Billing by a Supervising Physician for OHIP Services Provided by Postgraduate Medical Trainees

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.

Topic: Supervision of Postgraduate Medical Trainees
Category: Academic Physicians; Clinical Fellows; Residents
Date Issued: April 14, 2023

The Supervision of Postgraduate Medical Trainees section of the Schedule of Benefits – Physician Services (Schedule) specifies the payment requirements for a Supervising Physician to bill OHIP for an insured service provided by a Postgraduate Medical Trainee.

This Education and Prevention Committee (EPC) Billing Brief focuses on appropriate billing by the Supervising Physician. A subsequent publication will address the circumstances where a Resident or Clinical Fellow with an OHIP billing number may themselves submit claims for insured services that they provide.

Common claims issues

• Supervising Physicians claiming for procedural services performed by residents when the Supervising Physician is not physically present in the clinical facility at the time the service is rendered.
• Supervising Physicians claiming for procedures or time-based services provided by a Medical Trainee when they are not aware that the Medical Trainee will render the service or when insured services are provided by Medical Trainees without Supervision.
• Claiming for more concurrent services than the Schedule allows (see table on page GP83).
• A lack of documentation in the patient’s medical record supporting that payment requirements were met at the time of the provision of the Supervised service.

For the purposes of this section of the Schedule only, insured services are grouped into three defined categories:

Procedure – An insured service that has anaesthesia base units listed in the column headed with “Anae” (note that this is just for the purpose of this definition and does not mean that an anaesthesia claim is required). This includes anaesthesia services provided by Anaesthesiologists.

Time-based service – Time-based services refer to services that are described on pages GP54-GP61 of the Schedule as Psychotherapy, Psychiatric and Counselling, Interviews, Hypnotherapy, Psychiatric Care and Primary Mental Health Care.

Non-procedure – All other insured services.

Definitions

For the purposes of this section of the Schedule only, the following definitions apply:

Supervision: Supervision is performed by the Supervising Physician and includes the responsibility to guide, observe and assess the educational activities of the Medical Trainee and assures the quality of an insured service while being rendered by the Medical Trainee.

The Supervising Physician and the Medical Trainee must be physically present in Ontario.

Supervision is only performed:

1. In person, by telephone, or videoconference, the method being consistent with the acuity of the service being rendered by the Medical Trainee as well as the Medical Trainee’s level of competence.
2. When the service is provided within a setting approved by the educational institution where the Medical Trainee is registered.
3. When the service is within the scope and oversight of the postgraduate medical training program in which the Medical Trainee is registered.

Supervising Physician: The Supervising Physician is a physician who performs Supervision of a Medical Trainee who renders an insured service to an insured person. The Supervising Physician must hold an academic appointment with the educational institution where the Medical Trainee is registered. The Supervising Physician of a Medical Trainee involved in the care of a patient may or may not be the most responsible physician for that patient.

Medical Trainee: A Medical Trainee is a physician who is registered in a postgraduate training program as a Resident or Clinical Fellow at the time he/she performs an insured service.

• Note that an undergraduate medical student is not a physician and does not meet the definition of a Medical Trainee.
• When a physician is supervising a medical student providing a medical service (e.g., assessment, time-based service, procedure, etc.) the fee code claimed should be consistent with the service personally performed by the physician.

Resident: A Resident is registered in an accredited postgraduate training program that leads to certification for practice in Canada as a specialist or subspecialist by the Royal College of Physicians and Surgeons of Canada or to certification by the College of Family Physicians of Canada for practice in Canada as a family physician.

Clinical Fellow: A Clinical Fellow is registered with a postgraduate training program that is approved by a university postgraduate medical education office in Ontario. The Clinical Fellow must have a Certificate of Registration with the College of Physicians and Surgeons of Ontario.

Procedure Services

• A Procedure rendered by a Postgraduate Medical Trainee is only eligible for payment to the Supervising Physician when the Supervising Physician is aware the Trainee will render the service and is immediately available to personally attend the patient when requested by the Trainee or other health care professional.
• When a Resident renders the Procedure, the Supervising Physician must be physically present in the clinical facility at the time the service is rendered.
• When a Clinical Fellow renders the Procedure, the Supervising Physician must be available to personally attend the patient when requested by the Clinical Fellow or other health care professional in a timely manner consistent with the acuity of the clinical scenario.

Time-Based Services

• A Time-Based Service rendered by a Postgraduate Medical Trainee is only eligible for payment to the Supervising Physician when the Supervising Physician is aware the Medical Trainee will render the service.
• Any time taken in discussion with the Medical Trainee about the case is not eligible for payment.
• Where there is more than one Medical Trainee participating in the rendering of a time-based service concurrently, only the time units rendered by one Medical Trainee are eligible for payment to the same Supervising Physician.
• A maximum of 2-time units are payable when a time-based service is rendered by a Medical Trainee to an individual patient; a maximum of 4 units are payable when a time-based service is rendered to a group of 2 or more patients.

Services that are not eligible for payment to the Supervising Physician when rendered by a Medical Trainee

• Case Conferences; Multidisciplinary Cancer Conferences.
• Physician-to-Physician/Nurse Practitioner Services; Telephone Consultations; E-Consultations; E-Assessments.
• Special Visit Premiums.
• Completion of forms (unless the form has been reviewed and signed by the Supervising Physician).
• Services provided by a Resident or Clinical Fellow with an OHIP billing number that are provided independently and outside of the training program to which the trainee is enrolled.
• Virtual care services provided to Emergency Department patients or hospital in-patients.

Maximum number of services that are payable for services rendered concurrently by Postgraduate Medical Trainee(s) and the Supervising Physician*

* See page GP83 of the Schedule for full details.

Medical Record Requirements

A service is only eligible for payment to the Supervising Physician when the medical record of the patient(s) identifies the following information at the time of the provision of the service:

• The Supervising Physician.
• The Medical Trainee and level of training.
• The description of the insured service (for example, a chart note outlining the assessment or procedure) performed by the Medical Trainee.
• Patient consent to the Supervision of services of a Medical Trainee.
• Where the service rendered is a Time-Based Service, the Supervising Physician has at a minimum, reviewed the nature and outcome of the service and the patient record(s), with the Medical Trainee.

In addition, the Supervising Physician must have signed off on the service rendered by the Medical Trainee in the patient’s medical record.

Where the Supervising Physician was not immediately available to sign off on the service rendered by the Medical Trainee, the Medical Trainee must document the date and time a discussion occurred with the Supervising Physician regarding the provision of the service in the patient’s medical record.

Note that each entry into the patient’s medical record does not need to contain all of the above medical record keeping requirements. However, it must be evident upon review of the entire medical record that all requirements were met at the time of the provision of the Supervised service.

Supervision of the Medical Trainee by the Supervising Physician must be evident in the medical record. This may include a physical visit to the patient and/or a chart review and detailed discussion between the Supervising Physician, the Medical Trainee, and other member(s) of the health team.

The service date to be used for claims is the date the Medical Trainee rendered the insured service to the patient.

Examples

Example 1:

During a pediatric rotation, Dr. Adamo, a second-year Family Medicine resident, conducts a 40-minute interview with a pediatric in-patient’s legal guardian to elicit collateral history and discuss treatment options. Following the interview, she discusses the case with her supervisor, Dr. Hankir, by phone for 10 minutes. She documents the service in the patient chart including start/stop time as well as the Supervising Physician’s name, her name and level of training, discussion with her supervisor and the parents’ consent to the interview. The following day, her supervisor reviews and countersigns her chart note.

What may be billed to OHIP by Dr. Adamo and Dr. Hankir?

Explanation:

• Dr. Adamo is a postgraduate medical trainee working under supervision; she is not eligible to bill OHIP for the described insured service (interview).
• Dr. Hankir, her supervisor, was aware of Dr. Adamo’s plan to conduct the interview. Dr. Hankir may claim for one unit of a time-based interview service (K002A, K003A or K008A depending on the exact service provided) reflecting the 40 minutes of interaction between Dr. Adamo and the parent (excluding the 10 minutes of Supervisor-Trainee discussion).

Example 2a:

Dr. Wei, an orthopaedic surgeon is conducting a clinic with a resident, Dr. Kilani, and a clinical fellow, Dr. Shah. Dr. Kilani, who is a PGY-3, assesses a patient with a distal radial fracture requiring re-reduction. Dr. Wei reviews the x-rays and discusses the treatment plan with Dr. Kilani who then confirms patient consent, identifying Dr. Wei as the supervising physician, and proceeds to perform a closed reduction of the fracture under hematoma block in the clinic procedure room. Dr. Wei does not directly participate in the reduction and continues seeing patients in clinic in parallel with Dr. Shah.

Is it appropriate for Dr. Wei to claim for the fracture reduction performed by Dr. Kilani? If so, how many concurrent services are payable to Dr. Wei in this situation?

Explanation:

• Yes, as Dr. Wei was aware that Dr. Kilani was going to perform the closed reduction in the same clinical facility and provided supervision, she is eligible to claim for the procedure.
• Dr. Wei may also claim for one other concurrent insured service (either performed personally or by another resident or fellow under supervision) provided to a different patient at the same time as the procedure.

Example 2b:

If the patient were in the Emergency Department and Dr. Wei were providing supervision for Dr. Kilani from home, would she be able to claim for the fracture reduction?

Explanation:

• No, Supervising Physicians may only claim for procedures performed by residents when they are physically present in the same clinical facility where the procedure is being performed, and immediately available to attend the patient at the request of the resident or another health care professional. Additionally, they must be aware that the resident plans to render the service.

Example 2c:

If Dr. Shah (clinical fellow) had performed the fracture reduction in the Emergency Department and Dr. Wei provided supervision for Dr. Shah from home, who would be able to claim for the fracture reduction?

Explanation:

• In this scenario, Dr. Wei would be eligible to claim for the fracture reduction (despite not being in the same clinical facility) if she was aware that the clinical fellow planned to render the service and was immediately available to attend the patient at the request of the clinical fellow or another health care professional.
• Supervising Physicians are not required to be physically present when procedures are performed by clinical fellows, however they must be available to personally attend the patient when requested by the clinical fellow or other health care professional in a timely manner consistent with the acuity of the clinical situation.
• Note that even if he has an OHIP billing number, Dr. Shah is not eligible to claim the fracture reduction fee as he is performing the procedure under supervision within the training program to which he is registered.

Example 3:

Dr. Volfson is a rural family physician who regularly works with Family Medicine residents who complete rotations in his community. One of his residents completes a homecare form for Dr. Volfson’s patient prior to hospital discharge. Dr. Volfson does not review and sign the form.

Is it appropriate for Dr. Volfson to claim K070 for completion of the home care application form?

Explanation:

• No, fees for completion of forms by a Medical Trainee under Supervision are only payable when the Supervising Physician has reviewed and signed the form.

Example 4:

Dr. Williams is a neurology resident under Supervision. He takes a call from a family physician, discusses a patient case, and provides advice, avoiding patient transfer. The phone conversation is documented as 12 minutes long. The referring family physician claims K730A.

What may Dr. Williams’ Supervising Physician claim for this physician-to-physician telephone consultation?

Explanation:

• As the telephone consultation was rendered by a Medical Trainee, the Supervising Physician may not bill OHIP for the phone call with the referring physician.

Example 5:

Dr. Isaac is a third-year psychiatry resident working under Supervision in Psychiatry clinic. She conducts a video assessment of a repeat patient with anxiety, reviewing the patient findings and her provisional management plan with her supervisor prior to completing the patient visit.

What fee code may Dr. Isaac’s supervisor claim for this visit?

Explanation:

• Dr. Isaac’s supervisor may claim the appropriate assessment fee code from the Psychiatry sub-section of the Consultations and Assessments section of the Schedule, submitted as a video assessment.

Example 6:

Later that evening, Dr. Isaac is “on call” for psychiatry. She takes a call from a nurse practitioner working at a regional hospital and provides some advice which she later discusses with her Supervisor. What fee code may Dr. Isaac’s supervisor claim for this visit?

Explanation:

• Dr. Isaac’s supervisor may not claim a fee code for this interaction as provider-to-provider consultations are not payable when provided by Postgraduate Medical Trainees under Supervision.

Keywords/tags

Academic Medicine; Clinical Fellow; Postgraduate Medical Trainee; Resident; Supervising Physician; Supervision; OHIP Claims; OHIP Payment

More information

INFOBulletin 4726

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 Inquiry Services, Service Support Contact Centre (SSCC) by email or by calling 1-800-262-6524.

The Ministry of Health (MOH) and the Ontario Medical Association (OMA) have jointly prepared this educational resource to provide general advice and guidance to physicians on specific billing matters.

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Note: This document is technical in nature and is available in English only due to its limited targeted audience. This publication has been exempted from translation under the French Language Services Act. For questions or support regarding this document, please contact the Service Support Contact Centre (SSCC) by email or by calling 1-800-262-6524.

Remarque : Ce document est de nature technique et est disponible en anglais uniquement en raison de son public cible limité. Ce document a été exempté de la traduction en vertu de la Loi sur les services en français. Pour toute question ou de l’aide concernant ce document, veuillez contacter Les Services de renseignements, Centre de contact pour le soutien des services par courriel ou en téléphonant le 1-800-262-6524.