Bulletin 230601 — PSA related adjustments to Schedule of Benefits: Release 3
System changes implemented to ensure new fee codes are paid in accordance with the Schedule: therapeutic paracentesis and virtual care
To: All physicians and hospitals
Category: Physician Services
Written by: Claims Services Branch, Health Programs and Delivery Division
Date issued: June 13, 2023
Bulletin Number: 230601
The Ministry of Health and the Ontario Medical Association have been working together to implement the 2021 Physician Services Agreement.
As described in INFOBulletin 230310, permanent adjustments to fee schedule codes within the Schedule of Benefits for Physician Services (the Schedule) have been made effective April 1, 2023. Adjustments to the claims payment system related to these Schedule changes are being introduced through staged implementations to ensure correct payment of claims in accordance with the Schedule.
The following Release 3 changes are being implemented June 1, 2023, with an effective date of April 1, 2023.
As a result of staged implementations, physicians may have experienced incorrect payment of newly introduced fee schedule codes when billed in conjunction with virtual care modality indicators (K300A or K301A).
Adjustments to the claims payment system have now been completed to enable correct processing of these services billed with modality indicators when eligible for payment in accordance with the Schedule.
Services that have previously been submitted for payment and disallowed with ‘B8 - Service Not Eligible for Payment Virtually’ will be adjusted and paid at the correct value in the coming months. No further action is required on the part of physicians.
In scenarios where a previously submitted claim has rejected with ‘AT3 – No patient-physician relationship’, resubmission will be required after the claim establishing the patient-physician relationship has been approved.
For information about virtual care billing and related error codes please see Bulletin 221203 — Virtual Health Care in Ontario. For additional guidance including examples of virtual care billing, please refer to the Education and Prevention Committee Billing Briefs on this topic:
- Virtual Care 1: Comprehensive and Limited Virtual Care Services
- Virtual Care 2: Terms and Conditions
- Virtual Care 3: Case-Based Billing Examples
Z851A – Therapeutic Paracentesis
As described at page Y2 of the Schedule, Z851A is not eligible for payment in combination with E147A or E149A for the same patient, on the same date of service.
To ensure that therapeutic paracentesis services are paid in accordance with the Schedule, the claims payment system will now disallow Z851A with explanatory code ‘D7 – Not allowed in addition to other procedure’ if billed by the same physician, for the same patient, on the same date of service as E147A or E149A.
In scenarios where Z851A has been paid and E147A or E149A is subsequently submitted for payment, the E147A or E149A will be reduced by the amount of the Z851A ($70.00) with explanatory code ‘DC - Procedure paid previously not allowed in addition to this procedure - fee adjusted to pay the difference’.
Please note: When medically necessary therapeutic paracentesis is performed in conjunction with E147A or E149A, fee code E175A may be eligible for payment. Please refer to the relevant payment rules on page Y6 of the Schedule.
Therapeutic paracentesis services that have been previously submitted and paid may be adjusted and paid at the correct value in the coming months.
Z851; Virtual Care; Comprehensive virtual care; A021, A111, A114, A116, A118, A210, A710, A713, A715, A915, A930, C111, C112, C114, C116, C117, C118, C119, C210, C710, C713, C715, C915, C930, K042, K132, W930, E088, E098, E424, E150, K711; Physician Services Agreement; PSA; Physician Payment Committee; PPC