Chronic diseases require more management, and certainly call for more consistent outpatient follow up, than acute or short term health conditions. To remunerate physicians for their dedication and the more involved level of care in chronic diseases, a premium code was added to the Schedule of Benefits in 2005.
The chronic disease assessment premium (E078) is a percentage based premium payable on certain outpatient assessments. In 2005 E078 was worth 30%; the rate was increased in April of 2007 to 40%, and once more in January 2008 to 50%, which is where it remains today.
As usual, there are some limitations to its application: location, assessment code, diagnostic code and physician specialty. It is not payable to nternal medicine, cardiology, nephrology and gastroenterology specialists as of April 2015.
Location, Location, Location
This premium is billable only in an office setting or hospital outpatient clinic. E078 is not applicable when seeing admitted inpatients, long-term care facility patients or patients in the emergency department.
The keyword for E078? Outpatients.
50% of what?
The E078 premium is payable only on assessments. Consultations (regular, comprehensive, limited, repeat, etc.) are not eligible for the chronic disease premium. In the list below, we demonstrate how E078 impacts the revenue of eligible Internal Medicine assessment codes.
Internal Medicine Assessments + E078
|Code||Assessments Billable with E078||Amount||50% Premium||Total|
|A133||Medical specific assessment||$ 79.85||$ 39.92||$ 119.77|
|A134||Medical specific re-assessment||$ 61.25||$ 30.62||$ 91.87|
|A131||Complex medical specific re-assessment||$ 70.90||$ 35.40||$ 106.30|
|A138||Partial assessment||$ 38.05||$ 19.02||$ 57.07|
Which Diagnostic Codes Apply?
Initially, 26 chronic diseases were approved for payment with E078. In January of 2008, five additional diagnostic codes were added to the list. Below is a selection of most common chronic disease diagnostic codes eligible for E078. A complete list is available on page 16 and 17 of the General Preamble of the Schedule of Benefits.
Some examples of chronic diseases:
|250||Diabetes mellitus, including complications|
|402||Hypertensive Heart Disease|
|428||Congestive Heart Failure|
|493||Asthma, Allergic Bronchitis|
|571||Cirrhosis of the Liver|
|714||Rheumatoid Arthritis, Still’s Disease|
Physician Specialty: Who can bill E078?
Another important aspect of this code is that it only applies to 17 of the 34 Physician specialty designations. This tally is up from the 13 original specialties – the MOH added Endocrinology (15), Nephrology (16), Medical Oncology (44), and Infectious Disease (46) to the list in 2007.
Specialties eligible for E078:
|13||Internal Medicine||44||Medical Oncology|
|15||Endocrinology & Metabolism||46||Infectious Disease|
|31||Physical Medicine||62||Clinical Immunology|
- the chronic disease must be clearly diagnosed and recorded in the patient’s medical record. Claims for patients at risk for a chronic disease are not eligible.
- the reason for the assessment must directly relate to the chronic condition or a complication thereof; visits for patients with a chronic disease being seen for another reason are not eligible for E078 (ie, a diabetic being seen for a cough unrelated to diabetes mellitus)
As always, physicians are responsible for their own billing. OHIP will automatically reject E078’s billed with the inappropriate diagnostic code, or for physicians with ineligible specialties, but the reason for a patient’s visit and the degree of involvement with their chronic condition is determined by the physician.