Physicians face unique challenges in managing billing and scheduling requirements as we approach the holiday season. The complexity of holiday billing codes, combined with an effort to balance quality patient care and personal time, can make this period particularly demanding for healthcare providers.
In this blog, we will walk you through everything you need to know about holiday billing, including the upcoming 2024 holiday billing schedule, the Q888 and A888 after-hours codes, the Q012 premium code, and common errors physicians encounter during this time of the year.
2024 Holiday Billing Schedule
The Ministry has announced special billing rules for emergency and after-hours services for the upcoming holiday season. Emergency department equivalent codes (A888/Q888) will be eligible from December 25-31, 2024, and January 1, 2025. Since no holidays fall on weekends this year, there will be no additional eligible days.
The special premium code Q012 has more restricted eligibility, limited to only December 25, 26, and January 1. While Q012 remains available during regular after-hours periods (evenings and weekends), please note it is not eligible for all Q888/A888 services. All standard billing requirements for A888 and Q888 remain in effect during this time.
Weekend Access (Q888) Code
Whether you are a new or experienced FHO physician, navigating the Weekend Access code (Q888) can be complex. This code allows physicians to bill for unscheduled in-person services provided to their FHO group’s enrolled patients during weekends and holidays.
Let’s break down the essential requirements for Q888 billing:
- The patient must be enrolled in the billing physician’s FHO group.
- The service provided is an unscheduled in-person visit. Virtual visits by phone/video cannot be claimed as Q888.
- The billing physician must offer at least three scheduled visits for each three-hour Saturday, Sunday, or Holiday block.
- Q888 must be billed with a valid diagnostic code.
After-Hours Requirement for FHO Groups
During a work week, FHO groups are obligated to meet their weekday after-hours requirements where, depending on the size of the FHO, at least one physician must work after 5:00 pm. Once that requirement has been fulfilled, the weekend physician can bill Q888 for eligible services rendered during a 3-hour block.
FHO physicians gain additional flexibility once they have fulfilled their minimum required weekend after-hours blocks. At this point, they can transition from billing Q888 to A888 when appropriate.
Consider this scenario: An unscheduled enrolled patient sees a physician for an intermediate assessment on a Saturday. The physician’s required weekend after-hours blocks have not been met. What do you bill?
Since the weekend after-hours requirements have not been met, the physician would bill Q888 for the intermediate assessment with the Q012 after-hours premium, as the unscheduled encounter is with a rostered patient.
Emergency Department Equivalent (A888) Code
Differentiating between regular after-hours billing and emergency department equivalent services during the holidays can be confusing, particularly when deciding when to bill A888. This confusion can lead to incorrect billing and potential payment delays or rejections.
The A888 code applies to emergency assessments provided outside of hospital emergency departments – including urgent care centres, walk-in clinics, and extended-hours clinics during weekends and holidays. This code is designed specifically for handling urgent, unscheduled care needs. What constitutes “scheduled” is any pre-arranged appointment, regardless of timing. For instance, if a patient books at 9:00 AM for an 11:00 AM same-day appointment, this is considered scheduled and ineligible for A888.
When billing A888, a physician cannot have scheduled patients.
Here is an example: An unscheduled, non-enrolled patient sees a physician for an intermediate assessment on a Sunday, and the group has fulfilled the required weekend after-hours block. The physician is not on call and has no pre-scheduled patients for the day. What do they bill?
Since the physician has no prescheduled patients and assuming the billing and payment requirements are met, the physician can bill A888.
A888 vs. Q888
Are you still puzzling over which code to use during the holidays? Many physicians and clinic managers struggle with A888 and Q888 billing codes, especially during this season.
Here are the main differences between A888 and Q888:
Code | Description | Differences | Value |
A888 | Emergency department equivalent | – Physicians are not allowed to have any patients scheduled. – The office will have to operate as a walk-in clinic and accept patients with time-sensitive matters which is considered as emergency department equivalent. | $37.95 |
Q888 | Weekend access | – Allows physicians to see scheduled enrolled and unscheduled enrolled patients (provided that three appointments were booked, or three slots were reserved for scheduled enrolled patients). – This physician would be on-call for the group. | $37.95 |
The main difference between the A888 and Q888 codes is the matter of scheduling. FHO physicians must offer scheduled and unscheduled appointments to patients during the after-hours block as per the FHO agreement. Therefore, physicians should not bill the A888 during the required weekend and holiday after-hours clinics. When the group has met the minimum required weekend after-hours blocks, then A888 can be billed.
After establishing the differences between the codes, here is a table summarizing when you would use both A888 and Q888:
Type of Patient | Required Weekend AH Block | Weekend Once AH Blocks Met |
Scheduled enrolled | A007* & Q012 | – |
Unscheduled enrolled | Q888 & Q012 | A888 |
Unscheduled non-enrolled | A007* | A888 |
Scheduled non-enrolled | A007* | – |
DoctorCare’s FHO Group Management
One thing we see physicians struggle with during the holiday season is having difficulty planning their after-hours schedule, mainly due to physicians having a preference not to work during the holiday season. It is important to note that physicians do not have to work after 5:00 pm during the holidays; they can work during the day and still be able to fulfil the after-hours obligation. Need help with holiday coverage? Our team at DoctorCare can create a schedule that works for your entire group during this holiday season.
Email us at info@doctorcare.ca to explore our different services tailored to your group’s needs.
Q012 Premium Code
Many physicians miss significant holiday revenue opportunities by overlooking the Q012 premium code. This 30% premium can substantially increase compensation for eligible services, yet confusion about timing, eligibility, and billing requirements often leads to missed opportunities or claim rejections.
Q012 is added to enrolled patient visits, unscheduled and scheduled, during FHO scheduled after-hours coverage (before 8:00 am and after 5:00 pm) for the following fee codes: A001, A003, A004, A007, A008, A888, K005, K013, K017, K030, K033, K130, K131, K132, K133, Q050 and Q888.
During the winter holiday period, Q012 can be billed for all A888/Q888 on qualifying dates at any time.
The maximum number of services allowed for Q012 is one per patient visit. If more than one is submitted in the same claim, this will result in an ‘A3H- Maximum number of services’ error. Also, Q012 must be submitted on the same claim as the visit. If Q012 is submitted separately, this will result in an ‘AD9- Not allowed alone’ error. Q012 must be submitted with a qualifying fee code.
I6 Explanatory Error
If a Q012 or Q888 is billed and the patient is not enrolled on the Ministry database, an ‘I6- Premium Not Applicable’ error will be reflected in your remittance advice (RA) file, and your claim will not be paid unless the patient becomes enrolled.
We see many physicians receive this remittance error, which often causes a delay in payment. To avoid delayed payments, we encourage physicians to review and update their roster regularly, including billing the roster code Q200.
Our newest service offering, Patient Care is an all-inclusive rostering service to take the burden off managing your roster and ensure your patient list stays up to date with the most active patients! To learn more about Patient Care, visit our website here.
The holiday season brings unique challenges for medical billing in Ontario, but with proper preparation and understanding, you can ensure accurate compensation while maintaining quality patient care. By staying informed about these OHIP billing requirements and keeping your roster updated, you can navigate the holiday season with ease.
