Systemic Health Care Reform and Physician Salary Freeze

The long awaited report from the Commission on the Reform of Ontario's Public Services has finally been released.  There are many issues addressed and many recommendations put forth, but basically the underlying recommendation is that Ontario should undertake major changes in the way health care is approached and delivered, while immediately imposing a physician wage freeze (based on statistics that Ontario physicians are now the highest paid in Canada).  Ballooning health care costs, despite sub-obtimal patient care and outcomes, are placing further strain on our already strained health care model.  One of the issues addressed in the report is disjointed delivery of care.

"Throughout this chapter, we have been referring to Ontario's collection of health care providers as a "system".  In reality, the province has a series of disjointed services working in many different silos.  The Ministry of Health and Long-Term Care (MOHLTC) must work with its health care providers, administrators and stakeholders to co-ordinate roles, simplify the pathways of care and improve the overall patient experience". 

"Simplifying the pathways of care" will ultimately mean that family physicians will be evermore undertaking the bulk of patient co-ordination".  Currently, one of the major factors driving up the costs of the health care system is chronic ER visits despite the level of acuity.  Those of us in the primary health care field understand that a significant amount of these "unnecessary" ER visits are often triggered by the inability to access care primary with the family physician.
 
"The system should be centered on the patient, not on the institutions and practitioners in the health care system."

In the last few years we have seen a big change in the handling of preventative care and health records, they will increasingly become major factors in health care reform movement.  Family Health Teams will also likely become the new wave of care in Ontario, due to the multi-disciplinary nature which also supports financial savings. 

"There should be a heightened focus on preventing health problems...". 

If you are a primary care provider and you haven't yet made it a habit to use the government preventative care tracking codes, you should.  Going forward, preventative/chronic care is only going to become more integrated, which also means more tracking will become necessary. 

"The primary goal for physician performance should be prevention and keeping people out of hospitals."

The recommendation, noted above, to tether physician performance (and ultimately income) to prevention and keeping people out of hospitals will mean further tracking systems will be rolled out in order to support OHIP billing.  At this point, using most tracking codes (Q codes) is not mandatory, however, to ensure you are maximizing your income --particularly in light of the coming changes -- you should be using this period of time to become as efficient as possible with using the tracking codes. 

While there are a few different salary/FFS models currently in operation, the reports recommends that the mix should ultimately land somewhere around 70 percent salary/30 percent FFS.  With the report strongly stating that the government should impose an immediate wage freeze, preventative care and chronic care service incentives will be what make a significant difference to your income. 

Are you utlizing tracking codes to your benefit?  If you aren't sure, then it's likely you're not.  Take the time now to better understand and utilize the tracking systems while it's still optional.  If you wait until it's mandatory you will lose income because your incentive income will depend on your efficient use of the tracking systems.

Whatever the changes will be, one thing is for sure, we know that there will be a decrease in funding and a rise in the level of care expected.  The next round of OMA negotiations should be interesting.  Get ready for sweeping changes...

To view the report in its entirely follow this link http://www.fin.gov.on.ca/en/reformcommission/chapters/ch5.html

K003 - Interview with Children's Aid Society (CAS) Billing Code

We have received some emails over the last year with questions, from non-members, regarding K003 (Interview With Children’s Aid Society (CAS) Billing Code) so we decided that we would pull our data from the billing database for all of our blog followers! 

Interviews are not to be claimed when the information being obtained is part of the history normally included in the consultation or assessment of the patient.  The interview must be a booked, separate appointment lasting at least 20 minutes.  K003 is billed per unit and unit means ½ hour or major part thereof - see related resources for definitions and time-keeping requirements at www.ombis.ca .

Interviews with Children’s Aid Society (CAS) or legal guardian on behalf of the patient in accordance with the Health Care Consent Act, conducted for a purpose other than to obtain consent.

K003 is claimed using the patient’s health number and diagnosis.  These listings apply to situations where medically necessary information cannot be obtained from or given to the patient or guardian, e.g. because of illness, incompetence, etc.

And, we almost forgot, K003 pays $62.75.

Q053 - Health Care Connect (HCC) Complex/Vulnerable Patient Billing Code

Q053 is payable at $350.00.  This code is applicable if you are a part of the Health Care Connect Program and accepting a patient, through the HCC program, deemed as being a complex and/or vulnerable patient.   You MUST be registered with the program PRIOR to claiming Q053.  For further  details on the HCC Program visit their website: http://www.health.gov.on.ca/en/ms/healthcareconnect/pro/default.aspx

This fee code is applicable for the following Billing Models:

1. Family Health Network (FHN);

2. Family Health Organization (FHO);

3. Rural and Northern Physician Group Agreement (RNPGA);

4. Community Sponsored Agreement Blended Salary Model (BSM);

5. Group Health Centre (GHC);

6. St Joseph's Health Centre (SJHC);

7. South Eastern Academic Medical Organization (SEAMO); and

8. Weeneebayko Health Ahtuskaywin (WHA)

9. Comprehensive Care Model (CCM); and

10. Family Health Group (FHG).

Ontario Medical Billing 2012 Schedule of Benefits Updates - Case Conferences

While I’m sure you’ve all received your email updates from the Ontario Medical Association, I’m also sure that we are all still getting our heads around all of the new codes in the 2011 Schedule of Benefits update!  We are still making changes and additions to the OMBIS Billing Module Database and will be sending emails to our membership shortly with some new great resources – but in the mean time we will start blogging about some of the new codes just to draw your attention to them so you can see whether or not it’s appropriate to start incorporating them into your practice.

One of the areas majorly affected by code additions and changes is case conferences.  The 2011 changes bring lots of revisions to the existing case conference codes and also lots of new codes for case conferences.  The case conference related codes are as follows:
K121 ($31.35) – Hospital In-Patient Case Conference
K700 ($31.35) – Palliative Care Out-Patient Case Conference
K704 ($31.35) – Paediatric Out-Patient Case Conference
K701 ($31.35) – Mental Health Out-Patient Case Conference
K702 ($31.35) – Bariatric Out-Patient Case Conference
K703 ($31.35) – Geriatric Out-Patient Case Conference
K707 ($31.35) – Chronic Pain Out-Patient Case Conference
K124 ($31.35) – Long-Term Care / CCAC Case Conference
K705 ($31.35) – Long Term Care – High Risk Patient Case Conference
K706 ($31.35) – Convalescent Care Program Case Conference

All of the appropriate changes regarding the above-noted codes have been made in the OMBIS Billing Module Database, so members can search away to see what the intended use for these codes are, as well as the appropriate billing instructions and rules entail.

We’ll be blogging over the next few weeks and drawing your attention to the significant changes and new codes that you should be aware of, so keep checking back!

Changes to the Schedule of Benefits

Based on recommendations of the Medical Services Payment Committee (MSPC), there are new changes being made to the Schedule of Benefits that become effective June 1, 2011.  There have been multiple changes made, however, of note are the following:

New Emergency Department Ultrasound Fee $19.65

A new ER ultrasound fee is to be introduced into the Schedule of Benefits when rendered for a patient that is clinically suspected of having at least one of the following life-threatening conditions:

Pericardial tamponade;

Cardiac standstill;

Intraperitoneal hemorrhage associated with trauma;

Ruptured abdominal aortic aneurysm; and

Ruptured ectopic pregnancy.

This fee will only be eligible to Emergency Department Physicians (see page GP40 for the definition of an “Emergency Department Physician”) when personally rendered and who meets standards for training and experience.

Pre-Operative Assessment $33.70

A new pre-dental/pre-operative assessment fee (A/C/W904) for specialists is to be introduced.  General and Family Practice, Pediatricians and Emergency Medicine specialists will remain eligible to bill A/C903 pre-dental/ pre-operative general assessment.

Deletion of Group 3 Plantar Verruca (fee codes Z169 – Z170)

Excising a plantar wart is not standard of practice and the appropriate service is layered excision with paring using chemical cautery or liquid nitrogen.  As such, Group 3 plantar verruca fee codes Z169 – Z170 are to be deleted. 

Weight Loss Services

Language is to be added to the Schedule of Benefits clarifying that monitoring effects resulting from calorie restricted weight loss programs are not insured benefits and should not be billed to OHIP. 

Clarification

Clarification of payment rules are to be noted for G489 Venipuncture, G372/G373 Intramuscular, subcutaneous or intradermal injections and G009/ G010 Urinalysis.

Pulmonary Function Tests

Language is to be added to the OHIP Schedule of Benefits clearly defining the service elements and record-keeping requirements of flow volume loop (J304 and J327) to reflect current professional standards (e.g., measurements with a scale on the tracing or graph of at least 5 mm per L per second for flow; and 10 mm per litre for volume and technical component of the study complies with CPSO Clinical Practice Parameters and Facility Standards for Diagnostic Spirometry and Flow Volume Loop Studies).

To see the update from OMA see: https://www.oma.org/Member/News/PresidentUpdates/Pages/PUVol16n23.aspx

Further details will be set out in a forthcoming OHIP Bulletin, which will be posted online.

Specific details of payment rules and medical record requirements will be described in the OHIP Schedule of Benefits and all of the new changes will be reflected on www.ombis.ca within the next few days.

Smoking Cessation Codes E079 & K039

We received a request through our chat forum (http://www.ombis.ca/) to breakdown the smoking cessation codes - so here goes!

The most confusion we have encountered when it comes to these codes is the order and appropriateness of the billing.  Before K039 can be billed you MUST first bill E079 but it isn't as simple as just billing E079.  E079 is billed in conjunction with another code (i.e. A001, A003, A007 - see billing modules for more associated codes).  The reason that the E079 has to be billed first is because E079 is for the initial discussion with the patient regarding smoking cessation and this initial conversation would generally be raised by the physician while the patient was attending clinic for another reason.  E079 is to be rendered by the primary care physician most responsible for the patient's ongoing care and, obviously, to a patient who currently smokes.  E079 is limited to a maximum of one service per patient, per 12 month period.

In terms of record keeping, the medical record must document that an initial smoking cessation discussion has taken place, by either completion of a flow sheet (smoking cessation flow sheet) or other documentation consistent with the most current guidelines of the Clinical Tobacco Intervention program or this service is NOT eligible for payment. Physicians may complete the flow sheet or alternatively document that an initial discussion consistent with the 5A's model of the CTI program has taken place.

Once you have seen the patient for the initial discussion (and appropriately documented as noted above) and billed E079 you can now have the patient book for their smoking cessation appointment for followup following which, you will be able to bill K039.  "Smoking Cessation Follow-Up Visit" is the service rendered by a primary care physician in the 12 months following E079.  The K039 appointment is dedicated to a discussion of smoking cessation, in accordance with the guidelines.  The same charting conditions as noted in the paragraph above for E079 also apply for K039.

K039 is only eligible for payment when E079 is payable (and has been paid) to the same physician in the preceding 12 month period.  K039 is limited to a maximum of two services in the 12 months following E079.
Both E079 and K039 are outside of the basket for FHO and FHN physicians.

It has been noted that some physicians are having difficulty claiming E079 with certain diagnostic codes and the MOHLTC is currently working to resolve this. A notice will be issues with any forthcoming information regarding this issue and updates will be posted on the OMA website.  *We haven't received a recent update on this issue and we are unsure as to the current status.

A good resource to find the required form and/or charting criteria noted above is  http://www.omacti.org/

E083 - Subsequent Visit Code

E083 is a code that we receive a lot of questions about and seems to be one of the many codes surrounded by confusion, so we decided to do a specific breakdown for everyone:

E083  - "subsequent visit by the MRP to subsequent visits and specific associated codes". 

E083 is a 30% increase to the associated code.  A few of the codes that can be associated with E083 are C002, C003, C007, C009, C132, C137, C139 - for an exhaustive listing of associated codes OMBIS members should search E083 under billing modules.

E083 is not eligible for payment with C121 additional visits for intercurrent illness.

E083 is only eligible for payment once per patient, per day, and E083 is only eligible for payment if:

a. The physician establishes that he/she does not receive any direct or indirect remuneration from a hospital or hospital foundation for rendering in-patient clinical services; or

b. Where the physician receives any direct or indirect remuneration from a hospital or hospital foundation for rendering in-patient clinical services, if the physician establishes that such remuneration has been reduced by an amount equal to the amount that would be eligible for payment to the physician had he or she not received any such direct or indirect remuneration.

E083 is not eligible for payment for palliative care visits to patients in designated palliative care beds in Long-Term Care Institutions.

E083 is only eligible for payment with subsequent visits and palliative care visits rendered by the Most Responsible Physician. E083 is not applicable to any other service or premium.

Examples of subsequent visits eligible for payment in association with E083 are C002, C007, C009, C132, C137, C139, C032, C037 or C039.

Ontario Medical Billing Code Confusion!

Anyone motivated to search out this blog already agrees with the following statement "Ontario medical billing codes are one of the most complicated and confusing systems to have ever graced the face of this planet."  So, like us, you want to simplify things but what can you practically do?  Go to the Schedule of Benefits?  Contact a colleague?  Both are valid options, though wouldn't it be much more efficient for everyone if we could combine both options PLUS resources in one place, then save the information and resources in an accessible and searcheable database for when the information is needed, on demand?  This is the goal of OMBIS Inc., and if you are reading this blog, and work within the medical billing system (or medical system at all) you probably agree!  So what can you do to support us so that we can, in turn, support you?  Tell your friends about this blog!  Let's get everybody openly discussing and understanding the mechanics of the medical system so that we can easily increase income the right way, based on work already done.  If there is a topic that you want us to tackle or research then let us know feedback@ombis.ca and send this link to your friends so we can continue to connect all of your colleagues to work towards a goal of all medical issues being touched on under one resource made for the medical community.  Work smarter, not harder!