travel premium code ohip

When can I bill special visit premiums?

Click here for a general guideline to All OHIP Special Visit Premiums. ​ Click here for a printable version. ​ SPECIAL VISIT PREMIUMS  

May only be applied with non-elective (urgent and emergent) consults and assessments.

May not be claimed for routine rounds.

May not be claimed for visits to admit elective patients.

Always use the “A” prefix general listing visit codes.  The “C” prefix consult codes are strictly for non-emergency inpatient consults (and therefore no special visits apply).

Travel Premium

Applies only to the First Person Seen. 

This is used when travel is required to the facility to see a patient and is always billed with the “First Person Seen”.   Any additional patients seen on the same visit are billed with the “Additional person(s) seen” premium instead.  

There is a special visit premium table for different visit locations.

Be sure to use premiums that MATCH the SLI (service location indicator) on the claim.  

NOTE: If a patient is being seen in the Emergency Department but is being admitted use the SLI - HIP but use  Emergency Department special visit premiums AND enter the admission date.    This indicates to OHIP that the patient was seen in ER and then admitted.  This is especially important if you are billing E082 (admission assessment by MRP)

Special visit premiums do not apply to subsequent hospital inpatient visits.

Visit fees and related premiums must be kept together on the SAME bill. ​ ​ ​

Want to know how to maximize your Ontario Billing? Check out our OHIP Billing Guide. ​

Motivehealth

Special Visit Premiums

How they work & when to use them.

Special Visit Premium Codes (SVPs) act like a bonus on top of your fee service codes. This incentive is used to compensate physicians who have specific specialties or sub-specialties or who provide care outside of their regular schedule. They can significantly increase your monthly revenue, however they can only be used in conjunction with an appropriate A-prefix consult or assessment fee. SVP’s can also provide you extra earnings if you work on a holiday or weekend, see below for a list of holidays.

The Ministry of Health’s Special Visit Premium dates observed.

They can be broken down into four time brackets:

• Weekdays – Daytime (07:00 – 17:00) OR Weekdays – Daytime (07:00 – 17:00) with Sacrifice of Office Hours
• Evenings – (17:00 – 24:00) Monday through Friday
• Sat, Sun & Holidays (07:00 – 24:00)
• Nights – (00:00 – 07:00)

They can be applied in 3 scenarios:

• Travel Premium — applies when you travel from any place other than the hospital where the service is performed.
• First Patient Seen — applies to your first patient seen. *If your shift spans past midnight, you can bill another ‘first persons seen’ for that new day.
• Additional Person(s) seen — Remember to bill for each additional patient seen after you’ve billed your first patient, in chronological order – maxes out depending on department and time. (see schedule below)

Special Visit Premiums are department-specific, so they can be used by any specialty:

• Emergency Department
• Hospital Out-Patient Department
• Hospital In-Patient
• Long-Term Care Institution
• Emergency Department by Emergency Department Physician
• Special Visits to Patient’s Home (other than Long-Term Care Institution)
• Palliative Care Home Visit
• Physician Office
• Other (non-professional setting not listed)
• Geriatric Home Visit
• Obstetrical Delivery with Sacrifice of Office Hours

*Bolded are commonly used SVP’s tables. See all Special Visit Premium tables here: http://www.health.gov.on.ca/en/pro/programs/ohip/sob/physserv/sob_master20160401.pdf#page=60

When you are providing a special visit service, proper documentation should be recorded:

• Requested by (Physician or Nurse)
• Travel – you can bill up to 2 travel premiums per day and 6 on weekends/holidays, but it must be documented that you left the facility grounds and had to return in order to receive payment for 2nd travel premium
• First patient seen

Special Visit Premium Examples:

Example 1 – being called in from home.

Dr. Apple is called in to attend an ER consult on Friday at 12pm. He will bill:

Patient 1 A130 – consultation K960 – travel premium – $36.40 K990 – first emergency patient seen – $20

He is then asked to consult on another patient while there, he bills:

Patient 2 A130 – consultation K991 – additional emergency patients – $20

Tip  If Dr. Apple admits either patient, he can also add the E082 Admission Premium to these claims.

*Please note: each Special Visit Premium has a limited number of use, highlighted in red

Example 2 – Being called from within the hospital:

Dr. Apple gets called to consult on an in-patient. This is a first consult outside of his normal schedule of the day and the time is now 8pm. He will bill an A code from his General Listings:

Patient 1 A435 – consultation C994 – first patient seen: evening – $60

* A travel premium is not applicable in this instance, as he is travelling within the hospital.

For more information on Special Visit Premiums, visit the OHIP Fee Schedule: http://www.health.gov.on.ca/en/pro/programs/ohip/sob/physserv/sob_master20160401.pdf#page=60

Updated: OHIP Billing Code Refresher – Palliative Care

• January 20, 2021

Providing important palliative care is good for your patients and can lead to a $5,000 bonus .

Palliative care is a service that provides specialized medical care to patients that are experiencing a serious illness. The primary physician in charge of the palliative care patient is required to develop a comprehensive care plan for the last year of life expectancy for the patient. With the focus on caring for the patient, it is often difficult for doctors to also spend time trying to understand and manage their billings. In response to these challenges, we have put together a summary of the palliative care codes in order to make the billing process easier and to help physicians save time in figuring out how to bill the codes to maximize their revenue. 

The codes that we see at DoctorCare being billed often by primary care physicians include: 

• K023 – Palliative Care Support (>20min)   This time-based K code is recommended for services provided in the office or at home. If at home, there are rules and additional codes you need to bill (based on time and day). Please remember to document start and stop times. 
• G511 – Telephone Management of Palliative Care This is the telephone support code you can bill if you provide support over the phone to the patient or family. 
• G512 – Palliative Care Case Management Fee This is the case management code you can bill when you provide supervision of palliative care to the patient for a period of one week, starting at midnight on Sunday. 
• B966 – Palliative Home Visit – Travel Premium   This code is billed for travelling to a patient’s home for a visit. This code can be billed as many times as needed. 
• B997/B998 – Palliative Home Visit – First Person Seen   This code is only applied for the first person seen on that day during the home visit. This code can be billed as many times as needed. 

Home Visits  

Note, for home visits, you likely will be billing three codes for that one home visit (K023/A900 + B966 + B997/B998). As a best practice, we recommend billing the K023 when you spend more than 20 minutes providing care to a patient. The A900 (complex house call assessment) may be billed on patients that are frail and elderly or housebound when the visit is under 20 minutes. 

Additional Related Codes  

Other codes that you may bill for providing services relevant to palliative care include the following home care codes: 

• K070 for home care application 
• K071 for acute home care supervision (first 8 weeks) 
• K072 for chronic home care supervision (after 8th week) 
• K015 for counselling of relatives 

Special Premium Bonus  

There is also a special premium bonus for providing these services. In the fiscal year, if you bill K023, C882, A945, C945, W882, W872, B997 and B998 on any patient (rostered or non rostered), it will count for the palliative care special premium bonus. 

• Ontario Medical Association (OMA) has excellent resources that contains even more codes for case conferences, special consultations, etc. 
• Download our Quick Reference Guide for a quick one-page reference on palliative care codes.
• Request a complimentary FHO special premiums use analysis from us and see how you can maximize your billings.

Need assistance in billing your codes? We’re happy to help.

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Understanding and Correcting EH2 and VH9 OHIP Billing Errors

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Special Visit Premiums: The Long Weekend Edition

August 25th, 2014 OHIP Billing Codes A195 , A895 , C963 , C986 , C987 , K963 , K998 , K999 , OHIP Premiums , Schedule of Benefits

Well there is. Special visit premiums (SVPs) are designed for those times when physicians are called unexpectedly to care for patients and – beyond a few limitations – add a generous boost to a doctor’s income. Although most doctors are aware of SVPs for evening and night shifts, many still don’t know that unique weekend/holiday SVPs are available, and with Labour Day (and the end of the summer…) approaching quickly, we thought we’d discuss them.

How to apply SVPs to my billing

Special Visit Premiums can be confusing because of all the rules, restrictions, and limitations. In a future blog post, we will explore these in detail. For now, however, we’re going to define a special visit as a “visit initiated by a patient or an individual on behalf of the patient for the purpose of rendering a non-elective service”. This is from GP43 of the Schedule of Benefits .  Any unexpected visit to a patient on a holiday or weekend is eligible for a SVP, except if the visit is part of hospital rounds or if the visit would be considered routine. Further, if the physician is following up on his or her own patient at his or her discretion, no special visit has taken place and no SVP would be payable.

The MOH has two different categories of SVPs for weekends and holidays – one for the first patient a physician sees at the destination, and one for any additional patients the physician sees on that same trip. The MOH also has a travel premium that’s payable on the first patient seen when the physician travels to the hospital from outside of hospital grounds.  To complicate things further, the SVPs are different depending on where the patient is seen, for instance in the Emergency Department or on the Ward. See the chart below:

For weekends and holidays, SVPs have very generous maximums. Physicians are limited to a maximum of 20 SVPs per day and up to 6 travel premiums in the Emergency Department and the same maximums for SVPs and travel premiums on the ward. Remember too that if you see a patient between midnight and 7am on a weekend or holiday, the night time special visits and travel premiums should be billed as they are worth more.

Example of Special Visit Premium Billing on Labour Day

Dr. G, one of our Internal Medicine Specialists, is on-call at her hospital on Labour Day .  At 8am, she gets called in to consult on a patient in the ED and travels from home. While there, Dr. G is asked to consult on two other ED patients and is then asked by staff to see two in-patients on the ward. After seeing these patients, Dr. G decides to round on two of her own patients that she’d been following all week as MRP. Here’s what she would bill:

Note for Psychiatrists: When billing SVP’s, use  A895  instead of A195.  It’s not only the rule, it’s worth more!

Dr. G now catches a break and heads home. At 2:20pm, she’s called back to the ED for a couple of new consultations, and the process starts again with a new first patient seen premium (K998) and a new travel premium (K963). What if Dr. G forgot to add a SVP for a patient? No problem – we always keep a sharp eye out for that sort of thing and would have corrected her billing already.

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Physician payment

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This document is technical in nature and is available in English only due to its limited targeted audience.

This publication has been exempted from translation under the French Language Services Act .

General Preamble of the Schedule of Benefits for Physician Services

The following is intended to be a brief overview of the critical elements within the General Preamble of the Schedule of Benefits for Physician Services (Schedule), and not a substitute for the actual document. In the event of a conflict between this overview and the full text of the General Preamble, the General Preamble prevails. Physicians are responsible for being familiar with all legislation and regulations applicable to the services they provide, including all relevant sections of the Schedule. All claims for payment will be assessed in accordance with the Schedule and not with this overview. Schedule changes may have taken effect since publication and the current version of the Schedule should always be consulted for the applicable payment rules.

Separate fee schedules exist for insured services provided by dental surgeons and optometrists, medical laboratories (licensed under the Laboratory and Specimen Collection Centre Licensing Act ) and facility fees for independent health facilities (licensed under the Independent Health Facilities Act ).

OHIP schedules of benefits and fees are posted electronically.

The first section of the Schedule is the General Preamble. The General Preamble provides important billing information that applies to services listed in the Schedule, including definitions of key terms used in the Schedule, common and specific elements of insured services, and descriptions of various consultation and assessment types.

It is necessary to review the General Preamble in addition to the service specific sections of the Schedule to have a complete understanding of the requirements for a service.

The following is an overview of the issues and information contained within the General Preamble that may guide you in a more detailed examination of the General Preamble.

Services insured by OHIP

The Ministry of Health (ministry), on behalf of the General Manager of the Ontario Health Insurance Program ( OHIP ), makes payments for services insured by OHIP in accordance with the legislative requirements of the Health Insurance Act ( HIA ) and its regulations including the Schedule of Benefits for Physician Services (Schedule).

The Schedule is a document incorporated by reference into Regulation 552 under the HIA and is amended only by regulation change. The Schedule lists approximately 6,000 physician services and the conditions under which each service can be claimed to OHIP . The Schedule is comprised of a General Preamble with rules of general application to all listed services, rules of general application to subsets of listed services separated by medical specialty, and rules and descriptions specific to individual listed services.

The HIA and Regulation 552 provide additional guidelines to help determine when a service is or is not insured and should be read along with the Schedule. For example, subsections 24(1) and (2) of Regulation 552 provide circumstances when a service listed in the Schedule is not insured, unless an exception in subsection 1.0.1, 1.1 or 1.2 applies.

According to the HIA , services are only insured when medically necessary.

Medical records

All insured services must be documented in the medical record. In addition to fulfilling professional requirements, this record is used as evidence of care. It must be clear from the medical record what services were provided, whether the OHIP payment requirements were met and whether the services provided were medically necessary. For example, for services insured only when a specific medical indication is present, the presence of the indication must be clear in the medical record.

For many procedures that may be considered cosmetic, the Schedule requires the physician obtain prior approval from the ministry. This requirement is specifically listed in notes next to applicable fee codes and/or in Appendix D of the Schedule. Download the “Request for Approval of Payment for Proposed Surgery” (0691-84) .

Common and specific constituent elements of insured services

Common elements are the components that are included in the payment for all insured physician services. The common elements are listed in the General Preamble. In contrast, specific elements are components that only apply to specific groups of services. The General Preamble lists specific elements that apply to some groups of services (example: assessments). However, specific elements for other groups of services may be listed in the additional preambles throughout the Schedule (for example: the surgical preamble).

Payment for an insured service includes compensation for performing any applicable common and specific elements of the service, as well as the skill, time and responsibility involved in performing the service. All elements taken together are referred to as the constituent elements of a service.

Unless the Schedule specifically states otherwise, the elements that are common to all insured services and not separately payable include:

• being available to provide follow-up insured services to the patient or making arrangements for coverage when you are not available
• making any arrangements for appointment(s) involving the insured service
• obtaining and reviewing information (including taking history) to make the appropriate decisions to perform elements of the service
• obtaining consents or delivering written consents
• keeping and maintaining appropriate medical records
• providing any medical prescriptions , except where the request for this service is initiated by the patient (or their representative) and no related insured service is provided
• preparing or submitting documents , records or information for use in programs administered by the ministry
• conferring with or providing advice, direction, information or records to physicians and other professionals associated with the health and development of the patient
• providing premises, equipment , supplies and personnel for the service
• please refer to the General Preamble for the full text

Please refer to the General Preamble for the full text.

Specific elements of assessments

Specific elements of assessments are included in the payment for all insured assessments and services that include assessments (for example: consultations). A direct physical encounter with the patient, including any appropriate physical examination and ongoing monitoring of the patient’s condition where indicated, is included in the payment for all assessment and services that include assessments. These services cannot be delegated.

Payment for an insured assessment includes compensation for performing any applicable common and specific elements of the service, as well as the skill, time and responsibility involved in performing the service. These specific elements include:

• other inquiry , including patient history, carried out in order to arrive at any opinion as to the nature of the patient’s condition, appropriate procedures, related services and/or follow-up care which may be required
• performing any procedure(s) during the same encounter as the physical examination unless separately listed in the Schedule and payable in addition to the assessment (examples include obtaining specimens, preparing the patient, interpreting results)
• making arrangements for related assessments, procedures, therapy, interpreting results and appropriate follow-up care
• discussion with and providing advice and information, including prescribing therapy to the patient (or their representative) by telephone or otherwise on matters related to the service and when appropriate, to convey the results of a related procedure prior to future patient visit (example: it would not normally be necessary to schedule a second visit with a patient to review the results from a diagnostic test such as a throat swab; however, if an examination such as an exercise stress test was ordered in the first appointment, then it may be necessary to have the patient return for a second appointment to discuss the results and the second appointment would accordingly be an insured service for which a claim for payment could be submitted)
• when medically indicated, monitoring the condition of the patient and intervening until the next insured service is provided
• providing the premises, equipment, supplies and personnel for the specific elements of the service (except for those performed in a hospital or long-term care home)
• annual limits may apply to various codes, including individual consultation and assessment codes

Please refer to the General Preamble for the full text as well as specific elements for other groups of services (example: specific elements of psychotherapy, psychiatric and counselling services).

Assessments

The Assessments section of the General Preamble lists descriptions for various types of assessments listed in the Schedule. The information below is intended to be provided as a summary of frequently claimed assessments. Please see the General Preamble of the Schedule for a full list of assessments and descriptions.

A general assessment (A003) is a family practice service provided somewhere other than the patient’s home and includes a full history (including medical, family and social history) and except for breast, genital or rectal examination where not medically indicated or refused, an examination of all body parts.

A periodic health visit is a general assessment of an individual who has no apparent physical or mental illness and which takes place after the second birthday. It may include instructions to the patient and/or parents regarding health care. A periodic health visit should be claimed using the following codes:

• K017 — child after second birthday
• K130 — adolescent
• K131 — adult aged 18-64
• K132 — adult 65 years of age and older
• K267 — child age 2 to 11 years (no diagnostic code required)
• K269 — adolescent age 12 to 17 years (no diagnostic code required)

A general re-assessment (A004) is a family practice code that includes all of the services included in a general assessment, with the exception of the patient’s history (which need not include all the details already obtained in the original assessment).

A minor assessment (A001) includes a brief history and examination of the affected part, region or disorder and/or brief advice or information regarding health maintenance, diagnosis, treatment, and/or prognosis. For example, seeing a patient with a simple skin rash or conjunctivitis would be billed as a minor assessment. This is a family practice code but should also be billed by specialists practicing outside of their specialty and/or in a primary care practice setting.

An intermediate assessment (A007) is a primary care service that requires a more extensive examination than a minor assessment. It also requires a history of the presenting complaint(s), inquiry concerning and examination of the affected part(s), region(s), system(s) or mental and emotional disorder as needed to make a diagnosis, exclude a disease and or assess function. This is a family practice code but should also be billed by specialists practicing outside of their specialty and/or in a primary care practice setting.

Consultations

The Consultations section of the General Preamble defines a consultation according to the Schedule and lists descriptions for various types of consultations. The information below is intended to be a summary of this section. Please see the General Preamble of the Schedule for the full text.

A consultation is an assessment rendered following a written request from a referring physician or nurse practitioner who, in light of their professional knowledge of the patient, requests the opinion of a physician (the “consultant physician”) competent to give advice in this field because of the complexity, seriousness, or obscurity of the case, or because another opinion is requested by the patient or patient’s representative.

The consultant must perform a general, specific or medical specific assessment, including the review of all relevant data. The consultant physician must submit his or her findings, opinions, and recommendations in writing to the referring physician. A copy of the written request must be maintained in the consulting physician’s medical record except in the case of a consultation which occurs in a hospital, or long-term care home where common patient medical records are maintained. In such cases, the written request may be kept in the common medical record.

In the absence of a written request, the amount payable for the consultation shall be reduced to the amount payable for an assessment. A consultation fee code is not to be claimed when either:

• a patient presents him or herself to a consultant’s office without a referral from his or her primary physician
• the patient simply asks his or her primary physician for the name of a specialist and the patient approaches the specialist directly

The information provided above is available.

A repeat consultation is an additional consultation rendered by the same consultant regarding the same problem, following care rendered to the patient by another physician following the initial consultation. If a consultant asks a patient to return for a later examination, this visit is not a repeat consultation.

A limited consultation involves all elements of a full consultation, but requires substantially less of the physician’s time than a full consultation. For example, when a physician sees a patient in consultation for a plantar wart a limited consultation code would be appropriate.

Non-emergency acute care hospital in-patient services

Non-emergency acute care hospital in-patient services include consultations and assessments rendered to admitted patients on a non-emergency basis and utilize the “C” prefix code. This includes, but is not limited to admission assessments, subsequent visits, concurrent care, and supportive care .

Emergency Department — Emergency Physician on Duty

Emergency Department — Emergency Physician on Duty: There are specific “H” prefix listings (H1-codes) for consultations, multiple systems assessments, minor assessments, comprehensive assessments and re-assessments rendered by the physician on duty in the Emergency Room. Any physician on duty or on-call in the emergency department should use these fee codes unless a special visit is required. If a special visit is required to the Emergency Department (example: the physician is called from home to make a special visit to see a patient in the Emergency Department and must travel to the hospital), the appropriate ‘A’ prefix fee code should be claimed for the first patient assessed (in addition to the special visit premium code(s)).

If the Emergency Department physician on call (or off duty) is already in the hospital or hospital environs a special visit premium cannot be billed when the physician is called to the Emergency Department. See the section on ‘Special Visit Premiums’ below for more information.

Psychotherapy and counselling services

Psychotherapy (K007) is treatment for mental illness, behavioral maladaptations or emotional problems, in which a physician deliberately establishes a professional relationship with a patient for the purpose of removing or modifying existing symptoms attributed to the problem.

Individual counselling (K013, K033) is defined as a patient visit dedicated solely to an educational dialogue between the patient and a physician. Advice provided to a patient that would ordinarily constitute part of a consultation, assessment or other treatment, is included as a common or constituent element of such other service, and does not constitute counselling in this context. If the patient does not have a pre-booked appointment, the amount payable for this service will be adjusted to a lesser assessment fee.

Delegated Procedure

A Delegated Procedure is a procedure carried out by a physician’s employee where the service remains insured if certain conditions are met. Procedures in this context do not include such services as assessments, consultations, psychotherapy, counselling, etc. One of the requirements (with few exceptions) is for “direct supervision”, that is, the physician must be physically present in the office or clinic at which the service is rendered. For more information including payment rules for delegated procedures, refer to the ‘Delegated Procedure’ section of the General Preamble.

Special visit premiums

Special visit premiums may be payable when a physician is required to make a medically necessary visit to a patient at a specific location. Special visits are generally non-elective; however, if a special visit is required at the patient’s home, the visit may be non-elective or elective.

A non-elective visit is one that is initiated by a patient or by an individual on behalf of the patient (for example: nurse) for the purpose of rendering a non-elective service.

An elective home visit is a visit to a patient’s home that the physician has determined to be medically necessary, initiated by the physician and carried out at a time convenient to the physician.

The General Preamble contains several tables, each representing a different location for a special visit (for example: long-term care home, patient’s home, hospital in-patient, etc.). Please refer to the table representing the location of the special visit to determine the appropriate fee code(s).

Special visits may have two components:

• a travel component
• a person seen component (first person seen and additional person(s) seen)

The travel component of a special visit requires the physician to travel from one location to another to see the patient (for example: from home to the hospital). Travel from one location of a hospital facility/complex to another location within the same facility/complex does not qualify for the travel premium (even if they are separate buildings).

In order for the first person seen premium to be eligible for payment, the physician must meet the requirement for travel. Additional persons seen may also qualify for a premium if there is a need to see other patients on a non-elective basis at the same location as part of the same visit. The travel component is not payable for additional persons seen at the same location.

Full payment rules and requirements, including the medical record requirements, are listed in the General Preamble under ‘Special Visit Premiums’.

Other than a hospital or long-term care facility, special visits do not apply when rendered in a place that is open for patients to attend (such as walk-in clinic). Patients seen during office hours held on nights or Saturdays, Sundays, or holidays do not qualify for any of the special visit premiums.

Surgical Assistants’ services

The Surgical Assistants’ services section of the General Preamble provides a list of specific elements for assistance at surgery as well as information regarding these services.

Appendix H of the Schedule contains a chart to assist in determining the number of assistant time units for billing purposes.

Anesthesiologists’ services

The anesthesiologists’ section of the General Preamble provides a list of specific elements for anesthesiologists’ services as well as information regarding these services.

Appendix H of the Schedule contains a chart to assist in determining the number of anaesthesia time units for billing purposes.

For further details or clarification regarding any of these topics, please refer to the Schedule or contact the Service Support Contact Centre at  1-800-262-6524 between 8:00 a.m. and 5:00 p.m., Monday to Friday (excluding holidays).

Schedule of Benefits appendices

There are several appendices found at the end of the Schedule. With the exception of Appendix D , these appendices do not form part of the Schedule; however, they do contain information that may be helpful. Regulations, such as those excerpted within the appendices are subject to change. Physicians are reminded to acquaint themselves with the current text of these regulations.

Appendix included as part of the Schedule:

Appendix D  — This section contains information regarding the criteria for OHIP coverage for surgical procedures that are for the purpose of altering or restoring appearance, including surface pathology and sub-surface pathology.

Appendices as attachments to the Schedule:

• Appendix A  — Provides an on-line reference and link to Section 24 of Regulation 552 under the HIA .
• Appendix B  — Provides on-line references and links to Regulation 114/94 relating to Conflict of Interest and Records in accordance with the Medicine Act, 1991 .
• Appendix C  — Information on Benefits Outside Ontario as well as Interprovincial. Reciprocal Billing of Medical Claims.
• Appendix F  — Services set out here are not “insured services” within the meaning of the HIA but are paid by the ministry, acting as a paying agent on behalf of the Ministry of Community and Social Services ( MCSS ), the Ministry of the Attorney General, the Ministry of the Community and Correctional Services, and the Workplace Safety and Insurance Board ( WSIB ). This appendix includes a list of important forms for physicians relating to the MCSS Ontario Disability Support Program and MCSS Ontario Works Program .
• Appendix G  — Provides on-line references and links to medical record requirements as found in the Medicine Act, 1991 and the HIA .
• Appendix H  — Table listing the number of units payable based on the duration of time spent rendering anaesthesia or surgical assistant services.
• Appendix Q  — Provides descriptions and information for ‘Q’ prefix codes for primary care models.

Call the Service Support Contact Centre ( SSCC ) at:  1-800-262-6524

Hours of operation: 8:00 a.m. – 5:00 p.m. Monday – Friday, except holidays

E-mail: [email protected]

OHIP Special Visit Premiums

• General Guidelines for OHIP Special Visit Premiums
• OHIP Special Visit Premiums can be used in 3 scenarios:
• Emergency Department
• Emergency Department by Emergency Department Physician
• Special Visit to a Patient's Home
• Palliative Care Home Visit
• Physician Office
• Other (non-professional setting not listed)
• Geriatric Home Visit
• Obstetrical Delivery with Sacrifice of Office Hours
• Want to maximize your earnings? New to Ontario Billing?

OHIP special visit premiums act like a bonus on top of regular fee codes and are incentives for physicians who have specific specialties or sub-specialties. You’ll also benefit from them if you work on weekends, late at night or on holidays. Therefore, they’re a great way to increase your monthly revenue!

However, while they do exist to make sure that you’re compensated for the extra work you do, there are several guidelines you need to know in order to use and benefit from them properly.

In order to make sure you qualify and are using OHIP premiums properly, we’ve outlined all the rules and guidelines below. For a printable version click here .

OHIP Special Visit Premium Rules

• May only be applied with non-elective (urgent and emergent) consults and assessments.
• May not be claimed for routine rounds.
• May not be claimed for visits to admit elective patients.
• Special visit premiums do not apply to subsequent hospital inpatient visits.
• Visit fees and related premiums must be kept together on the SAME bill.
• Always use the “A” prefix general listing visit codes.   Billing Tip: Only use the A prefix consult and visit fees and not C prefix codes. The “C” prefix consult codes are strictly for non-emergency inpatient consults (and therefore no special visits apply). Our billing agents see this error ALL the time!

They are categorized into 5 different time brackets:

Note: “Sacrifice of Office” is when you have an unscheduled visit to Emergency or Hospital In-patient during regular office hours.

OHIP Special Visit Premiums (separated by department): 

Each department below displays the scenario (on the left), the time bracket (above), and then:

The fee code The amount of the fee code The maximum times you can bill for it (per each time bracket).

***These are not eligible for Emergency Department Physicians, please see “Emergency Department by Emergency Department Physician” below.

Hospital Out-Patient Department

Hospital in-patient, long term care institution, special visit to a patient’s home.

(Excluding Long-Term Care Institutions). Note: elective stands for home visits.

Billing Tips:

When billing ohip premiums, make sure to include:.

• Requested by (Physician or Nurse)
• Travel – you can bill up to 2 travel premiums per day and 6 on weekends/holidays, but it must be documented that you left the facility grounds and had to return in order to receive payment for 2nd travel premium.
• First patient seen
•  Be sure to use premiums that MATCH the SLI (service location indicator) on the claim. Note: If a patient is being seen in the Emergency Department but is being admitted use the SLI – HIP but use  Emergency Department special visit premiums AND enter the admission date. This indicates to OHIP that the patient was seen in ER and then admitted.  This is especially important if you are billing E082 (admission assessment by MRP).

Check out our Ultimate OHIP Billing Guide that takes you through every step for billing successfully in Ontario.

This article offers general information only and is not intended as legal, financial or other professional advice. A professional advisor should be consulted regarding your specific situation. While information presented is believed to be factual and current, its accuracy is not guaranteed and it should not be regarded as a complete analysis of the subjects discussed. All expressions of opinion reflect the judgment of the author(s) as of the date of publication and are subject to change. No endorsement of any third parties or their advice, opinions, information, products or services is expressly given or implied by RBC Ventures Inc. or its affiliates.

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• OHIP Billing Support – How to Bill E078 (the Chronic Disease Premium)
• OHIP Billing Codes Sheet for General / Family Practitioners

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1/ * When you sign up for the Comprehensive Plan (fee of 1.95% of paid claims per billing cycle) with Dr.Bill you will receive a $150 billing credit (“Billing Credit”) to be applied to future Dr.Bill fees ( “Offer”). Offer is only available to new Dr.Bill users and can only be used once. Billing Credit cannot be converted to cash. If you cancel your Dr.Bill account or switch to the Essentials Plan at any time before the Billing Credit balance has reached $0, you will forfeit the balance of the Billing Credit. Offer cannot be applied retroactively and may not be combined or used in conjunction with any other Dr.Bill offer. Offer is only available in provinces where Dr.Bill operates. Offer may be amended or withdrawn at any time without notice. 2 Up to $7,500 in billings free refers to the maximum amount of billings with a fee rate of 1.95% of paid claims that the $150 billing credit would cover in full. You will be charged for any additional services requested outside of the Comprehensive plan.

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Internal Medicine OHIP Billing Codes ‘Cheat Sheet’

• Internal Medicine OHIP Billing Guideline for Consultations & Assessments
• Outpatient Internal Medicine OHIP Billing Codes
• Visit to Emergence Department for Consultation or Assessment
• In Patient Internal Medicine OHIP Billing Codes
• Subsequent Visit Internal Medicine OHIP Billing Codes
• Subsequent Visit (by MRP) Internal Medicine OHIP Billing Codes
• Subsequent Visits by MRP following transfer from Intensive Care Unit
• Long Term Care In Patient Internal Medicine OHIP Billing Codes
• Long Term Care Facility: Special Visit Premium
• Subsequent Visits
• Nursing Home or Home for the Aged

If you’re an internal medicine specialist in Ontario knowing which fee code to use can quickly get confusing. The complexity of submitting claims to OHIP , on top of your already heavy workload, is bound to cause a few headaches.

To help save you time, we’ve put together an internal medicine guide of all the available fee codes and when/how to use them. Knowing which codes are available in your speciality is essential in order to maximize your earning potential.

In general most internal medicine consultations are allowed once per 12-month period. All types of consultations (as outlined below) need to have been referred to you by a physician or nurse practitioner. 

A repeat consultation is only allowed once per 12-month period if pertaining to the same diagnosis. A second consultation is only payable in a 12-month period if the diagnosis is completely different than the first. A limited consultation is allowed 1 per 12-month period. What’s the difference between consultation and a limited consultation? Typically a limited consultation would take up much less of your time and wouldn’t require as much, if any, of taking a medical history.

General Assessments are allowed once per 12-month period. A general assessment requires less time spent with the patient than a consultation. Generally, a consultation is requested by another physician where as an assessment could be an appointment the patient booked, or that you saw in an emergency setting. 

If you need to see your patient again (for the same diagnosis) you can use a general reassessment – you can bill 2 of these per a 12-month period. You can also bill partial assessments which are unlimited. 

What’s the difference between a general assessment and a partial assessment? A General Assessment would include full history where as the partial assessment is limited in that you don’t need to take their history. A general assessment is typical when you see a patient for the first time and don’t know their history.

For outpatients, set the service location code to HOP and the facility number of the hospital to AM. A is the prefix for outpatient.

A135 Consultation

A765 Consultation patient 16 years and under.

A130 Comprehensive Consultation – minimum time spent 75 mins. Stop and start times recorded in patient record.

A435 Limited Consultation

A136 Repeat Consultation

A133 Medical Specific Assessment

A134 Medical Specific Re-Assessment

A120 Colonoscopy Assessment – same day as colonoscopy.

K045 Diabetes Management by a Specialist.

• Maximum of 1 service per patient per 12 month period, eligible if you’ve previously provided a minimum of 4 of the following – consultations, assessments, K013 , K033 , K029 , K002 , K003 in the 12 month period.

K046 Diabetes Team Management

*Use the A prefix and add a premium for time and travel if you were outside the hospital when called.

Emergency Department: Special Visit Premium

For inpatients, set the service location code to HIP and the facility number of hospital to acute care. C is the prefix for inpatient.

C135   Consultation

C765   Consultation, patient 16 years of age and under

C130   Comprehensive Internal Medicine Consultation – minimum time spent 75 mins. Stop and start times recorded in patient record.

C435   Limited Consultation

C136   Repeat Consultation

C133   Medical Specific Assessment

C134   Medical Specific Re-Assessment

C131   Complex Medical Specific Re-Assessment

E082 MRP Premium – Add this to Admission consultation or admission assessment.

In Patient: Special Visit Premium

When using a special visit premium to travel for inpatients make sure the consult/assessment always uses the prefix A.

C132   First 5 weeks per visit.

C137   6th to 13th week, 3 per week.

C139   After week 13, 6 per month.

E083 MRP Premium – Add to subsequent visits when you are MRP.

C122   Day 1 following MRP admission – add E083 .

C123   Day 2 following MRP admission – add E083.

C124 Day of discharge – add E083 , if the patient in hospital for at least 48 hours.

C142 Day 1 after transfer – add E083 .

C143 Day 2 after transfe r – add E083 .

***Note: the patient must be admitted to ICU by a different specialty.

C121   Additional visits due to intercurrent illness.

C138   Concurrent Care.

C982 Palliative Care.

For inpatients, set the service location code to HIP and the facility number of the Long Term Facility. For long term care make sure your patient card has an admission date. Long Term Care facilities are considered an extension of a hospital, they are “inpatients” therefore an admit date is needed.

W235   Consultation

W765   Consultation patient 16 years of age and under.

W130   Comprehensive Consultation – same as A130.

W435   Limited Consultation

W236   Repeat Consultation

Admission Assessment

W232   Type 1

W234   Type 2

W237   Type 3

W239   Periodic health visit.

W134 General Re-Assessment.

When using a premium for time and travel for Long Term Patients make sure the consult/assessment is the prefix A.

W132 First 4 visits per patient per month

W131 Additional visit (max 6 per patient per month)

W982 Palliative Care

W133   First 2 visits per patient per month

W138   Subsequent visits per month (max 3 per patient per month)

W972   Palliative Care

W121 Additional visits due to intercurrent illness.

COMMON BILLING SCENARIOS

Scenario 1:

You’re called in to the ER on a Saturday evening at 7p.m. for a consultation. You head to the hospital and see the patient. Your claim would look like this:

A135 ( outpatient consult) K963 (travel premium) K998 (first person seen premium) The Service Location Indicator (SLI): HOP Facility number: the # for Ambulatory Care

After the consultation – If your patient is then admitted, you would also bill the following: E082 (Admission Assessment by the MRP) The Service Location Indicator (SLI): HIP Facility number: the # for Acute Care

If the patient was already an inpatient when you were called into the hospital then you’d bill the following: 

C135 for inpatient consult or 

A135 for inpatient consult IF claiming Special Visit Premiums. OHIP will only pay Special Visit Premiums on consults and assessments if it’s the A prefix code, even for an inpatient (which is the C prefix code). They will know it is an inpatient by the Special Premium Visits that are used.

Scenario 2:

You’re in the hospital and rounding on inpatients, one of your patients has been admitted for less than 5 weeks. Your claim would look like this:

C132 ( subsequent visits). 

However – if you’re rounding on inpatients and you’re the MRP you’d bill the following:

C122 : day following the hospital admission assessment

C123 : second day following the hospital assessment

C124 : day of discharge

For subsequent visits with the same patient (as the MRP) you can also add the following premiums)

E083 (adds a 30% premium to the subsequent visit code) E084 (adds a 45% premium to the subsequent visit code if provided on Saturdays, Sundays and holidays);

Reminder: Special Visit Premiums are NOT eligible with subsequent visits. If the physician was called in to see the patient on an urgent matter, subsequent visits shouldn’t be billed.

Scenario 3:

At the hospital, you see a patient for a consult who is 15 years old. Your claim would look like this: C130 (comprehensive internal medicine consultation inpatient). However, if you saw the patient outside of the hospital you’d only need to change the prefix: A130 (comprehensive internal medicine consultation outpatient)

Common Billing Mistake: Getting rejections on Counselling Codes

We often see rejections of counselling codes due to the following reasons:

• Billing special visit premiums on counselling codes.
• Billing counselling (such as K013 ) on the same bill as an assessment with the same diagnosis code.

Counselling appointment s are technically pre-booked and therefore no special visit premiums apply .

However, counselling codes CAN be billed on the same day as an assessment BUT:

• They need to be on separate claims.
• They need to have different and unrelated diagnostic codes.

*** With the exception of the codes listed below , no other services are eligible for payment when rendered by the same physician on the same day as any type of counselling service.

Exceptions: 

G039  

G040  

G041  

G042  

G202  

G365  

G372  

G384  

G385  

G394  

K002  

K003  

K008   

K014  

K015  

K031  

K035  

G480  

G489  

G482  

G538  

G590  

G840  

G841  

G842  

G843  

G844  

G845  

G846  

G848  

K036  

K038  

K682  

K683  

K684  

You get paid for both the insured insurances you provide and for reports, there are two different ways to submit claims:

• WSIB Forms: When you fill out a form, you bill WSIB. You need to upload these claims directly to WSIB through the online portal Telus Health. These claims have different fee codes than OHIP, which outline which form you’re using.
• WSIB Physician Fee Schedule

If you’re interested in other OHIP fee codes , make sure to save a link to our OHIP searchable database below. You can search by specialty, billing code or keyword.

OHIP billing codes Searchable Database

This article offers general information only and is not intended as legal, financial or other professional advice. A professional advisor should be consulted regarding your specific situation. While information presented is believed to be factual and current, its accuracy is not guaranteed and it should not be regarded as a complete analysis of the subjects discussed. All expressions of opinion reflect the judgment of the author(s) as of the date of publication and are subject to change. No endorsement of any third parties or their advice, opinions, information, products or services is expressly given or implied by RBC Ventures Inc. or its affiliates.

Related posts:

How to avoid common ohip billing mistakes.

• OHIP extends temporary payments for Selected Premiums and Management Fees
• Retroactive Increases to Physician Laboratory Fees

Search All OHIP Billing Codes

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Same MDBilling.ca you know. Now part of the Dr.Bill suite.

Already an MDBilling.ca client?

It’s business as usual and you’ll still be using the same product you’ve come to know and trust for your medical billing. Click here to sign in to your MDBilling.ca account as you normally would.

Looking for MDBilling.ca?

You’re in the right place! Dr.Bill and MDBilling.ca have come together to make it even easier to find the right codes, submit claims and get paid.