Bulletin 4755 — COVID‑19 Temporary Fee Schedule Codes Implemented — Physicians can begin to submit claims for COVID‑19 on May 1, 2020
Keeping Health Care Providers informed of payment, policy or program changes
To: All Providers
Published by: Claims Services Branch, Ministry of Health
Date Issued: April 30, 2020
Effective May 1, 2020, system changes have been implemented in association with the temporary Fee Schedule Codes (FSCs) listed below. Physicians can now submit claims for these (FSCs).
In support of the government’s efforts to limit the spread of COVID-19 in Ontario, the Minister of Health has made an Order under the authority of subsection 45(2.1) of the Health Insurance Act to temporarily list as insured services the provision of assessments of or counselling to insured persons by telephone or video, or advice and information to patient representatives by telephone or video, as well as two temporary sessional fee codes.
Temporary Fee Schedule Codes K080A, K081A, K082A, K083A and H409A are effective March 14, 2020. Claims for services provided on or after March 14, 2020 can now be submitted.
Sessional Fee Schedule Code H410A is effective March 21, 2020. Claims for services provided on or after March 21, 2020 can now be submitted.
K080: minor assessment of a patient by telephone or video, or advice or information by telephone or video to a patient’s representative regarding health maintenance, diagnosis, treatment and/or prognosis-$23.75
a) intermediate assessment of a patient by telephone or video, or advice or information by telephone or video to a patient’s representative regarding health maintenance, diagnosis, treatment and/or prognosis, if the service lasts a minimum of 10 minutes; or
b) psychotherapy, psychiatric or primary mental health care, counselling or interview conducted by telephone or video, if the service lasts a minimum of 10 minutes-$36.85
K082: psychotherapy, psychiatric or primary mental health care, counselling or interview conducted by telephone or video per unit (unit means half hour or major part thereof) per unit-$67.75
K083: specialist consultation or visit by telephone or video payable in increments of $5.00.
Please refer to ‘Notes’ in ministry INFOBulletin 4745.
Sessional Fee Schedule Codes
H409: COVID-19 Sessional Unit per one hour period or major part thereof, Monday to Friday 7 a.m to 5 p.m-$170.00
H410: COVID-19 Sessional Unit per one hour period or major part thereof, Saturdays, Sundays, holidays, or Monday to Friday 5 p.m to 7 a.m-$220.00
New Diagnostic Code for COVID-19
Effective March 14, 2020, a new diagnostic code has been created for the COVID-19 outbreak.
The new diagnostic code should be used when treating patients with suspected or confirmed COVID-19 and/or when treating a patient by telephone/video for suspected or confirmed COVID-19. Use the appropriate diagnostic code when treating a patient for unrelated diagnoses by telephone/video due to COVID-19 related concerns.
Fee for Service Claim Submissions:
- Eligible payment programs to submit claims for K080A, K081A and K082A include Health Claims Payment program (HCP), Workplace Safety and Insurance Board (WCB) and Reciprocal Medical Billing (RMB) where the billing number is in the range of 010009 to 333798.
- If a physician submits a claim with a billing number outside this range the claim will reject “V35-Invalid OOP/OOC Service”.
- K080A-K083A require a diagnostic code to be submitted on the claim. If claim is submitted without a diagnostic code the claim will reject “V21-Diagnostic Code Required”.
- If a claim is submitted that exceeds the maximum number of services allowable for the temporary fee codes, the claim will reject “A3H-maximum number services FSM”.
- If a claim is submitted under an Assessment Centre group number for these new K codes, the claim will reject “ESF-Not eligible to bill (FSC)”.
- K080A-K082A will pay $0 with explanatory code “D7-Not allowed in addition to other procedure” when K083A has been previously paid or is on the same claim for same physican, patient and service date.
- K083A can only be billed by specialists. If claim is submitted for K083A by physician with specialty code ‘00’ the claim will reject “A3F-No Fee for Service code”.
- If a claim for K080A-K082A has already been paid or appears on the same claim for same physician, patient and service date and a claim is submitted for K083A, the claim will pay at $0 with explanatory code “D7-Not allowed in addition to other procedure”.
- All new fee codes are excluded from telemedicine. If a claim is submitted with an SLI code ‘OTN’, the claim will reject “TM3-Service not payable under telemedicine”.
- K083A-The fee will be set at $5.00 and the physician should submit the number of services necessary to make payment equivalent to a service provided, rounded to the nearest $5.00.
- For Fee Schedule Codes using time units, calculate units by taking the normal fee and rounding it to the nearest $5, then divide that number by 5. For example, K197 (2 units or 46 minutes minimum) is $173.70 ($86.85 per unit). Now round that number to the nearest $5 ($175) and then divide by 5 = 35 units. Physicians should submit this number as the number of services on the claim and a fee billed of $175.
- For Fee Schedule Codes not based on time units round to the nearest $5 and divide by 5. For example, an A485 consultation is $170.10. This rounds to $170 or 34 units. This code would be billed at $170 with the number of services equal to 34.
- K083A when billed by a Primary Care affiliated physician who has a non-‘00’ specialty and who bills with that specialty will pay FFS and the service will not accumulate to any caps or ceilings.
Assessment Centres Fee Schedule Codes H409A and H410A
- H409A and H410A must be billed with the unique group number assigned to each individual Assessment Centre.
- Claims submitted for (FSC)s H409A and H410A are only eligible for payment if submitted with payment type (HCP).
- Claims submitted for Fee Schedule Codes H409A and H410A must be billed with a blank health number (no zeroes or spaces in that field). If not the claim will reject “VHB-No HN Required for (FSC)”.
- Claims submitted for Fee Schedule Codes H409A and H410A must be billed with a blank version code and blank date of birth.
- H409A is for services provided Monday to Friday 7am to 5pm and is not payable on weekends and statutory holidays.
- H410A is for services provided Monday to Friday 5pm to 7am and all day on weekends and statutory holidays.
- If a claim is submitted with an Assessment Centre group number for any fee code other than H409A or H410A, the claim will reject “ESF-Not eligible to bill (FSC)”.
- If a claim is submitted for H409A/H410A and billed with any group number other than an Assessment Centre, the claim will reject “ESF-Not eligible to bill (FSC)”.
- H409A/H410A are excluded non-core services in all Primary Care Patient Enrolment Models and all Primary Care Specialized contracts/agreements.
- H409A/H410A will pay fee-for-service when submitted by any physician who participates in Assessment Centre work.
- Physicians rendering services at the Assessment Centre are not required to apply for affiliation to the Group, but are required to submit their claims for rendered services in conjunction with the group number.
- Physicians should contact their Assessment Centre administrator to obtain their group number in order to submit their claims.