Ontario Health Insurance Plan (OHIP) Billing Codes Information and Procedures for Claiming the Cumulative Preventative Care Bonus

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1 Ontario Health Insurance Plan (OHIP) Billing Codes Information and Procedures for Claiming the Cumulative Preventative Care Bonus Eligible Patient Enrolment Model (PEM) physicians may receive Cumulative Prevention Care Bonuses for maintaining specified levels of preventive care to their enrolled patients. There are five preventive care categories for which an individual physician may earn an annual bonus. Three of these categories are for breast, cervical, and colorectal cancer screening. 1. Pap Smear This bonus is based on the percentage of the target population who has received a Pap smear in the 30 months prior to March 31 st of the fiscal year for which the bonus is being claimed. The target population consists of enrolled female patients who are between 35 and 69 years of age, inclusive, as of March 31 st, of the fiscal year for which the bonus is being claimed (i.e. a patient who turns 70 on March 15 th, 2011 would not be considered part of the 2010/2011 Pap smear target population). 2. Mammography This bonus is based on the percentage of the target population who has received a mammogram in the 30 months prior to March 31st of the fiscal year for which the bonus is being claimed. The target population consists of enrolled female patients who are between 50 and 69 years of age, inclusive, as of March 31st of the fiscal year for which the bonus is being claimed (i.e. a patient who turns 70 on March 15 th, 2011 would not be considered part of the 2010/2011 Mammography target population). 3. Colorectal Cancer Screening This bonus is based on the percentage of the target population who has received a Fecal Occult Blood Test (FOBT) in the 30 months prior to March 31st of the fiscal year for which the bonus is being claimed. The target population consists of enrolled patients who are between 50 and 74 years of age, inclusive, on March 31 st of the fiscal year for which the bonus is being claimed (i.e. a patient who turns 75 on March 15 th, 2011 would not be considered part of the 2010/2011 Colorectal Cancer Screening target population).

2 Below is a list of the Fee Schedule Codes that are applicable for each Cumulative Preventive Care Bonus Category: Cumulative Preventive Care Bonus Category Pap smear Mammography Colorectal Cancer Screening Applicable Services G365A, L713A, L643A, E430A, Q678A, tracking code Q011A, and exclusion code Q140A X185A, X185B, X185C, tracking code Q131A, and exclusion code Q141A G004A, L179A, L181A, Q700A, tracking code Q133A, and exclusion code Q142A Below is a list of tracking and exclusion codes that can be submitted using the normal billing practices to submit Fee for Service claims and premium codes applicable to their agreement. The fee billed should be zero dollars. Category Tracking Code Exclusion Code and Criteria Pap smear Q130A Not applicable Mammography Q131A Q141A Exclusions apply for women who had had a mastectomy, or who are being treated for clinical breast disease. Colorectal Cancer Screening Q133A Q142A Exclusions apply for patients with known cancer being followed by a physician; with known inflammatory bowel disease; who have had a colonoscopy within the last 10 years; with a history of malignant bowel disease; or with Colorectal Cancer any disease requiring regular colonoscopies for Q133A Screening surveillance purposes. Please note that although the above change has increased the length of time that the colonoscopy is valid for exclusion, the Q142A must still be submitted every 30 months to be reported on the Target Population and Service Reports.

3 Steps to Claim for your Cumulative Preventive Care Bonuses 1. Calculate the coverage level as follows: (Number of Covered Patients*/[Number of patients on the Preventive Care/Target Population Service Report Excluded Patients**] ) x 100 *Covered patients are those patients eligible Target Population that received the preventive are services previously defined. **Physicians may adjust the number of patients oh their Preventive Care/Target Population Service Report and remove any patients who meet the exclusion criteria for Pap smear, mammography, and colorectal cancer screening. 2. Determine the appropriate Q Code for the bonus and coverage level. Preventive Care Category Achieved Compliance Rate Pap smear 60% 65% 70% 75% 80% Mammography 55% 60% 65% 70% 75% Colorectal Cancer 15% Screening 20% 40% 50% 60% 70% Fee Payable $220 $440 $660 $1320 $2200 $220 $440 $770 $1320 $2200 $220 $440 $110 $2200 $3300 $4000 Service Enhancement Code Q105A Q106A Q107A Q108A Q109A Q110A Q111A Q112A Q113A Q114A Q118A Q119A Q120A Q121A Q122A Q123a See the following document for more information:

4 Other Billing Codes: Q005A Q150 Q152 Q043A Code Definition Fee For the phone/letter invitation for a $6.86 colon cancer check FOBT test (FHN/FHO) For counseling and directly giving $7.00 patients a colon cancer check branded FOBT kit For review and follow up of a $5.00 completed colon cancer check FOBT kit Accepting a new patient with a $ $ positive FOBT/diagnosed cancer depending on age Please see next page for chart to hang in your clinic.

5 ColonCancerCheck FOBT Re-Orders and Expiry Dates The ColonCancerCheck (CCC) FOBT kit, as with most medical devices, has an expiry date. The expiry date is found on the bottom of the FOBT card on the side that says Do Not Open. Kits received by a community laboratory after the expiration date will not be processed. Patients who submit an expired kit for processing will be advised by mail from ColonCancerCheck that the kit has expired and that they will need to repeat the test with a valid kit. Patients will be advised to obtain a replacement kit from their family physician or nurse practitioner, or from Telehealth Ontario or their local pharmacy if they do not have a family physician or nurse practitioner. What do you need to do? 1. Check your current inventory of FOBT kits to ensure that they are not expired or about to expire. The expiry date of your kits should be at least three months away to allow time for the kit to be completed and returned for testing. 2. Dispose of any kits which are expired or will expire in three months or less. CCC FOBT kits do not contain hazardous materials. You may throw away the kit in your garbage and/or recycle the pieces in the kit as is appropriate for your community. 3. Point out the expiry date to patients when you give them a CCC FOBT kit. Ask them to complete the kit at least a month before the kit expires. Explain that the kit will not be processed if it has expired. 4. Reorder new CCC FOBT kits as needed. Order kits through your community laboratory supplier. Follow the link: 5. If a patient informs you that they have an expired kit, please make it as easy as possible for them to get a replacement kit.

6 CANCER BILLING CODES Breast Cancer (Mammogram) Billing Codes Q131A Ages To help calculate your year-end bonus Q141A Exclusion for Mammogram Cervical Cancer (Pap Testing) Billing Codes Q011A Ages To help calculate your year-end bonus Q140A Exclusion for Pap Colorectal Cancer Billing Codes Q005A For the phone/letter invitation for a colon cancer check FOBT test (FHN/FHO only) $6.86 Q150 For counseling and directly giving patients a colon cancer check branded FOBT kit $7.00 Q152 For review and follow-up of a completed colon cancer check FOBT kit $5.00 Q142A An exclusion code for those who do not need a FOBT test (i.e. previous colonoscopy) To help calculate your year-end bonus Q043A Accepting a new patient with a positive FOBT/diagnosed cancer $150-$230 (depending on age) Smoking Cessation Counseling Billing Codes Q042A Smoking cessation counseling fee (patient enrolment models only) $7.50 E079 Smoking cessation premium $15.40 K039 Smoking cessation follow-up visit $33.45

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