Bulletin 210310 — Medical Claims Adjustment for E405A
A Medical Claims Adjustment for E405A premium and anaesthesiology extra units will appear on March RA
To: All Physicians
Category: Physician Services
Published by: Claims Services Branch, Ontario Health Insurance Plan Division
Date Issued: March 30, 2021
Further to INFOBulletin 4758 titled ‘Temporary Fees for Identified AGMP Procedures-COVID-19-Hospital Physician Compensation’ and INFOBulletin 201105 titled ‘COVID-19 Hospital Physician Compensation: E405A Changes’, the Ministry of Health (ministry) implemented temporary payments for specified physician services provided in hospital as a result of COVID-19.
As per INFOBulletin 201202, an issue occurred during the implementation of this Fee Schedule Code (FSC) where E405A was not paying with some anaesthesiology extra unit fee codes.
A system solution was implemented on December 1, 2020, that calculates the amount for the E405A premium when billed with one or more eligible anaesthesiology extra unit fee codes. Note: The ministry will perform a Medical Claims Adjustment (MADJ) to reprocess previously submitted E405 premium claims on eligible anaesthesia extra units. The premium will be adjusted to pay 30% of the fee paid (fee approved for shadow billed claims) on the applicable extra units claimed for services dates between April 3, 2020 and July 31, 2020. No further action is required by physicians.
The eligible anaesthesiology extra unit fee codes are as follows:
Patient with body mass index (BMI) > 40.
Patient in prone position during surgery.
Patient who is known to have malignant hyperthermia or there is a strong suspicion of susceptibility, and the anaesthetic requires full malignant hyperthermia set up and management.
American Society of Anaesthesiologists (ASA) V-moribund patient not expected to live 24 hours with or without operation.
ASA IV-patient with incapacitating systemic disease that is a constant threat to life.
ASA E-patient undergoing anaesthesia for emergency surgery which commences within 24 hours of operating room booking, to E022C, E017C or E016C.
Premature newborn less than 37 weeks gestational age.
ASA III-patient with severe systemic disease limiting activity but not incapacitating.
Patient in sitting position during surgery, greater than 60 degrees upright.
Unanticipated massive transfusion-transfusion of at least one blood volume of red blood cells.
The change implemented on December 1, 2020 to apply the 30% complexity premium to the anaesthesia extra units listed on page GP97 of the Schedule of Benefits did not include the automated Anaesthetic Age Premiums (E007C, E009C, E014C, E018C and E019C). The 30% complexity premium will be calculated and paid separately on these extra units (E007C, E009C, E014C, E018C and E019C) and further information will be communicated in a future INFOBulletin.
Medical Claims Adjustment
Due to this issue, a Medical Claims Adjustments (MADJ) was required to reprocess claims for the temporary FSC E405A and anaesthesiology extra units.
- E405A claims submitted prior to December 1, 2020 that were billed with anaesthesiology extra units for service dates between April 3, 2020 and July 31, 2020 will be reprocessed.
- E405A claims submitted after December 1, 2020 with anaesthesiology extra units were paid correctly as the system fix was implemented.
- Adjustments will appear on the March 2021 Remittance Advice (RA).
- Please note that during the MADJ process, the claims processing system selects an entire claim for reprocessing.
- A single claim can include multiple fee schedule codes and all codes will be reprocessed.
- Claims that were reprocessed will appear on the Remittance Advice (RA) with explanatory code ’55-This deduction is an adjustment on an earlier account’ and ’57-This payment is an adjustment on an earlier account’.
“E405A: COVID Hospital Complexity Modifier” is a temporary new fee code to enable the payment of the temporary modifier of 30% for Aerosol Generating Medical Procedures (AGMP). Read more about this code in bulletin 4758.
E405A; COVID-19; Hospital Complexity; premium; Aerosol Generating Medical Procedures; AGMP;
For more information
Schedule of Benefits for Physician Services
The latest version of the Schedule of Benefits for Physician Services is available on the Ministry of Health website. Hard copies of the Schedule of Benefits for Physician Services will not be distributed. If you would like to order a paper copy or compact disk (CD) of the Schedule for a fee, please visit Publications Ontario. Physicians without access to the Internet can contact ServiceOntario at
Please review the Health Insurance Act
This bulletin is a general summary provided for information purposes only. Physicians are directed to review the Health Insurance Act, Regulation 552, and the schedules under that regulation, for the complete text of the provisions. You can access this information at ontario.ca/laws. In the event of a conflict or inconsistency between this bulletin and the applicable legislation and/or regulations, the legislation and/or regulations prevail.