Bulletin 231106 — PSA related adjustments to Schedule of Benefits - Release 6
New payment rules are being applied to fee schedule codes E182A, E183A, E184A, E185A, E877A, G552A and K133A
To: All physicians
Category: Physician services
Written by: Claims Services Branch; Health Programs and Delivery Division
Date issued: November 10, 2023
Bulletin Number: 231106
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 6 changes are being implemented November 1, 2023, with an effective date of April 1, 2023.
The following fee codes will be affected by the change:
- E182A - transposition of extraocular muscle to treat paretic or lost, damaged eye muscle
- E183A - superior oblique muscle (per muscle)
- E184A - inferior oblique muscle (per muscle)
- E185A - horizontal or vertical rectus muscle (per muscle)
- E877A - repeat strabismus procedure(s)
- G552A - removal of intrauterine contraceptive device
- K133A - periodic health visits for adults with Intellectual and Development Disabilities (IDD)
The new fee codes are payable as follows:
Any combination of four services of E182A, E183A, E184A and/or E185A may be billed by any physician for the same patient for the same date of service. The highest paying service will pay in full, and any subsequent services will pay at 85%.
For example, if a physician were to claim one E183A, two E184A and one E185A for the same patient and date of service, E183A will pay at 100%, and the other three services will pay at 85%.
If any combination of four of the above strabismus fee codes have already been paid, any additional strabismus fee codes submitted by any physician for the same patient for the same date of service will pay at zero dollars with explanatory code ‘M1 - Maximum fee allowed or maximum number of service has been reached same/any provider’.
E877A will pay 30% of the fee approved value on any combination of E182A, E183A, E184A or E185A billed by the same physician for the same patient and same date of service, on the same claim or on history.
If E877A is submitted and E182A, E183A, E184A, and/or E185A is not approved on the same claim or on history, E877A will pay at zero dollars with explanatory code ‘DF – Corresponding fee code was not billed or paid at zero’.
Removal of Intrauterine Contraceptive Device (IUD)
G552A is not eligible for payment for the same patient, on the same service date, by the same physician as G378A.
If G552A is submitted with G378A on the same claim, for the same service date, G378A will pay in full and G552A will pay at zero dollars with explanatory code ‘D7- Not allowed in addition to other procedure’.
If G552 has been paid previously for the same patient, same service date by the same provider, and G378A is submitted for payment, G378A will be reduced by the amount of the G552A ($20.00) with explanatory code ‘DC – Procedure paid previously not allowed in addition to this procedure fee adjusted to pay the difference’.
If G378A has been paid previously and G552A is submitted for the same patient, same service date by the same physician, G552A will pay at zero dollars with explanatory code ‘D7 - Not allowed in addition to other procedure.’
Periodic health visit for Adults with Intellectual and Developmental Disabilities (IDD)
K133A is only eligible for payment when billed with one of the following diagnostic codes: 299, 319, 343, 741, 758. If K133A is not submitted with one of these diagnostic codes, the claim will reject with error code ‘V16 - Unacceptable Diagnostic Code’.
K133A is not eligible for payment for the same patient, same physician, within the same 12-month period as K130A, K131A, K132A, K017A, K267A, K269A or any long-term care periodic health visit.
- If K130A, K131A, K132A, K017A, K267A, K269A or a long-term care periodic health visit has been previously paid, and K133A is submitted for the same patient, same provider, within the same 12-month period, K133A will pay at zero dollars with explanatory code ‘R1- Only one health exam allowed in a twelve-month period.’
- If K133A is previously paid and K130A, K131A, K132A, K017A, K267A, K269A or a long-term care periodic health visit is submitted for the same patient, same provider within the same 12-month period, the incoming service will pay at zero dollars with explanatory code ‘R1- Only one health exam allowed in a twelve-month period.’
K133A is eligible for payment with add-on code E079A.
Medical Claims Adjustments (MADJ)
Due to staged implementations, Medical Claims Adjustments may be required. Further information will be provided in advance of a Medical Claims Adjustment.
Please note: No action is required by the physician.
E182; E183; E184; E185; E877; E542; G552; G378; K300; K301; K133; K130, K131, K132; K017; K267; K269; E079; Physician Services Agreement; PSA; Physician Payment Committee; PPC
Do you have questions about this INFOBulletin? Email the Service Support Contact Centre or call 1-800-262-6524. Hours of operation: 8:00 a.m. to 5:00 p.m. Eastern Monday to Friday, except holidays.