A901 will be removed from the list of fee codes eligible for the Home Visits Special Premium.
A901 will also be removed from the list of fee codes eligible for the Annual Complex House Calls Assessment Premium.

  • A903 - Pre-dental/pre-operative general assessment

Pre-operative assessment A903A is an Included Code for the Family Health Network (FHN) and Family Health Organization (FHO), and will be removed from the Included Code list of services for Regular and Long-Term Care enrolled patients effective September 30, 2019.

  • Z321 - Laryngoscopy – with or without biopsy

Laryngoscopy – with or without biopsy is an Excluded Code for the Group Health Centre.  This code will be removed from the Excluded Code list effective September 30, 2019, and will no longer pay fee for service (FFS).

If any of the above removed fee schedule codes are submitted with a service date equal to or greater than October 1, 2019, they will be rejected to the error report - A3E “No Such F.S. Code”.

If any of the above removed fee schedule codes are submitted with a service date prior to October 1, 2019, they will be processed through the payment system as per the payment rules in effect prior to this change.

For any further inquiries, please contact the Service Support Contact Centre at 1-800-262-6524.


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