Emergency Department Special Visit Premiums

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: Emergency Department Physicians, all physicians providing services in an emergency department   
Date of publication: March 6, 2026

Key requirements — Special Visit Premiums

• A special visit means a visit initiated by a patient or an individual on behalf of the patient for the purpose of rendering a non-elective service.
• A non-elective visit is unscheduled. While the patient's concern may not require immediate attendance, it requires a visit with the patient on an urgent basis, typically within several hours of the request.
• All special visit premiums are subject to the maximums, limitations, and conditions set out in the applicable table in the Special Visit section of the General Preamble.
• Special visit premiums are only eligible for payment when rendered with certain services listed under "Consultations and Visits" and "Diagnostic and Therapeutic Procedures" sections of the Schedule, if they are not excluded as described below.
• Special visit premiums are not eligible for payment with services described by ED assessment and consultation "H" prefix fee codes.
• A travel premium is only eligible for payment for travel from one location to another location ("the destination") subject to the following:
  • A travel premium is not eligible for payment when a physician is required to travel from one location to another within the same long-term care facility, hospital complex or within buildings situated on the same hospital campus.
  • A hospital corporation may comprise multiple geographically separated campuses. In this case, a travel premium is eligible for payment for eligible travel between these campuses.
  • Only one travel premium is eligible for payment for each separate trip to a destination regardless of the number of patients seen in association with each trip.

Common claims concerns

• Submitting claims for special visit premiums that are not eligible for payment, such as:
  • when arriving early for a scheduled ED shift when early arrival to attend to a patient has not been requested
  • for patients seen during rounds at a hospital
  • with admission assessments of patients who have been admitted to hospital on an elective basis
  • for a visit which critical care team fees are payable under the Schedule
• Not documenting the time that the special visit takes place (or was requested) or the specific situation which required the physician's attendance on the medical record for each patient seen.
  • Note that when a special visit service occurs in a hospital, ED or long-term care institution where common medical records are maintained, the time when the visit takes place may be documented anywhere in the common medical record.

Emergency Department Physicians in the Emergency Department

For the purpose of special visit premiums under the Schedule heading Emergency Department Physician, an "Emergency Department Physician" means a physician:

• who on a day when the physician is scheduled to work in a hospital ED specifically for the purpose of rendering services to patients who attend the ED for physician services,
  • is requested by the ED to attend at a time when the physician is not otherwise scheduled to work in the ED, and
  • who is not at the hospital at the time the ED request for attendance is made, or
• is on-call on a scheduled basis specifically to be available to a hospital ED to render services to patients who attend the ED for physician services and who is not at the hospital at the time the ED request for attendance is made.

Emergency Department Physician Special Visit Premium Table

For Emergency Department Physicians (as defined above), the restrictions applicable to special visit premiums are listed in the Schedule under Special Visit Premium Table V (Schedule page GP74).

Please refer to the current version of the Schedule for fee payment values.

If the Emergency Department Physician is already present at the hospital but working in a location other than the Emergency Room (for example, making rounds on inpatients) at the time the ED request for attendance is made, special visit H prefix code(s) for first patient and or additional patient seen are not eligible for payment. The physician may claim the appropriate H-prefix assessment code(s) for services provided, subject to Schedule requirements.

If the "on duty" Emergency Department Physician is called to a hospital in-patient ward on a non-elective basis, the General Listings ("A" prefix) apply, and "C" prefix first person seen/additional person seen special visit premiums from Table III (Schedule page GP72) may be eligible for payment.

Other Special Visits to the Emergency Department

When special visits are rendered to the ED by physicians who do not meet the Schedule definition of Emergency Department Physician referenced above (example, a specialist physician not scheduled to work in the ED or is not on-call as an Emergency Department Physician, who attends to complete a consultation or other service), the restrictions applicable to special visit premiums are listed in the Schedule under Special Visit Premium Table I (Schedule page GP70).

Please refer to the current version of the Schedule for fee payment values.

Examples

Example 1

Dr. Baker is at home on Saturday when she receives a call at 3:30 p.m. from the Charge Nurse on behalf of the emergency department physician on duty, requesting Dr. Baker to attend the emergency department earlier than scheduled to assist with high patient volume. Dr. Baker is scheduled for an emergency department shift beginning at 6:00 p.m. later that day.

Dr. Baker agrees, commutes from her home to the hospital, and begins seeing patients in the emergency department at 4:00 p.m., subsequently seeing 12 patients over the 2-hour period in advance of her scheduled shift.

Dr. Baker documents the time of the request to attend the emergency department (3:30 p.m. call from the Charge Nurse on behalf of the ED physician) and the situation which required the attendance (high patient volume) in the medical record for each patient.

What fee codes are eligible for payment to Dr. Baker?

Explanation:

• As Dr. Baker satisfies the definition of Emergency Department Physician, Special Visit Premium Table V fee codes are eligible for payment, including:
  • H963 x 1 for travel to the hospital
  • H988 x 1 for the first patient seen
  • H989 x 9 for the next 9 patients seen
• Note that a maximum of 10 special visit premiums (total of first and additional person seen) are eligible for payment per time-period.
• Consultation/assessment codes and procedural codes (if applicable) applicable for the services provided to each patient seen are eligible for payment to Dr. Baker. In this example "A", or "K" consultation/assessment codes for each of the first 10 patients, as well as the appropriate weekend emergency department "H" consultation/assessment codes for the remaining 2 patients.

Example 2

Dr. Andrawis is scheduled to work a day shift in the emergency department on Wednesday from 10:00 a.m. to 6:00 p.m.. Dr. Andrawis arrives early for his shift and begins seeing patients at 8:00 a.m.

In the time-period from 8:00 a.m. to 10:00 a.m., Dr. Andrawis sees a total of 4 patients.

What fee codes are eligible for payment to Dr. Andrawis?

Explanation:

• Although Dr. Andrawis satisfies the definition of an Emergency Department Physician, he was not requested to attend the emergency department by a patient or a patient's representative (such as the on-duty ED physician); therefore, no special visit premiums codes are eligible for payment.
• Dr. Andrawis may claim emergency department "H" consultation/assessment fee codes (for example, H101, H102, H103, H104) or the appropriate "K" (such as counselling and other time-based codes), "G" (such as diagnostic/therapeutic), or procedure codes (if applicable) for each patient seen, if payment requirements have been met.

Example 3a

Dr. Catana, a cardiologist, is at home on a Friday providing on-call cardiology services for the hospital and receives a request from the emergency department physician at 7:00 p.m. to attend the emergency department to assess and provide a consultation for a patient who has presented with chest pain.

Dr. Catana travels to the hospital, completes an assessment of the patient at 7:45 p.m., and documents the time of the assessment (7:30 p.m.) in the patient medical record. Note that the consultation request from the ED physician on the medical record supports the medical necessity of this non-elective visit.

What fee codes are eligible for payment to Dr. Catana?

Explanation:

• The applicable special visit premiums for the services provided by Dr. Catana are listed in Special Visit Premium Table I. Dr. Catana is not working as an Emergency Department Physician (he is not on duty to the emergency department seeing unscheduled patients presenting with all complaints) but is instead on-call to provide cardiology services for all hospital departments.
• The following fee codes listed in Special Visit Premium Table I apply and are eligible for payment, including:
  • K962 x 1 for travel to the hospital
  • K994 x 1 for first patient seen
• Dr. Catana may claim the appropriate "A" prefix consultation/assessment and procedure codes (if applicable) for services provided, if payment requirements have been met.

Example 3b

While still in the hospital emergency department, a second patient presents with a recurrence of congestive heart failure. The emergency department physician on duty requests that Dr. Catana assess the patient.

Dr. Catana performs an assessment, treats the patient, and documents the time of the assessment in the patient medical record.

What fee codes are eligible for payment to Dr. Catana?

Explanation:

• Fee code K995 (Special Visit Premium Table I) is eligible for payment to Dr. Catana for the additional patient seen as well as the appropriate "A" prefix consultation/assessment and procedure codes.
• As Dr. Catana is already on-site, no additional travel premium is payable.

Example 3c

Once he has completed the work in the emergency department, Dr. Catana decides to visit three patients that are currently admitted to him on the hospital’s internal medicine ward.

What fee codes are eligible for payment to Dr. Catana?

Explanation:

• Dr. Catana may claim the appropriate "C" prefix assessment code for each patient.
• As Dr. Catana is making rounds, no special visit premiums are payable.

Example 4

Dr. Dalmia, a family physician, is on-call for admissions to the hospital’s Family Medicine Unit every Thursday evening. While Dr. Dalmia also works part-time as an Emergency Department Physician, she is not scheduled to work in the Emergency Department on Thursdays.

During her Thursday evening on-call shift for family medicine, Dr. Dalmia receives a request from the emergency department physician on duty to attend and admit a patient to the hospital.

Dr. Dalmia travels to the hospital, assesses, and admits the patient at 9:30 p.m., and documents the time of the assessment in the patient medical record.

What fee codes are eligible for payment to Dr. Dalmia?

Explanation:

• Special Visit Premium Table I fee codes apply in this situation. As Dr. Dalmia is on-call for family medicine admissions and is not scheduled to work in the Emergency Department, she does not meet the definition of Emergency Department Physician at the time of the visit. The fee codes in Special Visit Premium Table I that are eligible for payment include:
  • K962 x 1 for travel to the hospital
  • K994 x 1 for first patient seen
• Dr. Dalmia may claim the appropriate "A" prefix consultation/assessment and procedure codes (if applicable) for services provided, if payment requirements have been met.

Keywords/Tags

OHIP Claims; OHIP Payment; Special Visit Premium; Emergency Department; Emergency Physician

More information

Special visit premiums

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.