OHIP BILLING for ANESTHESIOLOGY (Updated November 2007) Getting started. Keeping on track Review the SOB (Schedule of Benefits) on line at either the OMA website or the MOHLTC website at www.health.gov.on.ca/english/providers/providers_mn.html#ohip. Another good place to look is the Physician Manual at the website www.health.gov.on.ca/english/providers/pub/ohip/physmanual/physmanual_mn.html. Read the Preamble of the SOB, paying particular attention to the section for Anesthesia (pg. GP54) The schedule has just been updated October 2007. Updates may occur every 6 months so be vigilant for any increases/changes. Remember: everything we do is billable. Submit your bills as soon as possible. Please check to see that the correct date is on the top with the month in writing rather than numbers. GENERAL PREAMBLE: The Anesthesia unit is currently worth $12.51. The minimum basic unit is 6 for any anesthesia code. All anesthesia service codes should have the suffix C. (This means that the claim is being submitted for the anesthesia component.) In general, the A prefix is used with consultations/assessments in outpatients or in-hospital emergency/urgent situations; C denotes any other type of in-hospital assessment. Note: EPACU patient visits must be billed as A013/A014C since it is not designated as an in-patient hospital. All assessments, visits and consults require a Diagnostic Code. Consultations (A015A, C105A ): -requires a written request either in the form of a letter or an order in the patient s chart -requires a written response, either as a letter or in the patient s chart -requires a Diagnostic Code *these can be found in the Physician Manual at the site noted above in Section 4. Some commonly used codes are attached at the end of this outline. The diagnostic code does not have to be accurate, just present.
- The A prefix should be used preferentially (usually paid without difficulty) as most consults are urgent/emergent situations. Repeat Consultation (A/C 016A): - requires all of the above and some element of interval care which changes the situation and therefore requires another consult (written) Limited consultation for Acute Pain Management (C215A): -must be requested by another physician -is for other than chronic pain or routine post-op pain management (routine is im/sc injections) -must perform a specific assessment and submit opinions in writing Specific Assessment (A013A): -requires a full history of presenting problem and focused physical and documentation in chart -this is the code most often applicable for PACU assessments or EPACU assessments requested due to specific problems Partial Assessment (A014A): -focused history/physical to assess response to treatment or advice -same as subsequent visit - usual EPACU assessment day of surgery AND morning following surgery Preoperative or Pre Dental General Assessment (A903A): -is a general assessment required prior to surgery under anesthesia in a hospital -can be done by anesthesia as long as it is not done on the same day as the surgery -does not require a written request or diagnostic code Detention (K001A per ¼ hour): -read preamble -not always paid by OHIP so try not to use this Subsequent Visit (C012A): -routine assessment in hospital -limited to one/day (day means calendar day) MAC (Monitored Anesthetic Care) = E003C B6 -premiums apply -is only for standby when no interventions are done -if medication is given, then bill the surgical procedure code
Specific Anesthetic Services (C suffix): Basic units plus time units plus add on codes times any premiums for after hours (1700-0700) Time units : value for each 15 minute period or part thereof o During the first hour or less = 1 unit/15 minutes or part of o After the first hour but before the second hour = 2 units/15 minutes or part of o After the second hour = 3 units/15 minutes or part of Anesthesia afterhour premiums for surgical procedures and obstetrical anesthesia: o Evenings (1700-2400) Monday to Friday or daytime and evenings Weekends and Statutory holidays = E400C = 50% o Nights (0000-0700) =E401C= 75% o Payable when the case starts Anesthesia afterhour premiums for major invasive procedures*: o Evenings (as above ) = E409C =50% o Nights (as above) = E410C = 75% o *The codes which we can apply these afterhour premiums to are : G125A, G246A (lumbar epidurals), G268A, G269 A(arterial and central lines), G211A (intubation) Special Visit premiums: - payable when you are required to make a special visit to the hospital - consider billing this for the first case you do after starting call o Evenings (as above) = C998C, add $54.55 o Nights (as above) = C999C, add $80.25 Cancelled surgery: - if you have seen the patient but not started anything, bill a visit - if you have started the anesthetic but not the surgery, bill E006C B6 plus time (or the basic for the case, if you feel justified) - if the surgery is started and aborted, bill full procedure codes Second Anesthetist : - E001C B6 plus time plus premiums. Add on units (can be added in addition to any code with base units, even if the Base is 0): Premature newborn less than 37 weeks E021C B9 Newborn E014C B5 Infant from 29 days to 1 year E009C B4 Child from 1 to 8 years inclusive E019C B2 Adult aged 70-79 years inclusive E007C B1 Adult 80 years and older E018C B3 Patient with BMI >45 (must be noted on the chart) E010C B2 Patient in prone position E011C B4 Patient with MHS E012C B5
Patient requiring controlled hypotension E004C B10 ASA 3 E022C B4 ASA 4 E017C B10 ASA 5 E016C B20 For patients seen on a visit to ICU or CCU C101C $8.50 Emergency case, ASA 3+, if case started within 24 hours of booking E020C B4 Trauma premium E420C(p.GP62): applies to claims on day of trauma or within 24 hours; adds 50% to all consults, resuscitation codes and anesthesia codes; requires the ISS score to be on the medical record and greater than 15 for an adult. Injury Severity Score ISS See calculator on www.anesthesia.ca (Links) Special circumstances: - in the following situations, the base units are replaced by the following base units when Cardiopulmonary bypass is done with an anesthetic E650C B28 Hypothermia E002C B25 Anesthetic management for the emergency relief of acute upper airway obstruction (above carina) E013C B10 Other codes of interest: Arterial puncture G459A Arterial cannulation G268A Central venous cannulation G269A Pulmonary artery catheter Z438A Thermal dilution CO G360C (max once/day for 5 days) Endotracheal intubation for resuscitation G211C Bronchoscopy (for intubation) Z327A Bronchoscopy for placement of endobronchial blocker or double lumen tube Z342A Cardioversion Z437C B5 ECT in patient G478C ECT out patient G478C Nasogastric tube placed during anesthesia G322C Insertion of duodenal feeding tube Z540 Resuscitation: (needs Diagnostic Code) Life threatening emergency First ¼ hour G521A Second ¼ hour G523A After first half hour, for every 15 minutes or part thereof G522A Other resuscitation ( see J17), not usually applicable but can be used for Code 99 if it was a minor type of resuscitation First ¼ hour G395A
After first ¼ hour, for every 15 minutes or part thereof.g391a Nerve Blocks: (p.j41) -these cannot be billed if they are the sole anesthetic but only if they are done to provide postoperative pain relief Epidural catheter insertion for analgesia: Lumbar G246A -if concurrent with anesthesia time units, G 125A Thoracic G117A -if concurrent with anesthesia time units, G118A Visits: G247A max 4/day (plus premiums where applicable; E402 from1700 to 2400 hrs weekdays or daytime and evenings on Sat/Sun; E402 from 2400 to 0700 hours) Lumbar puncture Z804C Lumbar puncture with instillation of medication Z805A G228A Paravertebral nerve block (any) G123A additional pv blocks, max. 4 Intercostal blocks Sciatic nerve block (for ankle) Femoral nerve block = 3:1 block G260A always Brachial plexus Obstetrical Anesthesia/Analgesia: Epidural Acute Pain assessment C215A (with diagnostic code, suggest 787) + Insertion of catheter P014C B6 Maintenance P016 (one unit for each ½ hour, to a max of 12, for each calendar day this means that you can rebill after midnight but.) Premiums E400C,E401C Premiums for obesity, ASA class can be added Delivery Standby or top up E100C time units only (suggest using the other standby code for MAC..) Operative delivery (forceps, vacuum) P020C B6 Repair of tear or extension of episiotomy P028C B6 PPH, including uterine curettage Z774C B6 Removal of retained placenta P029C B6
C-section P018C B7 + Z805A if intrathecal narcotics are given Remember to bill C012A for next date (code 650) IV PCA Consult plus visits (only one/day) plus delivery attendance prn Neonatal resuscitation (see Obstetrical Preamble p.k2) If applicable, can bill full resuscitation codes or intubation plus specific assessment Some Common Diagnostic Codes for Consultation billing: Coronary Artery Disease 412 CHF 428 Atrial Fib 427 Diabetes 250 CVA 436 PVD 443 Dementia 331 Coagulopathy 286 COPD 496 Other respiratory system 398 HTN 401 Obesity 278 Pre-eclampsia 642 Pain assessment Abdomen 787 Chest 785 Joint/leg 781 Muscle 781 Headache 780 Hypotension 447 Shock 785 Asthma 493 Sleep apnea 307 Anxiety 300 Seizures 780 M.H. 367 M.S.340 Myoneuronal disorders 367 M.D.359 Pregnancy 650 Billing for Cardiac and Critical Care (CVRI): CVRI patients = Comprehensive Care G557A 1 st Day G558A 2 nd Day
**This is an all-inclusive fee to which nothing can be added*** Call back for Cardiac case = Bill Special Visit premium C998 or C999 + case TEE Specific assessment or consult plus E001 plus G580 (probe insertion) plus G581A (professional component). Call also bill Special visit premium if it is afterhours. Cardiac Surgery (p. Q2) E650C B28 replaces the basic unit fee for all cases using cardiopulmonary bypass Add on codes are applicable If surgeon wants BP low post pump, bill controlled hypotension ACUTE PAIN SERVICE BILLING This service is being billed automatically once the patient in entered into the APMS site. The billing for the blocks will also occur here so you should not put them on your pink sheet if you are entering this information into the pain site. IV PCA: Initial assessment = C215A (acute pain assessment) or A015A(consult) Daily visits C012A (once/day) Consider billing another assessment A013C or Partial Assessment A014A if it is complicated No premiums EPIDURAL: If epidural is placed in PACU prior to procedure by a different doctor, bill the full code. If it is placed in the OR or concurrent with time units, bill the reduced code. There are different codes for lumbar and thoracic. Visits: We should bill 4/day for all; suggest 2 at daytime rate and 2 at premium rate. NERVE BLOCKS: These can be billed in addition to the operative procedure if they are not used as the sole anesthetic. They are only placed to provide postoperative pain relief, as we know. They are billed in full, according to the value in the nerve block section in Diagnostic and Therapeutic procedures.
There is currently no code for a catheter or for more than one visit/day (this may change soon). If you put in a continuous catheter and rebolus to reestablish the block, I recommend billing the block again (no more than once/day). Can also bill for specific or partial assessment at that time. There are no premiums for any of these procedures or assessments.