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 physicians    
Date Issued: March 31, 2021    
Date Updated: June 27, 2025 – Updated to provide additional information and clarifications to support physician claims for payments. This EPC Billing Brief has also been updated to web page-based format, replacing the previously published PDF version.

Claims Tips: For additional information, please see EPC Billing Brief - Requirements for time-based services, which provides additional information about payment requirements and conditions for time-based services.

Overview

Some OHIP insured physician services are only eligible for payment if they have been performed for a certain period of time (“time-based services”). Time-Based Services in the Schedule are one of two types:

  1. Services required to be performed for a minimum amount of time to be eligible for payment (“minimum time services”).
  2. Services paid based on time-based units or a combination of basic units and time-based units (“unit services”).

This EPC Billing Brief provides case-based examples to illustrate the application of some time-based code payment requirements and conditions and should be reviewed together with the EPC Billing Brief – Requirements for time-based services. Physicians should also refer to the Schedule for the requirements and conditions that must be met to claim a time-based service.

Examples

Example 1 – Interview fee code

Dr. Lennon is a family physician who assesses an 85-year-old patient whose chief complaints are fatigue and weight loss. Dr. Lennon performs an intermediate assessment in office, noting that the patient has difficulty providing a history and seems confused.

Dr. Lennon obtains permission to contact the patient’s daughter for additional information and asks his assistant to schedule a separate appointment with the patient’s daughter. Dr. Lennon subsequently has a 30-minute interview with the patient’s daughter to obtain collateral history.

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

Explanation:

  • A007A (intermediate assessment) is eligible for payment.
  • K002A (interviews with relatives) (1 unit) is eligible for payment, provided that the interview is at least 20 minutes in length, start and stop times are documented in the medical record, and the interview is a booked, separate appointment.
  • Note that if these two services occur on the same calendar day, the claim must be submitted for manual review with documentation that Schedule requirements have been met.
Additional information:
  • In calculating the time unit(s), please see page GP61 of the Schedule.
  • Interview services that last less than 20 minutes are not eligible for payment as interviews.
  • Inquiry, discussion, or provision of advice or information with/to a patient, patient’s relative or representative which ordinarily constitutes part of a consultation or assessment are included as a common or constituent element of the consultation or assessment service and therefore does not constitute a separately billable interview.
  • All services described as interviews must be rendered personally by the attending physician or they are not insured services and are not eligible for payment.

Example 2 – Educational counselling codes

Dr. Gonzales sees a 26-year-old patient in office for a scheduled appointment to discuss concerns related to the patient’s risk of breast cancer, given her mother’s recent mastectomy and positive BRCA gene tests. Dr. Gonzales spends 35 minutes counselling the patient. Following this, Dr. Gonzales administers an annual influenza immunization to the patient.

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

Explanation:

  • K013A (counselling – individual care) (1 unit) is eligible for payment, provided that the start and the stop times of the counselling are documented in the patient’s medical record.
  • G590A (immunization – influenza agent) is eligible for payment. Note that only the specific fee codes listed below are eligible for payment when rendered by the same physician the same day as any type of counselling service (such as K013A). These are also listed in the Psychotherapy, Psychiatric and Counselling Services section of the Schedule General Preamble (page GP58).
    • E080, G010, G039, G040, G041, G042, G043, G202, G205, G365, G372, G384, G385, G394, G462, G480, G489, G482, G538, G590, G593, G840, G841, G842, G843, G844, G845, G846, G847, G848, H313, K002, K003, K008, K014, K015, K031, K035, K036, K038, K682, K683, K684, K730.
Claims Tip: When providing counselling services in the in-patient setting, physicians should document the date/time of the pre-scheduled appointment as a note in the patient permanent medical record.

Example 3 – Eligibility of payment when time-based services delegated to non-physician

A patient attends Dr. Chue’s office to receive an influenza immunization from a nurse employed by Dr. Chue (the patient does not see a physician during the visit). The patient’s partner has recently passed away, and the nurse spends 20 minutes with the patient, in addition to the time spent for the immunization, talking to the patient about their reaction to grief.

In addition to fee code(s) associated specifically with the immunization provided in accordance with Schedule delegation rules by the physician’s employee, what is eligible for payment to Dr. Chue?

Explanation:

  • No other fee codes are eligible for payment for the 20 minutes spent by the nurse discussing the patient’s grief reaction as counselling services may not be delegated by a physician to a non-physician for payment purposes.
  • A physician cannot delegate services such as assessments, consultations, psychotherapy, counselling, etc. For more information on the rules of delegation please see pages GP62-63 of the Schedule.

Example 4a – Calculating anaesthesia units

Dr. Shaw, an anesthesiologist, provides anesthesiology services for a 71-year-old patient who is undergoing a primary total hip replacement (R440). Start and stop times for anesthesia services are documented in the medical record as 07:35 and 10:00, respectively, for a total time of 145 minutes.

What is eligible for payment to Dr. Shaw?

Explanation:

  • Dr. Shaw may claim 10 basic units associated with R440C as well as time units.
  • Time units are calculated on the basis of time spent by the anaesthesiologist and commence when the anaesthesiologist is first in attendance with the patient in the OR for the purpose of initiating anaesthesia and end when the anaesthesiologist is no longer in attendance (when the patient may safely be placed under customary post-operative supervision).
  • In this scenario, the time units are calculated as follows:
    • 1 unit per 15 minutes for the first 60 minutes = 4 units
    • 2 units per 15 minutes for the next 30 minutes = 4 units
    • 3 units per 15 minutes (or part thereof) for the remaining 55 minutes = 12 units
    • Total of 10 basic + 20 time units = 30 units are eligible for payment as R440C
  • Dr. Shaw may also claim one additional unit (E007C) as the patient is between the ages of 70 and 79.

Example 4b – Calculating surgical assistant units

Dr. Ruest provides surgical assistant services for the procedure described in 4a above.

Dr. Ruest spends 10 minutes in direct contact with the patient in the operating room assisting with patient preparation prior to scrub time, and then spends 120 minutes assisting with the surgical procedure.

Start and stop times for the time spent for patient preparation and assisting with the surgical procedure (including scrub time) are documented in the medical record as 7:40 and 9:50, respectively, for a total time of 130 minutes.

What is eligible for payment to Dr. Ruest?

Explanation:

  • Dr. Ruest may claim 8 basic units associated with R440B as well as time units.
  • For the purpose of calculating time units, time is determined per operation as the total of the following, excluding any time spent waiting between surgical procedures:
    • time spent by the physician in direct contact with the patient in the operating room prior to scrub time to assist with patient preparation; and
    • time spent by the physician assisting at the patient's surgery starting with scrub time and ending when the physician is no longer required to be in attendance with that patient.
  • In this scenario, the time units are calculated as follows:
    • 1 unit per 15 minutes for the first 60 minutes = 4 units
    • 2 units per 15 minutes (or part thereof) after the first 60 minutes, but before 150 minutes = 10 units
    • Total of 8 basic + 14 time units = 22 units are eligible for payment.
  • Start and stop times for time “unit” based insured services (including surgical assisting) must be documented in the patient permanent medical record or chart (see Schedule page GP7 g).
  • If routine operating room nursing record time stamps (start/stop of anaesthesia time; start/stop surgical procedure time) do not accurately reflect the surgical assistant time, for example, because additional time was spent by the surgical assistant accompanying the patient to the recovery room, a brief chart note would be suitable to record start/stop times.

Example 4c – Waiting time

Dr. Ruest assists during a second orthopaedic case on the same day for a different patient. There is a 15-minute wait between surgical cases for room change-over.

What is eligible for payment to Dr. Ruest?

Explanation:

  • No fee code is eligible for payment.
  • Surgical assisting fee codes may only be claimed when the assistant is required to be in attendance with the patient.
  • “Unit” time calculations exclude any time spent waiting between surgical procedures (see Schedule page GP 86).

Example 4d – Unforeseen surgical delay

Dr. Ruest assists during a third orthopaedic case on the same day for another patient. The start of the case is delayed for 55 minutes beyond the scheduled start time because the anaesthesiologist is called away to assist with an emergency in another operating room.

What is eligible for payment to Dr. Ruest?

Explanation:

  • E101B (surgical assistant standby) x 2 units (25 minutes of delay commencing 30 minutes after the scheduled procedure start time, calculated at 15 minutes for each unit or part thereof) is eligible for payment as long as the payment rules (below) are met.
    • E101B is a time-based service limited to one surgical case per physician per day payable for standby as a surgical assistant following a minimum of 30 minutes of unforeseen delay beyond the scheduled start time for surgery.
    • The physician must be physically present in the operating room suite for the period between the scheduled and actual surgical start time.
    • For calculation of time units, the start time for this service commences 30 minutes after the scheduled surgical start time and ends when the surgery actually commences as recorded in the hospital’s operating suite records. There are no basic units.
    • E101B is not eligible for payment if, during the standby time for which E101B would otherwise be eligible for payment, other insured services are rendered for which payment is made by OHIP.
    • E101B is payable with after-hours premiums.

Example 5 – Detention

Dr. Marucci, a neurologist, performs a complex neuromuscular assessment of a patient being seen in follow up for long-standing amyotrophic lateral sclerosis. Dr. Marucci spends 75 minutes in direct contact with the patient who has experienced deterioration of clinical conditions since a previous appointment.

What is eligible for payment to Dr. Marucci?

Explanation:

  • Fee code A113A (complex neuromuscular assessment) is eligible for payment for the complex neuromuscular assessment.
  • As the appointment lasted more than 60 minutes, K001A (detention) x 1 unit (15 minutes) is also eligible for payment (see Detention table in the Schedule General Preamble).
  • Dr. Marucci should document the start and stop times of the assessment in the patient’s medical record and submit the claim and a written explanation with a manual review indicator for review by a ministry medical consultant.
  • Note that detention is only payable when the physician is required to spend considerable extra time in active treatment and/or monitoring of the patient to the exclusion of all other work and is based on full 15-minute time units. Detention is not payable for time spent waiting.

Example 6 – Life-threatening critical care

Dr. Betta, a family physician, is making routine ward rounds on his hospital inpatients when a Code Blue is called for the patient in the next room. Dr. Betta is the first physician to respond and initiates resuscitation at 9:15 am.

During resuscitation, Dr. Betta assesses and monitors the patient’s condition, performs defibrillation and endotracheal intubation, and draws a set of arterial blood gases. The nurse who is assisting him inserts two intravenous lines.

The patient is stabilized for transfer to the hospital intensive care unit. Dr. Betta remains in constant attendance providing care until handover to the ICU physician.

Dr. Betta completes all these tasks at 10:30 am and documents both the start time of the resuscitation and the stop time of the elements of life-threatening critical care in the patient’s medical record.

What is eligible for payment to Dr. Betta?

Explanation:

  • The duration of "life threatening critical care" and "other critical care" services that physicians should document is the time they actually spend evaluating, managing, and providing care to the critically ill or injured patient to the exclusion of all other work.
  • For example, time spent reviewing laboratory test results or discussing the critically ill patient's care with other medical staff in the unit or at the nursing station on the floor would be included in the definition of critical care, even when it does not occur at the bedside, if this time represents their full attention to the management of the critically ill/injured patient.
  • Time spent involved in activities in any location other than the bedside, emergency department or hospital floor where the patient is located cannot be claimed as the physician is not immediately available to the patient.
  • Dr. Betta may claim life threatening critical care for the period between 9:15 and 10:30 am (75 minutes or 5 x 15-minute time units) as follows: G521A (first ¼ hour), G523A (second ¼ hour), G522A x 3 (subsequent 3 x ¼ hour units).
  • The assessment, monitoring, and procedures that Dr. Betta performed are included in the life-threatening critical care codes and are not eligible for payment.
  • The procedures performed by the nurse are also included in the life-threatening critical care codes and are not eligible for payment separately. Additionally, the nurse is not Dr. Betta’s employee which also makes any delegated procedures performed by the nurse ineligible for payment to Dr. Betta.

Example 7 – Life-threatening critical care and procedure code

Dr. Amir, an Emergency Physician working as Trauma Team Leader, assesses a patient with critical injuries who arrives in the Emergency Room at 9:20 am. Dr. Amir performs primary and secondary surveys, intubates the patient, and inserts a Nasogastric tube.

After the initial intubation an x-ray demonstrates a hemopneumothorax on the left side. Dr. Amir then inserts a large thoracostomy tube prior to handing over care of the patient to the General Surgeon on call, as the patient requires an emergency laparotomy.

Dr. Amir was at the bedside for 80 minutes, 20 minutes of which was dedicated to the insertion and securing of the thoracostomy tube. Dr. Amir documents the start and stop times of her different activities in the patient permanent medical record as follows:

  • 9:20 am to 10:00 am – trauma assessment/resuscitation
  • 10:00 am to 10:20 am – insertion thoracostomy tube
  • 10:20 am to 10:40 am – patient reassessment, review imaging/lab results, handover to General Surgery – physician remained in the same physical location as the patient during this time (same ward)

What is eligible for payment to Dr. Amir?

Explanation:

  • Dr. Amir may claim for the 60 minutes of life-threatening critical care for the period between 9:20 am and 10:40 am as follows:
    • G521A (first ¼ hour),
    • G523A (second ¼ hour),
    • G522A x 2 (after first ½ hour, ¼ hour units or part thereof).
  • Given that Dr. Amir has excluded the time required (20 minutes in this case) to insert the thoracostomy tube from the life-threatening critical care claim, she may bill for the procedure using fee code Z341, which is not included in the description of resuscitation codes in the Schedule.
  • Note that there should be no overlap of the time claimed for critical care services with the period where the separately billable procedure (in this case thoracostomy tube) was performed.

Example 8 – Minimum-time fee codes - direct patient contact

Dr. Baker, a family physician working as a hospitalist, is called from home to the emergency department Saturday afternoon to provide a consultation for a patient who is diagnosed with congestive heart failure.

Dr. Baker spends 40 minutes in direct patient contact and another 10 minutes completing paperwork.  Dr. Baker decides to admit the patient.

What is eligible for payment to Dr. Baker?

Explanation:

  • Fee code A005A (consultation) as well as fee codes K963A and K998A (special visit premiums) are eligible for payment to Dr. Baker.
  • As the direct patient contact time was less than 50 minutes, fee code A911A (special family and general practice consultation) is not eligible for payment.
  • Note that the administrative work described does not constitute direct patient contact and should not be used in calculating the time to determine which fee code is eligible for payment.

Example 9 – Minimum-time fee codes - direct patient contact

Dr. Kench, a plastic surgeon, is asked to attend the emergency department by the Trauma Team leader to provide a consultation to a multiple trauma patient with a complex facial fracture.

Dr. Kench spends 35 minutes in direct patient contact when the consultation is interrupted because the patient is taken away for imaging. Following the scans, Dr. Kench resumes her assessment, spending an additional 20 minutes with the patient.

What is eligible for payment to Dr. Kench?

Explanation:

  • As the direct patient contact time was more than 50 minutes, fee code A935A (special surgical consultation) is eligible for payment to Dr. Kench.
  • This scenario describes completion of the patient assessment following an unavoidable interruption, rather than post-assessment discussion/advice/information/monitoring which are included as specific elements of all assessments (see Schedule page GP15) and may not be added to time calculations if provided discontinuously from the original assessment or consultation.

Keywords/tags

OHIP Claims; OHIP Payment; Time Based Codes; Time Based Services; Time Based Units

More Information/Additional Billing Resources

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.

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 MOH/OMA Education and Prevention Committee.

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.

The Ministry of Health and the Ontario Medical Association logos

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.