In Ontario effective December 1, 2022, the changes to the OHIP Schedule of Benefits as a result of the new PSA (Physician Services Agreement) regarding virtual care billing come into effect.
At the beginning of the COVID19 pandemic, the Ontario Ministry of Health (MOH) setup temporary billing codes for virtual care, which won’t be available after December 1st.
The new virtual care funding framework financially encourages more in-person visits and only allows care to be rendered virtually when it is medically appropriate to provide the services without a direct physical encounter.
In addition, the new virtual care framework only allows video visits to be rendered by virtual visit solutions on eHealth Ontario’s “Verified Solutions List for Virtual Visits.”
Effective December 1st, the virtual care services are divided into Comprehensive Virtual Care Services, and Limited Virtual Care Services.
What are Comprehensive Virtual Care Services? These are services that can be billed if the patient has an existing/ongoing patient-physician relationship. This means that the patient is enrolled to the provider or with another provider within the same group, or the patient has been seen in person over the past 24 months. Any codes in Section 1 of Appendix J in the Schedule of Benefits are billable under this category.
What are Limited Virtual Care Services? These are billed for patients who are not enrolled and have not been seen in person in the preceding 24 months. These two codes (listed below) in Section 2 of Appendix J in the Schedule of Benefits are billable under this category.
| Code | Description | Fee |
|---|---|---|
| A101A | Limited virtual care by Video | $20 |
| A102A | Limited virtual care by Telephone | $15 |
Key Billing Requirements
- Existing Schedule of Benefits requirements will apply to all virtual care services.
- Virtual care services are not eligible for payment where it is not medically appropriate to provide the services without a direct physical encounter.
- Video visits must be performed using a Verified Virtual Visit Solution (Cortico is a verified provider).
- If during the course of a Virtual Care Service it becomes apparent that the service cannot be appropriately completed without a direct physical encounter, the Virtual Care Service is not eligible for payment (only the service with a direct physical encounter is eligible for payment).
- The physician and patient must be located in the province of Ontario during the visit.
For more information, see the Schedule of Benefits here.
Existing K-codes for billing virtual services
The existing temporary virtual care K-codes (K080, K081, K082, K083, K092, K093, K094, K095) expire November 30th, 2022, and cannot be used to bill for any future virtual care services.
Amount payable for virtual services
Comprehensive Virtual Care Services (Existing Patient Relationship)
| Mode | Payable Amount |
|---|---|
| Telephone* | 85% of the fee amount |
| Video | 100% of the fee amount |
*except for K007, K005, K197 and K198 which will be payable at 95% of the
corresponding in-person fee.
Limited Virtual Care Services (No Patient Relationship/Walkin Clinic)
| Mode | Payable Amount |
|---|---|
| Telephone | $15 |
| Video | $20 |
What is the “Fee Amount”?
How do I submit claims?
Comprehensive Virtual Care Services Billing:
- Add the virtual service using the fee codes listed in Appendix J - Section 1 in the Schedule of Benefits.
- Add the modality indicator code to the bill to identify the technology used to deliver the service (claim rejects without this).
Modality Indicator Codes ($0 payment as they are only tracking codes)
| Code | Description |
|---|---|
| K300A | Identifies video technology used during the services (verified virtual visit solution required). |
| K301A | Identifies telephone technology (audio only) used during the service. |
Limited Virtual Care Services Billing:
- Submit one of the two fee codes (A101A or A102A). No need for modality indicator here as the A101A/A102A themselves identify the method the limited virtual care service was rendered.
Can I bill the Q012A after hours premium?
Not all virtual care billing codes are eligible for the Q012A after hours premium (group registered patients). If the following services are rendered virtually during after hours, then Q012A can be added: A001A, A007A, A008A, K005A, K013A, K030A, and K033A.
How easy is it to use a verified virtual visit solution for video visits?
A verified virtual visit solution is Cortico, which directly integrates with your EMR and provides a seamless, automated experience for conducting virtual care in accordance with requirements. Patient’s don’t have to download any apps or login, as they receive text messages and emails prior to their appointment automatically with a secure link to join the virtual visit through their browser, without having to download or sign-in to anything.
The physician easily clicks the “Join Video Visit” link from their daysheet and joins into the virtual visit. Existing appointments in the EMR can be switched to virtual Cortico visits instantly with the push of a button, and the patient gets notified automatically by SMS and email with the link and instructions to join.
In addition, since Cortico provides a full suite of patient engagement and clinic automation services, patients are able to directly book virtual visits online if the provider chooses to allow that. No hassles of manually creating links for appointments and manually sending them to patients - those days are long gone! The virtual visit through Cortico is seamless and secure, and the doctor can send the patient attachments directly from the EMR without having to download and re-upload anything.
Which codes do I use to bill for comprehensive virtual care and how?
The new comprehensive virtual care billing framework requires doctors to submit the claim with the regular in-person equivalent code for the service rendered virtually, with the modality indicator (phone or video) code, and phone appointments get paid less than video (as explained above).
What are the Comprehensive Virtual Services in Appendix J – Section 1 in the Schedule of Benefits?
Eligible Comprehensive Virtual Care Services
Video or Telephone
A001A, A007A, A008A, A013A, A014A, A020A, A023A, A024A A033A, A034A, A043A, A044A, A051A, A053A, A054A, A058A A063A, A064A, A071A, A073A, A074A, A078A, A083A, A084A A093A, A094A, A113A, A131A, A133A, A134A, A138A, A151A A153A, A154A, A158A, A161A, A163A, A164A, A168A, A173A A174A, A181A, A183A, A184A, A188A, A193A, A194A, A203A A204A, A221A, A233A, A234A, A243A, A244A, A261A, A262A A263A, A264A, A283A, A284A, A310A, A311A, A313A, A318A A338A, A340A, A341A, A343A, A348A, A353A, A354A, A411A A413A, A414A, A418A, A441A, A443A, A444A, A448A, A461A A463A, A464A, A468A, A471A, A473A, A474A, A478A, A480A A481A, A483A, A484A, A488A, A510A, A511A, A570A, A601A A603A, A604A, A608A, A611A, A613A, A614A, A618A, A621A A623A, A624A, A628A, A632A, A633A, A638A, A643A, A644A A661A, A760A, A917A, A920A, A927A, A937A, A947A, A957A A967A, H313A, K002A, K003A, K004A, K005A, K007A, K008A K010A, K012A, K013A, K014A, K015A, K016A, K019A, K020A K022A, K023A, K024A, K025A, K028A, K029A, K030A, K033A K037A, K039A, K040A, K041A, K044A, K122A, K123A, K140A K141A, K142A, K143A, K144A, K195A, K196A, K197A, K198A K203A, K204A, K205A, K206A, K208A, K209A, K222A, K623A, K680A, K887A, K888A, K889A, P005A
Video Only
A010A, A011A, A015A, A016A, A025A, A026A, A035A, A036A A045A, A046A, A050A, A055A, A056A, A065A, A066A, A075A A076A, A085A, A086A, A095A, A096A, A130A, A135A, A136A A150A, A155A, A156A, A160A, A165A, A166A, A175A, A176A A180A, A185A, A186A, A190A, A191A, A192A, A195A, A196A A197A, A198A, A205A, A206A, A220A, A223A, A225A, A226A A235A, A236A, A245A, A246A, A253A, A255A, A256A, A260A A265A, A266A, A275A, A285A, A286A, A315A, A316A, A325A A335A, A345A, A346A, A355A, A356A, A365A, A375A, A385A A395A, A400A, A405A, A415A, A416A, A425A, A435A, A445A A446A, A460A, A465A, A466A, A470A, A475A, A476A, A485A A486A, A515A, A525A, A545A, A565A, A575A, A586A, A590A A595A, A600A, A605A, A606A, A615A, A616A, A625A, A626A A635A, A636A, A645A, A646A, A655A, A662A, A665A, A667A A675A, A680A, A682A, A695A, A735A, A745A, A765A, A770A A775A, A795A, A800A, A801A, A802A, A814A, A817A, A818A A835A, A845A, A865A, A906A, A913A, A914A, A921A, A935A A945A, C010A, C013A, C014A, C015A, C016A, C020A, C023A C024A, C025A, C026A, C033A, C034A, C035A, C036A, C043A C044A, C045A, C046A, C051A, C053A, C054A, C055A, C063A C064A, C065A, C066A, C071A, C073A, C074A, C075A, C076A C083A, C084A, C085A, C086A, C093A, C094A, C095A, C096A C113A, C130A, C131A, C133A, C134A, C135A, C136A, C150A C151A, C153A, C154A, C155A, C156A, C160A, C161A, C163A C164A, C165A, C166A, C173A, C174A, C175A, C176A, C180A C181A, C183A, C184A, C185A, C186A, C190A, C193A, C194A C196A, C203A, C204A, C205A, C206A, C220A, C223A, C225A C226A, C233A, C234A, C235A, C236A, C243A, C244A, C245A C246A, C255A, C260A, C263A, C264A, C265A, C266A, C275A C283A, C285A, C286A, C311A, C313A, C314A, C315A, C316A C325A, C335A, C341A, C343A, C344A, C345A, C346A, C353A C354A, C355A, C356A, C365A, C375A, C385A, C395A, C411A C413A, C414A, C415A, C416A, C425A, C435A, C441A, C443A C444A, C445A, C446A, C460A, C461A, C463A, C464A, C465A C466A, C470A, C471A, C473A, C474A, C475A, C476A, C480A C481A, C483A, C484A, C485A, C486A, C510A, C511A, C515A C545A, C565A, C570A, C575A, C585A, C586A, C590A, C595A C600A, C601A, C603A, C604A, C605A, C606A, C611A, C613A C614A, C615A, C616A, C623A, C624A, C625A, C626A, C635A C643A, C644A, C645A, C646A, C655A, C661A, C662A, C665A C667A, C675A, C680A, C682A, C695A, C735A, C745A, C760A C765A, C770A, C775A, C795A, C845A, C865A, C895A, C935A C945A, K630A, W025A, W026A, W075A, W076A, W130A, W150A W155A, W156A, W165A, W185A, W190A, W196A, W235A, W236A W275A, W310A, W355A, W356A, W375A, W395A, W425A, W435A W465A, W466A, W510A, W511A, W515A, W516A, W535A, W770A W775A, W795A, W895A
What are applicable premiums for comprehensive virtual care billing codes?
Applicable Premiums for Virtual Care
| Applicable Premium | Description | Premium Payable |
|---|---|---|
| E060 | Post renal transplant assessment premium | 25% of fee for virtual service |
| E078 | Chronic disease management premium | 50% of the fee for virtual service |
| E079 | Smoking cessation: Initial discussion with patient, to eligible services | $13.20 for phone and $15.55 for video |
| E080 (video only) | First visit by primary care physician after hospital discharge | $25.25 |
| K187 | Acute post-discharge community psychiatric care | 15% of fee for virtual service |
| K188 | High-risk community psychiatric care | 15% of fee for virtual service |
| K189 (video only) | Urgent community psychiatric follow-up | $216.30 |
| Age-Based Fee Premiums | ||
| 10-30% of fee for virtual service | ||
| Focused Practice Psychotherapy Premium | ||
| 17% of fee for virtual service | ||
| Internal Medicine Office Assessment Premium | ||
| 12% of fee for virtual service | ||
| FHG In-Basket Premium | ||
| 10% of fee for virtual service |
What are the applicable management fees?
Applicable Management Fees for Virtual Care
| Fee Code | Description |
|---|---|
| K045 | Endocrinology & Metab/Internal Med-Diabetes management by a specialist-annual |
| K046 | Endocrinology & Metab/Internal Med-Diabetes team management-annual |
| Q040 | GP/FP-Diabetes management incentive-annual |
| K119 | Paediatrics-Paediatric developmental assessment incentive-annual |
| K481 | Rheumatology-Rheumatoid arthritis management by a specialist-annual |
| K682 | Opioid Agonist Maintenance Program monthly management fee-intensive per month |
| K683 | Opioid Agonist Maintenance Program monthly management fee-maintenance, per month |
| K684 | Opioid Agonist Maintenance Program-team premium, per month, to K682 or K683 add |
| K030* | Diabetic management assessment |
Payment rules: *A virtual K030 is only eligible for payment if a K030 involving a direct physical encounter has been performed in the preceding 12 months.
What if I need to send the patient a secure message before the virtual visit?
You can use the Cortico plugin to send secure messages including email and SMS, directly from the chart without having to copy-paste their information into other systems as Cortico is connected to your EMR. The secure messaging system is OntarioMD compliant and certified. You could also use plugin to re-send the secure video visit link with one touch.
Billing Examples (FHG)
A physician in a walk-in clinic sees a patient who is not enrolled to them, via video, and they haven’t seen this patient in person in the past 24 months. What do you bill?
Bill the limited virtual care service code for video services: A101A = $20
A physician meets an enrolled patient through telephone for a minor assessment. What do you bill?
Bill the code A001A for the minor assessment plus the modality code K301A to indicate that the visit was completed through telephone. Since the physician is providing an in-basket service over telephone to an enrolled patient, they will be paid 85% of the fee submitted.
A001A + K301A = ($23.75 X 85% = $20.19
Billing Examples (FHO)
A physician meets an enrolled patient through telephone for a minor assessment. What do you bill?
Bill the code A001A for the minor assessment plus the modality code K301A to indicate that the visit was completed through telephone. Since the physician is a FHO physician providing an in-basket service over telephone to an enrolled patient, they will be paid 15% of the 85% of the fee submitted.
A001A + K301A = ($23.75 X 85% ) X 15% = $3.03
Virtual Care Billing Roadmap
Graphic from DoctorCare
Citations:
