Remittance Advice Explanatory Codes: Maximums

ohip explanatory rejection code

We’ve all seen OHIP rejection codes on the remittance advice summary sent monthly by the Ministry of Health, but many physicians aren’t sure what they mean, or what to do about rejected codes. In this blog, we’ll cover some of the RA explanatory codes that deal with maximums exceeded, and point out tips for dealing with the rejections where possible.

OHIP rejection codes vs. explanatory codes

Most of us use the terminology ‘rejection code’ whether we’re referring to rejections on error reports, or on the remittance advice summary. There is a difference: 3 character rejection codes are found on error reports, and are properly called “error codes”. Any 2 character rejection code on your monthly RA report is a “remittance advice explanatory code” in OHIP speak.

When the first character of your explanatory code is an “M”, you can be pretty sure you’ve hit a max. Below we go through two of the most common M codes, then explain the pesky H3/H5 rejection codes that plague any hospitalist in Ontario.

M1 – Maximum number of services reached – same/any provider

Many of the codes in the Schedule of Benefits have a maximum of 1 per day for any provider. If you’re the second physician billing the same code as someone else, your claim will be rejected with code M1. This happens most often when procedures are billed. There is no choice here but to write off the claim. Your only recourse is to speak with the other physician in question about the claim, as claims assessors won’t get involved in these circumstances.

MD – Daily maximum reached

Codes such as special visit premiums have preset maximums per time period for one physician. If you’ve had an especially crazy on-call evening shift that required you to travel to the hospital four times, only the first two travel premiums will get paid. Similarly, on a busy weekend call shift, only 20 weekend special visits are payable. To avoid write off’s, you can keep track of the number of premium codes you submit to stay within the allowable range. If you go over, MD will mean writing off the offending code.

H3 & H5 – Maximum fee allowed per week after the 5th or 13th week for Hospitalists

MRP daily visit codes have maximums. After 5 weeks, even when seeing a patient daily, the Most Responsible Physician can only bill 3 visits per week, and after the 13th week from admission, only 6 visits per month. When visits billed are above these maximums (calculated by comparing the service date to the admit date), H3 and H5 error codes come back on the remittance advice report, with DF on the MRP premium E083 if it was billed.

What to do?

Consider the following two situations:

  1. Was the patient referred to you – not transferred to your service – by another physician during the hospital stay? If so, then the date of your initial assessment becomes the new admit date for billing purposes, and you might be eligible for those hospital visits if the time period allows.
  2. Were any of the visits due to acute intercurrent illness? For instance, if a stroke patient developed a hospital borne infection, and your visits were for the purpose of treating this second condition, you could resubmit C121 ($31.00) for those dates. C121 is payable even after the 5 and 13 week milestones are reached… but the code is only available to the MRP. Remember to document your work thoroughly, as the MOH may request supporting documentation for claims at any time.

If neither of the above situations apply, you’ll have to write off the codes over the maximums allowed.

C8 – Maximum # of Geriatric Consults

C8 is a code that will pop up on the Remitttance Advice report, indicating specifically that the geriatric consult has been billed before the 2 year time period has elapsed. In this case, the MOH will pay down the fee to that of a regular consultation instead of the comprehensive geriatric consultation. If your claim is paid at zero, you can resubmit the regular consultation code.

TIP: check the chart for billing Detention code units on page GP20 of the Schedule to account for extra time spent with the patient.

Similar situations may occur for other special consultations, such as the Psychiatric Neurodevelopmental Consultation – A695 – billable every 5 years.

 

Questions on other RA explanatory codes? Don’t be shy to use our comments section below, or Request a Blog here!

 

Blog Categories: Remittance Advice

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