OHIP Q-prefix codes are generally used to bill for preventive care services and incentives, offering physicians an opportunity to be better compensated for patient care. Unlike A-codes, which cover standard assessments, Q-codes apply to services like patient rostering, after-hours care, chronic disease management, and mental health tracking. They are especially important in primary care models like FHOs, where they can impact both monthly capitation and bonus eligibility.
Despite their value, Q-codes are often missed or underused by physicians. This means doctors may miss out on billing for services they’re already providing. In this blog, we cover the most commonly overlooked Q-codes and how to ensure you’re billing them correctly.
Q200/Q202 Rostering Codes
The Ministry of Health in Ontario requires each patient to be enrolled or “rostered” with a family physician. However, physicians often encounter discrepancies between the patients they believe are enrolled and those rostered to them by the Ministry. In many cases, the Ministry’s roster count is lower than what’s shown in the EMR.
Q200 and Q202, used in CCM, FHG, FHN and FHO payment models, are billing codes that indicate a patient’s enrollment with a family physician, with Q202 specifically applying to patients in long-term care. For FHO physicians, you can earn approximately $200 per rostered patient annually, with higher capitation for long-term care patients.
Errors with rostering can happen for several reasons:
- Rostering codes (Q200 or Q202) are being rejected or are never being submitted.
- Patients falling off your roster without you knowing.
- Patients are accidentally rostered with another doctor at a walk-in clinic.
To ensure that these codes are accurately reflected in your patient roster, it is important to maintain an accurate and up-to-date roster. This requires regular reviews of the patient list and comparing your EMR with the Ministry’s records to confirm enrollment. Reviewing your error reports regularly can also help ensure that these codes are corrected and resubmitted to the Ministry. It is also best practice to bill Q200 on a separate claim from procedure codes billed that day to avoid any claim errors.
Q012/Q016 After-Hours Premiums
To allow physicians greater flexibility in their after-hours schedules and to enhance patient care accessibility, the after-hours codes Q012 and Q016 were introduced. The after-hours premium code Q012, used in FHG, FHN and FHO models, and Q016, used in CCM, are among the most commonly unoptimized billing opportunities for physicians. Many doctors miss out on additional revenue simply because they’re unsure of when these premiums apply during their workday.
Q012 and Q016 are applied to enrolled patients seen during regular after-hours services held before 8 a.m. and after 5 p.m. on weekdays, weekends, or statutory holidays, and provide a 30% premium on top of patient visits.
You are only allowed to submit one service per patient visit for Q012, and it must be submitted on the same claim. We often see physicians either submitting multiple Q012 services in a single claim or Q012 on a separate claim, resulting in an error that will prevent reimbursement. To avoid this issue, include Q012 only once on the same claim with the visit that has a qualifying fee code.
Q050 Heart Failure Management Annual Incentive Code
Chronic Disease Management is a key part of every family physician’s practice, including heart failure management. The Congestive Heart Failure Management Incentive Q050, used in CCM, FHG, FHN and FHO models, is a fee code premium for enrolled patients diagnosed with heart failure and the tracking of the patient’s condition via a flowsheet.
With busy schedules, many physicians overlook billing Q050, missing a valuable opportunity that supports proactive patient care. Here are some best practices to help you effectively manage your heart failure patients’ billing:
- Pick a date in the year when you update your patient’s heart failure flowsheet and bill Q050.
- Generate a list of heart failure patients through your electronic medical record (EMR) to assist with billing your Q050.
- Set up a reminder in your EMR for patients who are overdue for Q050 billing.
Q050 is valued at $125 and can only be billed annually. You can also complete the flowsheet after hours and bill Q012 with the claim, generating more revenue. It is important to utilize your EMR to identify these patients to make sure you are billing Q050 on a yearly basis and not missing out on revenue.
Q020/Q021 Bipolar and Schizophrenia Tracking Codes
Some physicians may come across cases of bipolar disorder and schizophrenia in their clinics, yet many might be unaware of billing codes that monitor these conditions in practice.
Most special premiums (hospital, labour & delivery, home care, palliative visits, etc.) don’t require special billing, as the requirements are tracked automatically by billing the regular code(s) associated with the service. The only exception is for the serious mental illness premium, which requires the billing of special Q-prefix tracking codes: Q020 and Q021.
Q020 and Q021, used in the FHN, FHO and FHG models, are billed annually for enrolled bipolar and schizophrenic patients, contributing to the annual special premiums and bonuses categories, and can earn you up to $2,468 per year.
Setting aside time once a year to bill these codes for patients, creating reminders in your EMR, and checking for billing errors after the codes are submitted can help ensure you are maximizing your bonuses.
Q042 Smoking Cessation Counselling Fee Code
Smoking cessation is another area where physicians in various payment models can enhance billing through structured patient support. However, many are unaware of the available codes or may simply forget to bill them at the right time. When tracked effectively, smoking cessation management allows physicians to bill three incentive fee codes: E079, K039, and Q042.
Q042 is a counselling fee code that is billed after the initial smoking discussion with the patient (E079) and can be applied to the K039 follow-up visit code, serving as an additional incentive for physicians to provide counselling to their rostered patients. Q042 can only be billed twice a year when counselling a patient on smoking cessation.
Knowing when to bill this code for your smoking cessation visits will help you mitigate billing errors and earn revenue in the long run.
To assist you in billing for smoking cessation, download our flowsheet here.
Q014/Q015 Newborn Care Add-On Code
Caring for newborns is a common part of primary care, yet many physicians often miss the opportunity to bill the available premium for well-baby visits during a child’s first year.
Q014, used in FHN and SEAMO and Q015, used in the FHO model, are premiums charged during each well-baby visit for enrolled patients. These premiums can only be billed alongside ‘A007 – Intermediate Assessment’. Ensuring that you bill this premium only with A007 will help prevent billing errors and payment delays. Moreover, billing this code exclusively for patients aged 12 months and younger can assist in reducing errors in claims.
Q040 Diabetes Management Incentive Code
Managing diabetic patients requires a comprehensive approach including regular assessments, treatment plans for continuity and quality of care, and proactive patient communication strategies. The complexities of diabetes care can make it challenging to accurately capture and bill for the services provided.
As a physician, you could be earning $20-30K in diabetic management fees annually, and we’ve seen that many practices are only capturing 10% of their potential earnings. Not billing the Q040 – Diabetes Management Incentive is a frequent cause of missed earnings.
The Q040 incentive code, valued at $60, can be billed upon completing three ‘K030 – Diabetes Management Assessment’ codes in the last 12 months and is billable annually. Here are some tips to ensure you are billing for Q040 correctly:
- Set up a reminder in your EMR for those overdue for K030 diabetes visits.
- Make sure to follow up and recall patients who are due for a diabetic visit.
- Bill Q040, along with the third K030 in the past 12 months.
Physicians also receive 100% of the value of the code, which is important to put into perspective the amount of money physicians can earn when they bill for this service to their diabetic patients. Take this example: If you care for 100 diabetic patients, you are ultimately losing out on $6,000 a year just by forgetting to bill Q040 alone or not correcting billing errors.
Our team can handle the task of recalling diabetic patients, ensuring you never miss a Q040 code.
Conclusion
Integrating Q-codes into your medical billing workflow might seem complex at first. Once you understand the purpose of each code and how to apply it, it becomes an important part of making sure you are properly compensated for the care you already provide.
Paying attention to these often-overlooked billing opportunities can lead to increased revenue, more efficient operations, and stronger overall practice performance, while also supporting more proactive and consistent patient care.
Need Support with Your Patient Workflows?
An effective way to ensure timely and accurate billing of Q-prefix codes is by implementing a systematic approach to patient recalls and reminders.
Our Patient Care service is designed to support proactive communication and timely follow-ups through tailored patient recall solutions. We help you stay on top of key preventive screenings like diabetic patient recalls optimizing your Q040 submissions and avoiding missed bonus payments. We can also help you identify patients for bipolar and schizophrenia, heart failure and smoking cessation and generate a list to remind you to bill all applicable add-on codes.
Interested in learning more about our Patient Care service? Contact us today!
