Virtual Care 3: Case-Based Billing Examples

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: April 14, 2023

New insured Virtual Care Services effective December 1, 2022

As part of the 2021-2024 Physician Services Agreement, the Ministry of Health (MOH) and the Ontario Medical Association (OMA) agreed to a new virtual care funding framework to insure certain services provided by video and telephone under OHIP. This new framework replaces the virtual care codes introduced in March 2020.

The December 1, 2022, version of the Schedule introduces a new section for Virtual Care Services within the Consultations and Visits section, which outlines payment rules and provides commentary related to these services.

This EPC Billing Brief provides case-based examples to illustrate the application of many of the Virtual Care payment rules and conditions.

The EPC welcomes suggestions for other case-based examples to assist in the understanding of the new Virtual Care Services. If you have suggestions, please send an email to the attention of the joint Ministry of Health/OMA Education and Prevention Committee.

Example 1: Initiating a virtual care service

Ms. Masalis is a patient of Dr. McCallum (a family physician) with a diagnosis of Type 2 diabetes mellitus. Her last appointment (in person) was four months ago. Based on Dr. McCallum’s clinic notes, the medical office assistant contacted Ms. Masalis to schedule a routine appointment to re-assess her diabetic control. Ms. Masalis requested a virtual appointment which is booked and completed using a verified video solution and fulfills Schedule requirements for a diabetes management assessment including maintenance of a diabetic flow sheet.

What is eligible for payment?

Explanation:

• Dr. McCallum has an established/ongoing relationship with Ms. Masalis.
• While the appointment was initiated by the physician’s medical office assistant, it constituted a medically necessary follow-up service.
• Dr. McCallum may claim a Comprehensive Virtual Care Service by video, for the assessment rendered (in this case, K030A, since he performed a K030A involving a direct physical encounter in the preceding 12 months).
• A virtual K030A requires a preceding in-person K030A within the preceding year.
• If there was no K030A with a direct physical encounter in the preceding 12 months, an A007A would be eligible for payment.
• Either a K030A or a A007A should be submitted along with the video modality indicator, K300A.

Example 2a: Specific elements of services

During the virtual visit described in Example 1, Dr. McCallum recommended to Ms. Masalis that she have a bone density screening test for osteoporosis. Following the test (which was normal), Dr. McCallum called Ms. Masalis to report the results by telephone.

What is eligible for payment?

Explanation:

• The phone call, initiated by Dr. McCallum to report the results of an investigation does not constitute a separate visit and, therefore, is not eligible for payment as a virtual visit.
• The specific elements of the previous visit include discussion with, and providing advice and information, including prescribing therapy to the patient or the patient’s representative, whether by telephone or otherwise, on matters related to the service (see page GP15 of the Schedule).

Example 2b: New assessment required

Let’s consider an alternate scenario for the physician and patient described in Examples 1 and 2a.

Upon reviewing Ms. Masalis’ bone mineral density test, Dr. McCallum notes that it is abnormal. Dr. McCallum initiates a phone call to provide a new assessment focusing on this concern allowing calculation of the patient’s 10-year probability of fracture which guides ongoing management.

What is eligible for payment?

Explanation:

• In this case, the phone call constitutes a new patient assessment rather than just reporting results from a previous assessment.
• Therefore, a new patient assessment (in this case A007A) is eligible for payment and should be submitted with the telephone indicator, K301A.

Example 3: Initiating a virtual care service

A family physician instructs their office staff to call all patients over age 45 years to invite them to schedule a telephone appointment to discuss wellness concerns such as stress reduction.

What is eligible for payment for the resulting virtual visits?

Explanation:

• Services are not eligible for payment when initiated by the physician (or the physician’s staff) unless the service is a medically necessary follow-up to a preceding visit initiated by the patient or patient’s representative, which is not the case illustrated in this example.
• Any virtual services provided under these circumstances would remain OHIP insured services for which the amount payable is zero. Patients cannot be charged for services described as “not eligible for payment” as they remain insured services.

Example 4: Delegation for payment purposes

Dr. Sondheim is a plastic surgeon who is the employer of a physician assistant who works in her office. The physician assistant provides a follow-up visit by telephone to a patient following an uncomplicated minor procedure by Dr. Sondheim and establishes that the patient does not need to travel back to the office for an in-person visit.

What is eligible for payment?

Explanation:

• Virtual care services may not be delegated for payment purposes therefore the phone assessment conducted by the physician assistant is not eligible for payment.
• Note that this service would also not be eligible for payment if provided in-person by the physician assistant as services such as assessments, consultations, psychotherapy, counselling, etc. may not be delegated for payment purposes (see page GP62 of the Schedule).

Example 5: Delegation for payment purposes

One of Dr. Sondheim’s patients presents to her office without an appointment, concerned that their arm cast (applied at the time of a surgical procedure performed 3 weeks previously) has broken. The office staff locate Dr. Sondheim, who is between surgical procedures at the hospital, and she provides a telephone visit to the patient. Dr. Sondheim determines that the cast should be changed. Her employee, the physician assistant, is available at the office and has appropriate training in cast removal and application. He proceeds to change the cast as instructed by Dr. Sondheim.

What is eligible for payment?

Explanation:

• Dr. Sondheim last saw the patient in-person 3 weeks previously and has an existing/ongoing relationship with the patient. She may claim the appropriate Comprehensive Virtual Care service, in this case a partial assessment by phone, using fee codes A084A + K301A.
• As the physician assistant is Dr. Sondheim’s employee, is appropriately trained in casting and the relevant fee codes (Z203 and Z204) are listed in the table on page GP63, these may be claimed even though Dr. Sondheim is not present in the office during the procedure.
• Note that as the delegated procedures are NOT virtual care services, they should be submitted on a separate claim without modality indicators.

Example 6: Supervision of Medical Trainees

Dr. Goan is the supervisor for a resident; they are working together in clinic. The resident provides a follow-up visit by video to a patient (who is at home) following a shoulder manipulation under anesthetic recently performed by Dr. Goan. The resident reviews the patient’s history and findings (visual inspection of range of motion by video) with Dr. Goan, and a management plan is developed and communicated to the patient.

What is eligible for payment?

Explanation:

• As the Supervising Physician, Dr. Goan may claim a Comprehensive Virtual Care Service consistent with the assessment the resident was able to provide by video – which in this case included examination of the affected region (shoulder) needed to assess function.
• This should be submitted with the appropriate fee code from Appendix J, along with the video modality indicator, K300A.

Example 7: Physical examination requirements

In Example 6, what if the patient requested a telephone assessment, instead of video?

Explanation:

• Given that follow-up of a shoulder manipulation requires visual assessment of shoulder range of motion (either by video or in-person) this visit is payable only as an in-person or video visit.
• Telephone visits in this clinical scenario where elements of the required physical examination cannot be performed with this modality would not be eligible for payment.

Example 8: Visits that require a direct physical encounter

A 20-year-old college student has had several episodes of fainting during physical activity and has also noted that her heart “races”. Her uncle passed away suddenly due to an undiagnosed cardiac issue in young adulthood. She is referred to a cardiologist whose medical office assistant arranges a video consultation because the student wants to minimize the time she will miss classes. The cardiologist initiates the video visit but realizes that an in-person physical examination including auscultation and other direct physical examination is required to appropriately assess and diagnose the patient’s presenting symptoms. This is arranged within the following week.

What is eligible for payment for the video visit?

Explanation:

• The cardiologist determined that the consultation could not be appropriately completed without a direct physical encounter with hands-on physical examination.
• Therefore, the initial video component of the consultation is not separately eligible for payment, and instead is a specific element of the subsequent in-person consultation (which should be claimed as having been rendered on the day of the in-person visit).
• The cardiologist should submit the appropriate consultation code with the date of the in-person assessment as the date of service. No additional claim is eligible for payment for the initial virtual interaction.

Example 9: Calculating the time that may be claimed for time-based virtual care services

Dr. Herra is a GP-focused practice psychotherapist. During a 50-minute video psychotherapy session with one of her regular patients she spends 40 minutes providing psychotherapy. The patient requires assistance in troubleshooting the video link which takes 10 minutes.

What is eligible for payment for this virtual visit?

Explanation:

• Dr. Herra may submit a claim for K007A (Individual care psychotherapy) x 1 unit (30 minutes or greater part thereof).
• The additional 10 minutes of psychotherapy does not meet the time threshold for an additional unit.
• The 10 minutes spent providing technical support to the patient may not be included in the time calculation for K007.
• As outlined in the General Preamble on page GP7, the physician must record on the patient’s permanent medical record or chart the time when the insured service started and ended.

Example 10: Management fees that apply to virtual care services

From Example 1, Dr. McCallum provides 3 appointments to Ms. Masalis in a 12-month period to assess her diabetic control. Two of the appointments are conducted virtually (one by telephone, one by video) and one in-person.

Is Dr. McCallum eligible to claim the diabetes management incentive (Q040) for Ms. Masalis based on these visits?

Explanation:

• Yes, provided that all elements of the diabetes management incentive (Q040) have been completed. This includes foot and neurologic examinations which must be completed during an in-person visit.
• Note that all management fees that apply to Comprehensive Virtual Care services are listed in the table on page A76 of the Schedule.

Example 11: Unbundling of services

A pediatrician, Dr. Velez, has developed a new pattern of practice for many of her elective patient assessments which improve the efficiency of her in person office administration and has been well received by families. She routinely assesses each patient by conducting the history (involving the child and the parent) by telephone and, several days later, completing an in-person physical examination in her office.

What is eligible for payment for these two encounters?

Explanation:

• As the assessment was not completed virtually (only the history was performed) nothing is eligible for payment for the initial telephone call.
• When Dr. Velez has completed her assessment following the in-person physical examination (informed by the prior information gained by telephone), an in-person assessment may be claimed.
• The telephone call is a specific element of the in-person assessment rather than a stand-alone virtual assessment.

Example 12: Continuation of the existing/ongoing patient-physician relationship

A psychiatrist, Dr. King, provided a video consultation in November 2022 that established an existing/ongoing relationship with the patient, Mr. Gordon. This service was paid using the K083 fee code. Subsequent video and telephone visits are eligible for payment as comprehensive virtual care services for 24-months after this visit. Eighteen months following the initial video consultation, Dr. King assesses Mr. Gordon in-person.

How does this in person visit affect the time-course of the ongoing/existing relationship?

Explanation:

• A consultation billed under K083 prior to December 1, 2022 is evidence of an existing/ongoing physician patient relationship.
• Following the in-person visit, Dr. King is eligible to continue to claim Comprehensive Virtual Care services for an additional 24 months following the visit – the in-person visit is considered to “reset the clock” on the relationship.
• Note that if a specialist has exceeded the 24-month window following the initial video consultation that establishes a relationship for Comprehensive Virtual Care services, an in-person visit at any time after the 24-month period will also re-establish the existing/ongoing relationship (this does not require a new referral from the referring physician).

Example 13: Establishing an existing/ongoing patient-physician relationship within a group practice

Dr. Zhang is providing services within a group model. If Dr. Zhang establishes a patient-physician relationship with a patient, will the relationship with Dr. Zhang also establish an existing ongoing relationship for other physicians in her group for the purposes of billing Comprehensive Virtual Care services?

Explanation:

The answer depends on 3 factors:

1. Whether Dr. Zhang is a primary care physician or a specialist,
2. If primary care, whether the practice is a patient enrolment model group, and
3. If a primary care patient enrollment model, whether the patient is enrolled to Dr. Zhang’s practice group.

• In primary care patient enrollment models, all (signatory or locum) group physicians will be considered to have a relationship with all patients enrolled to that group.
• In all other group practices (i.e., primary care non-enrollment models as well as all specialist practices) the existing ongoing relationship only exists between the patient and individual physician.

Example 14: Determining the correct modality to claim

Dr. Sutton, a family physician, performs a follow-up of an assessment of a patient using a Verified Video Solution. However, the patient’s computer camera is broken and there is no video stream available, only an audio connection.

What modality indicator should the physician use when submitting this claim?

Explanation:

• Sutton should submit the claim using the K301 (telephone) indicator.
• If Dr. Sutton is not able to see the patient, the requirements for a video service as defined in the Schedule of Benefits (page A67) would not be met, regardless of whether a video link was used or if the patient supplemented the telephone visit by sending an image to the physician by secure messaging. As such, only a telephone service would be eligible for payment in this scenario.

Example 15: Use of Verified Video Solution

Dr. Cruz is a specialist. She performs a patient consultation using a video platform that is not a Verified Video Solution. Is this service billable to OHIP or may the patient be charged?

Explanation:

• Virtual Care services provided by video are only eligible for payment when using a platform that is a Verified Video Solution.
• Please note: video services that do not use a Verified Virtual Visit Solution remain an OHIP insured service for which the amount payable is zero, and therefore the patient may not be charged for this service.

Example 16: When it is not medically appropriate to provide the service without a direct physical encounter

Mr. Lee, a parent, phones a virtual walk-in clinic to get advice for their 3-year-old child who is complaining of ear pain after being found playing with some small beads. Mr. Lee thinks that the child may have inserted one or more beads in their ear. The physician, Dr. Valderrama (who does not have an existing relationship with the patient) determines that it is not medically appropriate to provide or possible to complete the service without a direct physical encounter including otoscopy. Dr. Valderrama advises Mr. Lee to contact their family physician or attend an in person walk-in clinic.

What is billable for this virtual service?

Explanation:

• In this case, it was not possible to complete a Virtual Care Service and so no Virtual Care Service is eligible for payment.
• If Dr. Valderrama rendered a virtual assessment when it was not medically appropriate to do so, then the assessment would not be eligible for payment.
• Virtual Care Services (both Comprehensive and Limited) are not eligible for payment where it is not medically appropriate to provide the specific service without a direct physical encounter.

Example 17: Claiming for triage alone

A family physician, Dr. Emrani, develops a routine to assist in appropriately triaging her enrolled patients’ visit requests. She initiates a phone call with each patient to determine when and how to book new visit requests. As these calls are quite short and do not represent full patient assessments, Dr. Emrani wonders if she should submit claims for Limited Virtual Care services.

Explanation:

• Triage calls, as described in this example, are not eligible for payment as they are a specific element of the subsequent insured service (virtual or in-person).

Keywords/tags

OHIP; Virtual Care

More information

• INFOBulletins on Virtual Care:
  • Bulletin 221002: New Virtual Care Funding Framework – Updated Schedule of Benefits
  • Bulletin 221203: Introduction of the new virtual care model in the Ontario health care system
• EPC Billing Briefs:
  • Virtual Care #1: Comprehensive and Limited Virtual Care Services
  • Virtual Care #2: Terms and Conditions
  • Schedule of Benefits – Physician Services

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.

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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.