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Ontario Health Insurance Plan

OHIP Bulletins


INFOBulletin

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

To: All Providers

Published by: Claims Services Branch, Ministry of Health

Date Issued: January 2, 2020

Bulletin Number: 4737

Re: Kaplan Board of Arbitration Award - Appropriateness Working Group (AWG): Arthroscopic Knee Surgery

Posted Electronically Only

PDF Version


Claim Submission Rejections/Errors

Due to the staged implementation of new system processes, please note that some fee code combinations with service dates on or after October 1, 2019, may have rejected with the explanatory code DF during the month of October.

If the fee code combinations are consistent with new Schedule payment rules, these will be adjusted after November 1, 2019 and appropriate payments will be made.

These reconciliations will be documented on Remittance Advice reports after November 1, 2019. You will be notified through an INFOBulletin once the adjustment processing begins.

Kaplan Board of Arbitration Award - Appropriateness Working Group (AWG)

As directed by the February 2019 Kaplan Board of Arbitration Award, the Ministry of Health 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.

Recent changes to the Schedule of Benefits for Arthroscopy procedures have been implemented to promote appropriate medically necessary evidence-based care and are detailed and referenced within the schedule for physicians to read and apply. (N38-39).

Effective October 1, 2019, the ministry implemented the following changes to the Schedule of Benefits for Physician Services (the Schedule), as recommended by the AWG:

R687 has been redefined in the Schedule of Benefits (Schedule) Knee arthroscopy set-up for the treatment of degenerative disease of the knee only (subject to payment rules described subsequently).

Two new Fee Schedule Codes were created for the following clinical scenarios:

R699 – knee arthroscopy set-up, non-degenerative disorders of the knee or acutely locked knee.

E498 – Debridement (trauma) - substantial debridement of 1 or more focal flaps of unstable post-traumatic articular cartilage causing mechanical symptoms.

Allowable Fee Code Combinations:

NOTE: A knee procedure listed in the Knee section of the Schedule performed arthroscopically is eligible for payment in addition to R687 or R699 if that procedure is not described as a component of R699 or described by an E-add-on code to R699.

The following changes are for service dates on or after October 1, 2019. For service dates prior to October 1, 2019, claims will be processed through the payment system as per the payment rules in effect prior to this change.

Payment Criteria

R687: Degenerative disorders of the knee

R699: Non-degenerative disorders of the knee and acutely locked knee

Eligible for payment with the following E-add on codes

E494, E495, E476

E491, E492, E493, E495, E476, E478, E489, E496 or E498

Not eligible for payment with the following E-add on codes

E491, E492, E493, E478, E489, E496 and E498

E494

Explan codes

If a claim is submitted for R687 with an E-add-on code listed above (E498 excluded) the R687 will pay and the E-add-on code will pay at $0.00 with an explan code D7 – 'Not allowed in addition to other procedure'. If a claim is submitted for R687 with E498, the claim will pay at $0.00 with an explan code 'DF – Corresponding fee code has not been claimed or was approved at zero.'

D7 – ‘Not allowed in addition to other procedure’

DF – ‘Corresponding fee code has not been claimed or was approved at zero.’

 

R687 and R699 - R699 is not allowed in addition to R687. The R687 will pay and the R699 will pay at $0.00 on the providers remittance advice with explan code D7.

Prior Approval:

No prior approval is required for non-degenerative disorders or acutely locked knee arthroscopy (R699).

No prior approval is required for arthroscopy for degenerative disorders (R687, E494, E495) with x-ray evidence of mild osteoarthritis (Kellgen-Lawrence grade 2 or less) that meet the payment rule as outlined below. (N38 #5a and b).

  1. Kellgren-Lawrence knee osteoarthritis grade less than 3 as documented on standing knee x-rays performed within the last 12 months; and
  2. Unstable chondral pathology or meniscal tear causing mechanical symptoms which have not responded to a minimum of six months active non-surgical treatment.

The only code that requires prior approval is R687 (Knee Arthroscopy for Degenerative Diseases) with E494 (debridement) and E495 (partial or total meniscectomy) in patients with x-ray evidence of moderate to severe osteoarthritis (Kellgren-Lawrence Grade 3 or 4). These applications will be reviewed by a ministry medical consultant.

The Prior Approval Form, this form should be submitted to your OHIP Claims Offices Locations

Claims Adjustment/Further Inquiries:

Claims submitted with service dates on or after October 1, 2019, that were paid after October 1, 2019, will be adjusted accordingly to reflect payment rules in the Schedule. You will be notified through an INFOBulletin once the adjustment processing begins.

For details related to the AWG changes to the Schedule effective October 1, 2019, please refer to INFOBulletin # 4726.

For any further inquiries, please contact the Service Support Contact Centre at:
1-800-262-6524 or by email to Ministry of Health Service Support Contact Centre

For More Information

Call ServiceOntario, Infoline at:
1-866-532-3161 (Toll-free)
In Toronto, (416) 314-5518
TTY 1-800-387-5559.
In Toronto, TTY (416)327-4282
Hours of operation: Monday to Friday, 8:30am - 5:00pm

 
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