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How to Submit Claims for After-Hours Non-Elective In-Hospital Services

Effective April 1, 2000, after-hours non-elective hospital services provided during evenings, nights, weekends and holidays, as defined in the General Preamble B.11, have been exempt from threshold reductions. In order to process your after-hours non-elective in-hospital claims and calculate your threshold amounts accurately.

i.       Enter all in-hospital after-hours non-elective services and associated services that are rendered to the same patient on the same claim record. Otherwise, the associated service will not be exempted from the physician's threshold income calculation.

ii.      Do not include any other service on this claim record.

iii.    Enter the hospital number on the claim record. Claims submitted without a valid hospital number will not be exempted from the physician's threshold income calculation.

If you failed to submit an associated service on the same claim record and, as a result, did not receive a threshold exemption on that service, contact your District Office to have the matter corrected.

1.5    Update to Schedule of Benefits

The following fee codes have been revised, added or deleted from the Schedule of Benefits to reflect changes in medical practice and currently accepted standards of practice and to enhance patient care. A fee code is deleted when the service is replaced by a newly insured service, is no longer medically necessary or is obsolete.

Fee Code

Descriptor
Newly added text that modifies conditions of payment is underlined.
Deleted text is indicated by strike-though.

New (N) Revised (R) Deleted (D)

After-Hours Premium (General Preamble B.25)

E409/E410

Applicable in addition to the fees listed for Non Elective Surgical Procedures… Air-Ambulance Transfer (K111); and Transport of Donor Organs (K102)

 

R

Allergy (Diagnostic and Therapeutic Procedures)

G208

Serial oral (not sublingual) and parenteral provocation testing for food colours… test administration (maximum 5 sessions per year). Unit means 1 hour or major part thereof. See General Preamble for definitions and time-keeping requirements per test, per unit.

 

R

Anesthesia (General Preamble B.22 and Diagnostic and Therapeutic Procedures)

E014C

-          newborn patient up to and including 28 days, add

2 units

N

E009C

-          29 days to1 year, add

 

R

E010C

-          patient with body mass index (BMI) > 45, add

2 units

N

Z432

Specific Elements for Examination Under Anesthesia (EUA)

A.     While this may be performed for diagnostic purposes, the specific elements are those for a therapeutic procedure.

B.     EUA is payable only if sole procedure performed by examining physician. EAU claimed in conjunction with any other procedure is payable at nil.

C.     Claims for EUA submitted without the applicable diagnostic code are payable at nil.

 

R

 

EUA with or without intubation and may include removal of vaginal foreign body.

 

 

Cardiovascular (Diagnostic and Therapeutic Procedures)

#G298

Coronary angioplasty stent. Note:  J058 claimed same patient same day as G298 is payable at nil.

$70.75

N

G502

Carotid phonoangiography - professional component

 

D

G503

Oculoplethymography - professional component

 

D

G504/G505
/G506

Phonocardiogram - multiple channel with pharmacological intervention

 

D

G507/G508

Apex cardiogram

 

D

Cardiovascular (Surgical Procedures)

#E652

Use of internal mammary, epigastric or radial artery for construction of bypass graft

 

R

#R940

Pulmonary thromboendarterectomy (PTE) - includes circulatory arrest with hypothermia (18 assistant / 28 anesthetic base units)

$1961.80

N


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