In the world of paediatric medicine, navigating medical billing can feel as complicated as treating your young patients, whether they’re admitted to the hospital or visiting your clinic for a routine checkup. The OHIP Schedule of Benefits, with its various paediatric billing codes, can often seem like a long list of complex rules and regulations, making it difficult to apply them correctly.
In this comprehensive blog, we simplify paediatric billing for you, covering everything from consultations and assessments to subsequent visits and developmental/behavioural care billing.
We’ll also highlight common billing errors paediatricians encounter so that you can approach this crucial aspect of your practice with confidence.
Paediatric Consultation Codes
When it comes to managing medical billing, paediatric specialists might be relieved to know that they’re not starting from scratch. In fact, the payment rules and requirements for paediatric consultations are closely similar to those of general practitioners’ consultation codes, providing a familiar foundation for specialists in child healthcare.
To refresh, consultations are defined as assessments that are provided based on a written request from a referring physician, nurse practitioner, or dental surgeon (in connection with a dental procedure performed at a hospital). The referring professional, drawing on their knowledge of the patient, seeks the opinion of a specialist due to the complexity, seriousness, or unclear nature of the case, or upon the patient’s request.
This service includes the necessary services to enable the consultant to prepare the written report (findings, opinions, and recommendations) for the referring physician, nurse practitioner, or dental surgeon.
The Schedule of Benefits (SOB) General Preamble (GP) 17 lists the full payment rules and additional requirements for billing paediatric consultation codes.
Here is a full list of paediatric consultation codes:
Fee code | Description | Value |
A265 | Consultation- limit to one per 2-year period with same diagnosis, one per one year period with different diagnosis | $187.45 |
A260 | Special paediatric consultation | $310.45 |
A662 | Extended special paediatric consultation- Minimum of 90 minutes with direct contact w/ patient | $401.40 |
A667 | Neurodevelopmental consultation | $401.30 |
A665 | Prenatal consultation- upon request for a fetus or > 20 weeks gestation to be at risk | $100.65 |
A565 | Limited consultation | $91.35 |
A226 | Repeat consultation | $91.35 |
Note: All of these codes require start and stop times recorded in patient charts.
Paediatric Assessment Codes
Alongside consultations, paediatricians regularly perform and bill assessments when seeing their patients. Here is a list of assessment codes that paediatricians would be billing on a typical day-to-day:
Fee code | Description | Value |
A263 | Medical specific assessment | $82.90 |
A264 | Medical specific reassessment | $61.25 |
A661 | Complex medical specific reassessment | $74.75 |
A268* | Enhanced 18 month well baby visit- for a child 17-24 months of age | $64.30 |
A261** | Level 1 paediatric assessment | $21.50 |
A262*** | Level 2 paediatric assessment | $43.45 |
*18-month age-appropriate developmental screen and review with the patient’s parent/guardian using a standardized tool that aids with the identification of children at risk of developmental disorders.
**Includes one or both of a brief history and exam of the affected part or related to a mental or emotional disorder; or brief advice or information regarding health maintenance, diagnosis, treatment and or prognosis.
***Requires a more extensive exam than Level 1, including the history of presenting complaint, exam of affected parts or systems or mental or emotional disorder as needed to make a diagnosis. This also includes well-baby care.
Understanding assessment codes is crucial for paediatricians. From standard consultations to specialized assessments for neurodevelopmental issues, each code reflects the complexity and time involved in evaluating young patients.
Developmental and/or Behavioural Care
Paediatricians frequently bill codes directly related to their patient’s individual and familial developmental and behavioural care. This kind of care includes assessments and treatments by a paediatrician for mental health issues, behavioural problems, developmental disorders, and other related concerns that consider the patient’s biological and emotional well-being.
Here are the codes used to bill for these services:
K122 | Individual developmental and/or behavioural care – per unit | $89.70 |
K123 | Family developmental and/or behavioural care | $101.75 |
It is required that these services encompass at least 35% of a paediatrician’s annual fee-for-service billing. If they do not meet the criteria, they can resort to billing counselling codes (K013, K005, K007, etc.) to make up the 35%.
Attendance at Maternal Delivery
When a paediatrician is required to attend to a baby at the delivery, they can bill H267- Attendance at Maternal Delivery. This includes the assessment of the newborn and is not eligible for payment if any other service rendered by the same physician at the time of the delivery. In the case where the newborn is sick, a medical-specific assessment (C263) is payable in addition to ‘Attendance at Maternal Delivery (H267)’ code.
Note: Paediatricians can also bill special visit premiums in addition to H267.
Understanding these billing intricacies ensures that paediatricians are compensated while also being prepared to address any unexpected complications that may arise during delivery.
In-Patient Subsequent Visits
Navigating the nuances of hospital billing can be as complex as the care itself, especially when it comes to extended patient stays. If a patient is admitted to the hospital and requires routine assessments for the duration of their stay, paediatricians can bill different subsequent visit codes depending on the day.
A subsequent visit is any routine assessment in hospital following the hospital admission assessment.
Here are the subsequent visit codes that a paediatrician can expect to bill:
Fee Code | Description | Value |
Admission | Day 1 – Admission assessment | Varies |
C122 | Day 2 – (1st day following admission assessment) | $61.15 |
C123 | Day 3 – (2nd day following admission assessment | $61.15 |
C262 | Paediatric subsequent visit | $34.10 |
C124 | Day of discharge | $61.15 |
Physicians billing these subsequent visits can also add premiums like the ones below, as they are the most responsible physicians (MRP).
Fee Code | Description | Value |
E082 | Admission assessment by the MRP, add to admission assessment | 30% |
E083 | Subsequent visit by the MRP add-on premium (Weekday) | 30% |
E084 | Subsequent visit by the MRP add-on premium (Weekends & Holidays) | 45% |
Here is an example of what the billing for subsequent visits would look like for a paediatrician, depending on the day:
Day 2: 1st day following admission assessment (C122)+ Subsequent visit by the MRP add-on (E083/E084).
Day 3: 2nd day following admission assessment (C123) + Subsequent visit by the MRP add-on (E083/E084).
Day 4 and onward (as long as the patient is in hospital): Pediatric subsequent visit (C262) + Subsequent visit by the MRP add-on (E083/E084). Paediatric subsequent visits (C262) are limited to one per patient, per day for the duration of the admission. However, if the patient’s condition becomes critical, the physician would be able to bill critical care and be paid for both visits through a manual review process with times and descriptions of both visits.
Day of discharge (C124) + Subsequent visit by the MRP add-on premiums (E083/E084).
Doctors serving as the Most Responsible Physician (MRP) frequently overlook the E083/E084 premiums on their billing submissions. This oversight can lead to significant revenue loss, particularly for those who routinely work in hospital settings. To minimize the chances of missing these premium billings, consider setting up “supercodes” within your EMR system.
Paediatric Billing Common Errors
Understanding common pitfalls can help practitioners avoid costly mistakes and ensure proper reimbursement. The most common errors seen in paediatrician’s error reports sent by the Ministry are:
VH9 | Health Number Not Registered |
Sx | ICU Per Diem code Paid to Another Physician, MRP Premium Not Allowed |
AO3 | Most Responsible Physician (MRP) Visit Already Paid |
VH9 signifies that the patient’s health card number has yet to be registered with the Ministry. It frequently occurs when a family physician or paediatrician attends to a newborn patient who has not yet been issued a health card.
To rectify this, you would need to contact the patient for a new Version Code or Health Card Number. If a new health card number does not exist, such as in the case of a newborn patient, guide the parent/guardian to obtain the new health card number and version code at Service Ontario.
Sx concludes that the ICU code billed has already been claimed by another physician. It is commonly seen with G600 (Neonatal Intensive care, Level A- first day) and G400 (Critical Care, ICA- 1st day), and the Ministry will only pay this to a single doctor per day. In this case, the physician who received the error will rebill with G521 (Life-threatening critical care, first 15 min) with the proper units to reflect the exact time spent with the patient.
Lastly, AO3 occurs when a conflicting MRP service has been claimed by another practitioner. Although not always the case, this error commonly happens when another physician has already billed an assessment to a patient on the same day in another facility.
For example, a patient could be discharged and then later seen in the Emergency Department, or in the case of patient transfers, a patient can be discharged from one hospital and admitted to another on the same day. The physician who received the AO3 error would need to resubmit their claim for a manual review with documentation specifying the situation and including visit times wherever possible.
Conclusion
Fully understanding the intricacies of paediatric billing can significantly reduce common errors that lead to claim rejections and missed payments, helping you optimize your income. By streamlining your billing processes, you can dedicate more time and energy to what truly matters – providing exceptional care to your young patients and supporting their families through every step of their healthcare journey.
Additional Resources
We have additional resources to help doctors navigate the complexities of medical billing:
Understanding and Correcting EH2 & VH9 OHIP Billing Errors
Easing the Burden: Strategies to Tackle Burnout, Cut Costs and Streamline your Practice
OHIP Billing: ER Special Visit Premiums Guide
We’re happy to help!
If your schedule is too busy to manage billing on your own, our Trillium medical billing experts are here to provide personalized support. The Trillium team takes great pride in taking care of those who take care of the children in our community. We’ll take the administrative burden of medical billing off your plate, ensuring all billing opportunities are captured, errors are eliminated, and your well-deserved revenue is fully maximized.
