Education and Prevention Committee Billing Briefs

Education and Prevention Committee (EPC) Billing Briefs are prepared jointly by the Ministry of Health (MOH) and the Ontario Medical Association (OMA) to provide general advice and guidance to physicians on billing matters.

Category: All specialist physicians  
Date of publication: March 6, 2026

Claims Tip: As a general principle, physicians with more than one specialist designation should submit claims based on the nature of the service provided and using the specialty designation which aligns most appropriately with the service provided.

Billing for specialist services

  • A specialist physician is a physician who holds a certification issued by the Royal College of Physicians and Surgeons of Canada (RCPSC) or meets one of the other criteria outlined on page GP5 of the Schedule.
  • Specialist physicians may only submit claims for payment to OHIP for specialty visits using the consultation and assessment fee codes that are listed in the specialty section of the Consultations and Visits section of the Schedule that begins on A72.
  • Specialist consultation and assessment claims are only payable if the service is rendered by a physician with the appropriate specialist designation, and the claim is submitted using the fee code that corresponds to their specialist designation and to the service provided.
  • When a service rendered by a specialist does not fall within the scope of the specialist's practice and/or the specialist is providing primary care in a family or general practice setting, as noted in the General Information section of the General Preamble, the service is only eligible for payment when the claim is submitted using the appropriate code from the "Family Practice & Practice in General" listings within the Schedule.

Specialists with more than one specialty designation

  • Specialists who hold a RCPSC certificate in more than one specialty should select the fee code from the Consultations and Assessments section of the Schedule for the specialty designation that best represents the insured service provided.
  • Note that fee codes for diagnostic, therapeutic and surgical procedures are generally not restricted by specialty but should only be claimed by physicians with the appropriate skills and training.
  • When more than one consultation or assessment is rendered to a patient during the same visit by the same physician who holds a certificate in one or more specialties, only one consultation or assessment is eligible for payment.

Examples

Example 1a

Dr. Shand, who has RCPSC specialty certifications in both paediatrics (OHIP specialty 26) and clinical immunology and allergy (OHIP specialty 62), provides a consultation for a 32-year-old nurse with a suspected latex allergy at the request of the patient’s primary care provider.

What fee code is eligible for payment to Dr. Shand for this consultation?

Explanation:

  • The insured services provided to this adult patient are consistent with clinical immunology and allergy rather than paediatrics.
  • A625 (Consultation) from the clinical immunology and allergy (OHIP specialty 62) section of the Schedule is eligible for payment to Dr. Shand.
  • While the Schedule does describe limited circumstances where a physician with a specialty designation in paediatrics (OHIP specialty 26) may claim services for adult patients using Paediatric visit listings (page A155), this patient does not meet the required criteria.

Example 1b

Dr. Shand assesses one of her pediatric patients with an established history of diabetes. The patient has recently been discharged from hospital following elective surgery and has been having some difficulties with blood sugar control.

What fee codes are eligible for payment to Dr. Shand for this visit?

Explanation:

  • The insured services provided are most consistent with pediatrics.
  • A263 (Medical specific assessment) from the paediatrics (OHIP specialty 26) section of the Schedule is eligible for payment to Dr. Shand, provided that the limits for this service for this patient have not been exceeded for the year as described on page GP23 of the Schedule.
  • As the visit is an eligible office-based assessment described on page GP25 of the Schedule and relates to an established diagnosis of one of the chronic diseases listed on page GP26 of the Schedule, the chronic disease assessment premium (E078A) is also eligible for payment.

Example 2a

A 79-year-old male, Mr. Soo, presents to the emergency department with acute abdominal pain and distension. The emergency department physician requests a general surgery consultation.

Dr. Hopper, who has RCPSC specialty certifications in both critical care medicine (OHIP specialty 11) and general surgery (OHIP specialty 03), is on call for general surgery, provides a consultation, and arranges for an urgent surgical procedure.

What fee code is eligible for payment to Dr. Hopper for this consultation?

Explanation:

  • The insured services provided are most consistent with general surgery.
  • A035 (Consultation) from the General Surgery (OHIP specialty 03) section of the Schedule is eligible for payment to Dr. Hopper.
  • Even though Dr. Hopper is also qualified as a critical care physician, Dr. Hopper is providing insured services as a general surgeon, therefore critical care consultation and assessment fee codes are not eligible for payment for this visit.

Example 2b

Two days following Mr. Soo’s admission and surgical procedure, Dr. Hopper is working as the attending critical care physician in the intensive care unit (ICU) where Mr. Soo remains on a ventilator.

What fee code is eligible for payment to Dr. Hopper for care provided to Mr. Soo when working as the attending ICU physician on this day?

Explanation:

  • The insured services provided are described in the General Practice/Practice in General section of the Schedule.
  • The appropriate per diem fee from the Critical Care section of the Schedule, in this case G558A (Physician-in-charge, 2nd to 30th day) for 24-hours of care, provided is eligible for payment to Dr. Hopper. Dr. Hopper should claim this code using OHIP specialty 11.
  • Assessments from the General Surgery (OHIP specialty 03) and Critical Care (OHIP specialty 11) sections of the Schedule are not eligible for payment in addition to the per diem fee.

Example 2c

While working as the attending physician in the critical care unit, Dr. Hopper is called to assess a patient on the internal medicine floor with an acute worsening of clinical status. Dr. Hopper provides a consultation and determines that the patient does not require transfer to the intensive care unit.

What fee code is eligible for payment to Dr. Hopper for this consultation?

Explanation:

  • The insured services provided are most consistent with Critical Care.
  • A715 (Consultation) from the Critical Care (OHIP specialty 11) section of the Schedule is eligible for payment to Dr. Hopper.

Example 3

Dr. Blount is an Emergency Medicine specialist (OHIP specialty 12) with additional training in critical care, but no additional formal RCPSC Critical Care Medicine specialty certification.

While working as the attending physician in the critical care unit, Dr. Blount is called to assess a patient on the surgical ward with an acute worsening of chronic obstructive pulmonary disease (COPD). She provides a consultation and determines that the patient does not require transfer to the intensive care unit at this time.

What fee code is eligible for payment to Dr. Blount for this consultation?

Explanation:

  • As Emergency Medicine (OHIP specialty 12) consultations are restricted to physicians on duty in the emergency department, a consultation code that reflects the assessment performed (for example, A005 or A905) from the "Practice in General" section of the Schedule is eligible for payment to Dr. Blount.
  • Even though Dr. Blount works as a critical care physician, Dr. Blount does not have RCPSC certification in this area and therefore may not claim consultations/assessments from the Critical Care Medicine (OHIP specialty 11) section of the Schedule.

Additional information:

  • Note that if a physician does not hold the RCPSC Critical Care Medicine sub-specialty certification but believes they are eligible, they may contact the College of Physicians and Surgeons of Ontario (CPSO) directly to request an assessment of their eligibility.
  • Once eligibility is confirmed, physicians may request registration of the new OHIP billing designation by sending an email to the MOH's Provider Registration Services Unit at ProviderRegistration.MOH@ontario.ca

Keywords/Tags

OHIP Claims; OHIP Payment; Assessment; Consultation; Specialty; Specialist

More information

Understanding the Schedule of Benefits

Claims contact information

For additional information, please visit the Resources for physicians and the How to get help with billing questions pages on the ministry website.

If you have any billing or claims submission inquiries, please contact the Service Support Contact Centre (SSCC) by email at sscontactcentre.moh@ontario.ca or by calling 1-800-262-6524.

To provide feedback on EPC Billing Briefs, or to suggest topics for future EPC Billing Briefs, send an email to the attention of the joint Ministry of Health/OMA Education and Prevention Committee at info@oma.org.