wheelchair 1000 x 700Chronic 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
345 Epilepsy
402 Hypertensive Heart Disease
428 Congestive Heart Failure
493 Asthma, Allergic Bronchitis
571 Cirrhosis of the Liver
714 Rheumatoid Arthritis, Still’s Disease
902 Educational problems


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:

07 Geriatrics 41 Gastroenterology
13 Internal Medicine 44 Medical Oncology
15 Endocrinology & Metabolism 46 Infectious Disease
16 Nephrology 47 Respiratory Disease
18 Neurology 48 Rheumatology
26 Paediatrics 60 Cardiology
28 Pathology 61 Haematology
31 Physical Medicine 62 Clinical Immunology
34 Therapeutic Radiology


Additional Requirements:

  • 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.

*As of April 2015, E078 is not payable to the following specialties: Internal Medicine, Cardiology, Nephrology, and Gastroenterology.