OHIP Billing: A Guide to Diabetes Management

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.

In this blog post, we offer best practices for FHO physicians to effectively manage diabetic patients, highlighting key aspects of diabetes billing for timely care and optimized revenue.

Diabetes Management Billing

There are three main fee codes that physicians bill when managing their diabetic patients: K030, Q040, and K029. These billing codes are considered out-of-basket and are paid at the full fee-for-service rate based on the Schedule of Benefits.

Diabetes management assessment (K030)

The Diabetes Management Assessment code (K030) is an all-inclusive service payable to the most responsible physician for continuing management and support of a diabetic patient. The fee code is payable four times a year and requires a completion of the diabetes flow sheet.

Key Recommendations:

  • Schedule the next diabetes management visit right after the patient’s current visit.
  • Ask your staff to proactively call patients to schedule a diabetes visit.
  • Set up a reminder in your EMR for overdue diabetes visits.

Diabetes Management Incentive (Q040)

The Diabetes Management Incentive fee code (Q040) is payable to a physician’s ongoing management using a planned care approach, consistent with Diabetes Canada’s guideline. The fee code can only be billed once every 365-day period.

Key Recommendations:

  • Q040 must be billed with three K030 for the same patient within 365 days.
  • Set up a reminder in your EMR of the due date to bill for each patient.

Insulin therapy support (K029)

The Insulin Therapy Support fee code (K029) is payable to physicians who provide support and counselling on intensive insulin therapy requiring at least three injections per day or using an infusion pump, or training on insulin for patients who use glucose meters, insulin pumps or insulin pens. The fee code is limited to a maximum of six per patient per 12-month period.

We have created a quick reference guide for billing diabetes management codes. You can download it here.

Common Errors and Explanation Codes

Due to the complexity of billing for diabetic patients, errors and rejections may occur. The two most common error codes are M1 and MR codes.

M1 – Maximum fee allowed for these services has been reached.

Diabetes fee codes can be billed a limited amount of times per year. If you bill a code more than the specified amount within 365 days of a previously processed fee code, it will be processed at $0 and error code M1 will appear on the next month’s RA.

How to fix: resubmit alternate fee code or write-off fee code if not payable.

MR – Minimum service requirements have not been met.

Some codes have prerequisite codes that need to be processed for the same patient within 365 days. If the prerequisite codes have not been billed, the MR code will appear. In the case of diabetes management, you must bill three K030’s for the same patient before you can bill a Q040.

How to fix: refer to the Schedule of Benefits for the billing rules for specific fee codes.

At DoctorCare, we can help you submit your billing codes as well as fix your errors and rejections on your behalf. You can explore our Billing Care services here.

Diabetic Recall System

Having a recall system in place helps improve the quality of diabetes care as regular assessments allow physicians to monitor the progression of diabetes in patients and early detection of complications.

By proactively recalling diabetic patients and sending them timely reminders about their upcoming checkups, you will be able to bill the relevant codes at the right time. This approach increases your potential earnings on a standard-sized roster of diabetic patients.

Let’s look at a case study:

Roster Size: 1,300 patients

Diabetic Patients: 136

136 x $216 = $30,000 recovered annually

You have a roster size of 1,300 patients and 136 of your patients are diabetic (based on Diabetes Canada, around 10% of patients require diabetic management).

If effectively managed, a diabetes recall system can yield approximately $216 per rostered patient. With 136 patients at $216 per patient, you would be making an additional $30,000 a year for seeing those patients. 

In essence, effectively managing your diabetes patients not only enhances the continuity of their care but also generates more revenue for the physician.

Diabetes Management Support from DoctorCare

Diabetes management requires considerable time and effort to ensure that patients are being recalled for their visits. DoctorCare can help you with effectively managing your diabetic patient recalls making sure you can maximize your revenue potential with minimal effort required on your part.

With our new service, Patient Care, we will identify patients who have not been seen in over 3 months – right from your EMR. We will then conduct monthly diabetic recalls as well as help you set up the process for recalling patients on your online booking system.

Email us at info@doctorcare.ca to learn more about how we can help.

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