We often tell our doctors that one of the benefits of working with a knowledgeable medical billing company is that we are often among the first to pick up changes in the way the Schedule of Benefits is being interpreted. One reason for this is that we work with multiple doctors across multiple hospital settings so it’s easier for us to see patterns developing. Further, our focus on following up unpaid claims often forces us to communicate with claims assessors, so we get to hear first hand about billing issues that the Ministry is starting to look at.

For many years now, we’ve been hearing from claims assessors that the Ministry of Health was going to tighten up its interpretation around critical care billing in the ICU and CCU, and we’ve certainly seen this over the past year or two. Specifically, the Ministry of Health has started to more vigorously reject the billing of other Internal Medicine physicians when the per diem codes are billed.

Critical Care Per Diem Listings

Most physicians in the ICU bill what are known as per diem listings.  There are different fees depending on the type of the support the doctor provides:

Most ICUs are set up to have one physician – usually an internist – bill the Per Diem codes because they are most responsible for the patient.  According to J24 of the Schedule of Benefits, “while the physician-in-charge may change during the course of treatment, the daily fee formula as set out should be claimed by the physicians involved as if there was only one physician-in-charge during the treatment program.”  In other words, if one doctor bills the per diem listings, but another physician provides critical care or comprehensive care on the same day to the patient, these claims could be denied because they are covered by the team fees paid to the first physician.

Of note, there is a provision that the ministry can consider fees submitted by other physicians on an “Independent Consideration” basis.  This means that the ministry can and will pay claims for other physicians involved in the patient’s care but at their discretion, and this is where the shift has occurred. We are currently  seeing many more rejections on the billing of other internal medicine specialists, especially those covering the ICU in the evening or at night, then we’ve seen in years past. Assessments such as A133 and A138 are frequently being knocked down to routine hospital visits (C132), and the related special visit codes are consequently being denied.

The above rules about per diem ICU billing are not new.  The shift in interpretation and enforcement is a reflection of the government’s current ‘belt-tightening’ mindset.  For doctors in Ontario, this shift is obvious and palpable with the recently announced 2.65% payment discount recently imposed by the MOH.