As an Ontario emergency room physician, navigating medical billing is an added complexity to treating critically ill patients. From life-threatening critical care to resuscitative services, ambulance transfers to additional critical care codes and premiums, the array of OHIP billing codes and regulations can seem overwhelming. Yet, understanding these is crucial for ensuring proper compensation for your vital services.
In this blog post, we’ll dive into some key billing concepts every ER doctor should know. Whether you’re a seasoned veteran or a new physician, this guide will shed light on the often-overlooked aspects of critical care billing and provide real-world examples that can significantly impact your practice.
What are life-threatening critical care and resuscitative care?
When physicians are not performing routine ER assessments, they are likely performing critical care on patients. Life-threatening critical care and resuscitative care are two categories of critical care services provided in emergency situations.
Life-threatening critical care is provided when a patient is critically ill or injured, with acute impairment of one or more vital organ systems leading to organ failure. The billing codes for this care include:
- G521: First 15 minutes
- G523: Second 15 minutes
- G522: Additional 15-minute intervals (up to 6 units)
Note: Up to three physicians can bill G521 for the same patient on the same day. A fourth physician would need to use the G395 code instead.
Resuscitative care applies to emergency situations that don’t meet the criteria for life-threatening critical care but still involve a potential threat to life or a high likelihood of the patient suffering limb loss or requiring life-threatening care. The billing codes for resuscitative care are:
- G395: First 15 minutes
- G391: Additional 15-minute intervals (up to 9 units)
Critical care premiums
When a physician provides critical care services (caring for a patient without taking the time for proper intake/vitals, etc.) outside of regular hours, they may be eligible for additional compensation through premium codes. These premiums apply to critical care performed during specific time periods, billed alongside other non-assessment codes:
Night Premium (H112):
- Applicable hours: 12:00 AM to 8:00 AM
- Can be billed in addition to regular critical care codes.
Weekend and Holiday Premium (H113):
- Applicable hours: 8:00 AM to 12:00 AM
- Covers critical care services provided on weekends and designated holidays.
Note: These premiums can also be used for K623 (Form 1 psychiatric assessment) and K015 (Counselling of relatives on behalf of a terminally ill patient)
These premium codes allow physicians to receive extra compensation for providing critical care during less desirable hours or on days when most people are off work. They are added on top of the standard critical care billing codes to reflect the additional burden of working during these times and the added stress of providing urgent care to a patient with little to no background information.
Billing for assessments/consultations + critical care in the same visit
Many physicians are unaware that they can bill for both an assessment or consultation AND critical care for the same patient during a single visit. However, this scenario is subject to specific conditions:
Eligibility:
- Applicable only when a patient arrives for an ER assessment but subsequently requires critical care on the same day (usually with the doctor being called back immediately).
- The consultation or assessment must be completed before initiating critical care for the claim to be valid.
Billing Process:
- These claims require manual review.
- Physicians must clearly specify the time spent on each service (assessment/consultation and critical care).
- Clear and detailed documentation is crucial to support the necessity of both services.
Restrictions:
- Critical care codes cannot be billed alongside the H102 Comprehensive Assessment.
- If critical care is provided, the H102 must be downgraded to an H103 Intermediate Assessment for payment eligibility.
Correctly applying these guidelines can significantly enhance your reimbursement for complex patient encounters. We encourage you to familiarize yourself with these rules, which can impact your billing outcomes, especially in challenging clinical scenarios.
Example
Let’s examine a common ER scenario to illustrate the billing for both an assessment and critical care:
A patient is sent to the ER by their GP for a headache, and the ER doctor bills the ER consult code and then leaves the patient to attend to another patient. The doctor is called back 45 minutes later because the patient is now having a seizure. Here is the billing breakdown:
Initial Visit:
Time: 9:00 AM
Reason: Patient referred by GP for a headache
Billing: ER consult code (H065)
Subsequent Emergency:
Time: 9:45 AM
Situation: Patient experiences a seizure
Billing: Critical care code (G521)
Both the initial consultation (H065) and the critical care service (G521) are billable in this scenario, but due to the unique circumstances, a manual review is required. Clear documentation of the timing and medical necessity for both services is essential.
If the patient had initially presented requiring critical care, the assessment would be included in the G-codes (G521 or G395). In such cases, a separate consultation claim would not be eligible.
For any subsequent visits to the same patient for critical care, bill an additional unit of G521 or G395 as appropriate.
Common billing errors related to critical care
Physicians receive a variety of errors in their claims due to many reasons. The most common errors physicians see are M4 errors, which come back if the maximums have been exceeded.
Two other common errors that physicians see are:
- A36 and AI4 – Paid to another provider. These mean the Ministry is requesting supporting documentation for the visit. If you use Special Visit Premiums (SVPs), make sure the reason for the use is clearly stated. If you use an E420, make sure the full ISS breakdown is clearly written out. It is not enough to write ISS > 17 or ISS = 30
- VJ7 – Stale dated claim. If the Ministry asked you for documentation, and by the time you got it together and resubmitted, you could miss the deadline. If you have proof that it was originally submitted before it was stale, and the resubmission is only late because the Ministry asked for paperwork, you can resubmit as a stale claim.
Ambulance transfer billing
Emergency department physicians frequently bill for ambulance transfers as part of their services. Known as “detention in an ambulance,” these services cover the continuous care provided to patients during transport. Here’s what you need to know:
Detention in ambulance refers to the constant attendance and comprehensive care provided to a patient during ambulance transport. This service encompasses, initial patient examination, ongoing monitoring of the patient’s condition and all necessary interventions.
Billing Codes:
K101: Ground ambulance transfer with patient (billed per quarter hour)
K111: Air ambulance transfer with patient (billed per quarter hour)
K112: Return trip without patient to place of origin (applicable to both air and ground ambulance)
These codes cover the physician’s time and services during transport and are typically done in 15-minute increments (1 unit = 15 minutes).
Additional billing codes
Beyond standard emergency care codes, ER physicians should be aware of two particularly important billing codes:
H105 – Interim Admission Orders
- Purpose: Compensates the on-call ER physician for writing in-patient interim admission orders, pending admission of a “non-elective” patient by the Most Responsible Physician (MRP).
- Key consideration: This code is only payable if the patient is admitted. If the patient’s condition improves and they’re discharged from the ER without admission, H105 cannot be billed and will be rejected if billed.
H100 – ER Ultrasound
- Purpose: Covers ultrasound examinations performed by the ER physician in the emergency department.
- Key Consideration: Max 2 per patient per day. Claims over two services of H100 per day by the same physician for the same patient should be submitted using the manual review indicator and accompanied by supporting documentation.
Navigating complex medical billing is a vital skill for Ontario emergency room physicians, complementing their expertise in treating critically ill patients. Throughout this blog post, we’ve explored key billing concepts, from life-threatening critical care to resuscitative services, ambulance transfers, and the nuances of critical care codes and premiums. By mastering these billing practices, ER physicians can ensure they’re accurately compensated for the work they do while providing care to patients in their most critical moments.
Additional Resources
We have additional resources to help doctors navigate the complexities of Emergency Department billing:
ER Special Premiums Quick Reference Guide
ER Billing Frequently Asked Questions
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