Error maximum

The codes that are generated automatically by the MOHLTC’s error reports seem daunting at first. Strange creatures like EH2, VH8, and A3H don’t exactly calm the nerves when billing codes are rejected. But with a little help, and knowledge of the OHIP Schedule of Benefits, they’re easily fixable.

A new subscriber asked for our help this month in dealing with the A3H error code. We decided to go the extra mile and cover the most common error codes dealing with maximums. Read on to find out how to correct your claims for resubmission… and get them paid this time!

Error Report Rejection Codes

A3H – Maximum number of services

Getting an A3H rejection code means you’ve reached the maximum number of services for that code in your claim. In some circumstances, you are not entitled to bill more units.  But other times, depending on the circumstances, you can flag the claim for manual review and resubmit with an explanation.  That explanation may involve submitting supporting documentation such as surgical notes.  In some cases, an alternate code may be billed, but this depends on the physician’s specialty and what medical services were performed.

Note: Not all codes that reached the maximum will be rejected on error reports. Some will come back paid at nil on the Remittance Advice reports. For more on that, our next blog will cover some RA explanatory codes.

AC1 – Maximum reached

AC1’s come up often with consultation codes. A standard major consultation, requiring a referring physician, is billable once per 12 months for specialists. If a doctor provides a consultation via referral on June 1st, then the patient is referred once more to the same physician on May 30th of the following year, the consultation will be rejected as over the maximum number for that time period. A consult billed on June 2nd of the following year is payable according to the Schedule, as the service date is over 365 days from the previous one.

Note: There are other specialty specific consultation codes that have different time limits. For example A695 – the Neurodevelopmental Consultation for Psychiatrists – can only be billed once every 5 years.

The correct action here for most specialties is to bill a re-consultation code. Reconsults also require a new referral, but are payable at a lesser rate since the doctor is familiar with the patient’s case. The exception is if the patient is seen a second time for a completely unrelated medical condition – in this case the consult can be billed again. And finally, Psychiatrists have the option to bill treatment codes instead of a re-consult code.

V23 – Check number of services

Many codes are unit based – for example time based case conferences, psychiatric treatment codes, and the number of units of a surgical procedure. Though they aren’t listed in the Schedule of Benefits, most of these codes have maximums flagged internally by the MOHLTC claims assessors. When you see this error code, check if you’ve made a typo. Otherwise, you should resubmit your claim with the manual review indicator and documentation supporting the number of units billed for that service in order to get paid.

V39 – Number of items exceeds maximum

Surgical assists and anaesthesia services are also billed in time units. V39 will tell you when the number of units has exceeded 99, which is the maximum that the software allows. The proper procedure for submitting more than 99 units is to separate the billing into 2 separate claims with the same service code (99 units for the first claim, and the remaining number of units in the second claim) adding manual review flags that explain the total time for that procedure.

There are a few more specialized error codes related to billing over the allowed maximums, but they’re not seen very often… if we don’t see them at JCL, trust us, they’re rare! Hope you enjoyed this request a blog, and many thanks to our subscriber for getting in touch!

For JCL’s other blogs in the Error Code series, check out:

Explaing Error Codes: EH2 and Friends

More on Error Codes: the VH8 Flood of 2014

Error Codes: Problems with referral billing numbers