Ontario Health Insurance Plan

Schedule of Laboratory Fees – Preamble

Specific Elements

In addition to the common elements, (see General Preamble to the Schedule of Benefits, Physician Services under the Health Insurance Act), all services listed under Laboratory Medicine from L001 to L699 (including L900 codes), L701 to L799 and under the "Laboratory Medicine in Private Office" listings in the Diagnostic and Therapeutic Procedures Section of the Schedule, when performed by a physician for his/her own patients, include the following specific elements:

  1. Carrying out the laboratory procedure, including collecting specimens where not separately billable, and processing of specimens.
  2. Interpreting and/or providing the results of the procedure, where not interpreted by a physician under an L800 code, even where the interpreting physician is another physician.
  3. Discussion with and providing advice and information to the patient or patient's representative(s), whether by telephone or otherwise, on matters related to the service.
  4. Providing premises, equipment, supplies and personnel for the specific elements and for any aspect(s) of the specific elements, of any service(s) covered by a corresponding L800 code that is(are) performed at the place in which the laboratory procedure is performed.

Other Terms and Definitions

  1. The patient documentation and specimen handling benefit (see code L700 below) is applicable to all insured procedures, except for those listed under anatomical pathology, histology and cytology, the fees for which cover any administrative cost. This benefit is not applicable to referred-in samples, since the collecting laboratory will already have claimed the patient documentation and specimen collection benefit.
  2. The biochemistry section has been condensed so that one listing refers to a procedure for any of amniotic fluid (A), blood (B), CSF (C), faeces (F), gastrointestinal fluid (G), urine (U). Exceptions are indicated by B, U, etc., following the test name. Other specimens will be considered on an 'IC' (independent consideration) basis.
  3. A number of tests are listed in different sections of Laboratory Medicine, i.e., where more than one method of performing the test is available.
  4. Blood glucose by the dipstick method may be claimed only when assessed by an appropriate instrument such as a reflectance meter. It should not be claimed when used only as a check on the fasting blood sample of a glucose tolerance test. The blood glucose of the fasting sample in a glucose tolerance test is allowable only once even if assessed by two methods.
    Note: A standard glucose tolerance test for the diagnosis of diabetes mellitus is performed over 2 hours and includes 5 blood glucose (L104) and one urine glucose determination (L253). If the patient is pregnant, only 4 blood glucose specimens (L103) should be taken at hourly intervals (see CMAJ 126, 473 (1982)). When 5 hour glucose tolerance test is specifically ordered the blood glucose measurements are to be claimed individually (L111). Only one L253 may be claimed with a glucose tolerance test.
  5. Code L417 or L418 may not be claimed by a physician in addition to claim(s) for any treatment or assessment. However, Code G481 in the Diagnostic and Therapeutic Procedures Section may be claimed by a physician if a hemoglobin screen (any method or instrument is carried out in the course of an office or home visit. Urinalysis may be claimed with or without an associated visit to a physician's office (except for screening and urinalyses which are not medically necessary).
  6. When a screening culture method (e.g., Agar spoon) is used on a urine sample, L641 refers to a culture technique and does not apply to those kits using the nitrite test only. Where a significant growth is obtained and followed up by definitive identification methods, L633 or L634 only should be claimed. The benefits for L633 or L634 include any necessary microscopic examination of the urine. However, urine examination by microscopy may be claimed in addition to L633 or L634 if the authorized practitioner has specifically ordered the former and receives a report from the laboratory.
  7. Only those tests which are requested are to be claimed for with the following exceptions. It is intended that if the requested test yields abnormal findings or information which would be incomplete, insufficient or meaningless to the authorized practitioner, the medical director of a laboratory may add further appropriate tests and claim for them with the knowledge he/she may have to substantiate their justification.
  8. A test must be completed in accordance with the pertinent schedule listing in order to claim for it. The verbatim listing is intended as the definitive benefit for that test alone, unless otherwise specified, e.g., isoenzymes do not include total enzyme estimation; creatine does not include creatinine (as specified). Notwithstanding the foregoing and recognizing that it is impossible to list all variations in techniques of all listed tests, when there is a modification of the usual technique, the listing most closely approximating it should be used.
  9. This schedule, with the exception of L036, lists actual procedures performed. No claim shall be made for calculated values made and reported, or for control tests or repeat tests on same patient sample.
  10. Creatinine is a justifiable addition in the case of tests on 24-hour urine samples, where it is necessary to assess the sample as a complete 24-hour collection. However, if several tests (e.g., steroids) are done on a single such sample, only one creatinine would be claimed for that sample. In those estimations where the test result is expressed in terms of creatinine excretion the performance of a creatinine is mandatory and should be claimed.
  11. It is recognized that in requests for a serologic titre, if a screening test is used and would suffice, the lesser benefit for the screening test should be claimed. If positive and followed by serial titration, both the screening and titre fees should be claimed. If the titration is a micro technique using plates, it is the equivalent of a tube titre, the wells being miniature tubes.
  12. When a test for trichomonas identification (any method) is carried out in association with L625 or L627, wet preparation (L653) may be claimed in addition. L653 may be claimed when a wet preparation is used for direct examination of a fresh specimen for amoebae or similar parasites. However, the wet preparation used in the faeces concentration technique for parasites and ova is included in L650. The conditions set down in paragraph 7 of this preamble must be adhered to.
  13. It is recognized that in all laboratory tests there is a professional component.
  14. Complete Blood Count includes WBC Differential (L372), Platelet Count (L396), RBC Count (L397), WBC Count (L399), Hematocrit (L417), and Hemoglobin (L418). When one or more of these tests are ordered, claim L393, not the individual codes. Perform and report results for all six tests. The maximum number of LMS units which can be claimed per patient per day is 16. L700 is not included in this total and should be claimed separately, if appropriate.
  15. The maximum number of units which may be claimed for any combination of chemical analyses performed on a single sample by means of an automated chemical analyzer with simultaneously functioning channels is 5 LMS units (L225).
  16. The following preamble applies to the immunohematology section:
    1. L471 Antibody identification fee is per specimen regardless of method used. Preparation of eluate and/or antibody absorption is included.
    2. L473 Parallel Titration – to be used when two sequential patient serum specimens are tested to detect a change in antibody titre. Includes a repeat antibody identification on the current sample.
    3. L490 Blood Group – ABO and RhD. The subgroups of A and weak RhD phenotype are included where indicated. A direct AHGT is also included in L490, therefore L495 may not be claimed on the same patient when this code is claimed.
    4. L492 Crossmatch. When an initial crossmatch is requested, the appropriate claim is for L490 × 1, L482 × 1 plus L492 for each unit ordered. L490 and L482 may not be claimed more than once on the same day of service. L490 and L493 may not be claimed when these procedures are carried out as a confirmatory test on the units of blood to be transfused.
    5. L493. This code includes L490 [see Preamble, paragraph 16(c)] and Rh phenotype as well as antigens C, D, E, c, e, and weak RhD phenotype when indicated. Any other antigen is to be claimed under L494.
    6. L494 Blood Group per antigen. Antigens stated in L490 and L493 are excluded from this code.
    7. L495 Direct AHGT – can be used when ordered as a single procedure, or in addition to L482 when the latter is requested as a single procedure. L495 may not be claimed when L490 or L493 is claimed with L482 on the same patient, on the same visit.
  17. Code L623 refers to a specific request for the minimal inhibitory concentration (MIC) of an antimicrobial agent required to inhibit or kill a micro-organism, expressed in units or µg/ml, using multiple/serial dilutions of the antimicrobial agent. L623 must not be used as a routine antibiotic sensitivity test and does not include breakpoint susceptibility testing using manual kit or automated methodologies.
  18. The use of Nickersons Medium as a screening test for yeast is not a benefit.
  19. The carcinoembryonic antigen test (CEA) L690 is an insured service only when carried out in accordance with Cancer Care Ontario guidelines for following established malignancies, and not as a general cancer screen.
  20. The benefit for seminal fluid examination (complete) is to include sperm count, volume estimation, motility, morphology and viscosity.
  21. Fees for laboratory medicine testing are not to be paid (in whole or in part) to the referring practitioner by the laboratory performing the tests.
  22. The benefits for patient documentation and specimen collection and each test are calculated by multiplying the individual LMS Unit values by 51.7 cents effective October 1, 1989.
  23. Laboratory tests on specimens sent outside Ontario are not an insured benefit unless prior approval is obtained from the Ministry of Health.
  24. Secondary laboratories receiving specimens for additional (secondary) tests from another laboratory that normally would be claimed as L303, L319, L500 or L544 should be claimed as L903, L919, L900 or L944 respectively.
  25. When a pregnancy test is requested, L655 should be performed. L318 should only be performed, when H.C.G. or Beta sub-units are specifically requested by the authorized practitioner.
  26. The maximum number of units which can be claimed for the combination of L055, L153 and L243 is 30 units per patient per day. The maximum of 30 units applies on a per patient basis, regardless of the number of specimens submitted and regardless of the number of laboratories involved performing the test. Code L700 is not included in this maximum and should be claimed separately if appropriate.
  27. The following codes cannot be claimed when the tests are done, either individually or in any combination, for fetal assessment: L311, L318, L691.
  28. Codes L319 and/or L919 cannot be claimed when done for prenatal assessment.
  29. The fee for L575 must include a gammopathy screen using antisera to the individual immunoglobulins (IgG, IgA, IgM) as well as both Kappa and Lambda Light Chains. In the event that further antisera are required to type the paraprotein, the fees for these extra antisera are included in the 120 units for L575. L080/L085/L086 are not justifiable add-ons to code L575. Code L575 should not be used for qualitative determinations of acute phase proteins. Requests of this type should utilize code L085 - Protein Electrophoresis or specific protein determinants as requested, e.g., Transferrin (L554), Ceruloplasmin (L553), Alpha 1 antitrypsin (L555). In appropriate cases when clinically indicated based on the results of the immunoelectrophoresis test, and with written approval of the medical director of the laboratory, code L550 Immunoglobulin quantitation may be a justifiable add-on to L575.
  30. L720 surgical pathology billable per block of tissue processed to a maximum of 8 per patient per day, regardless of the number of specimens received. The laboratory must meet the standard of practice that the number of blocks processed is the minimum required. Normally additional blocks would be required only if the amount of tissue exceeds the available space in the cassette or the pieces of tissue must be separately identified. Additional work required is not billable, e.g.;
    • Special Stains,
    • Deeper Sections,
    • Block Rotation,
    • Block Retrieval,
    • Decalcification.

Note: Claims for laboratory services, when referred by a Dentist, Osteopath, Chiropodist or Chiropractor are not insured services.


LMS

Code Units

L700 patient documentation and specimen collection fee

See Preamble, paragraphs 1, 14 & 26

  1. Limited to 1 per patient, per day.
  2. Not allowed to the recipient of a referred sample from another laboratory.
  3. Not allowed to the attending physician.
  4. Not applicable to a patient visit solely to receive instructions or collection containers.
  5. When multiple tests are ordered for the same patient, for the same day, only one L700 may be claimed even though all specimens may not be available on any one day.
  6. Not applicable to items under anatomical pathology, histology and cytology sections (Fee Codes L701 to L733 inclusive, L800 – L848 or L900 – L944 inclusive).

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