New Changes for OHIP Fee Codes K229, R766 and R767

OHIP issued a bulletin detailing changes for K229 (Complex Genetic Test Interpretation), and R766/R767 (New Surgical Procedure Codes). While the following changes were announced January 1st, 2021 – they are being backdated from April 1st, 2020.

K229A-Complex genetic test interpretation

K229A is only eligible if you are a specialist in genetics and/or a specialist with a Fellow of the Canadian College of Medical Geneticists (FCCMG) designation.

Claims Processing-K229A Changes

1. K229A can be claimed for as many as two services per patient, per physician, per 365 days.
2. Error code ‘M1-Maximum number of services has been reached’  means K229A has been claimed for more than two services and will pay $0.
3. Error code ‘DF-Corresponding fee code has not been claimed or was approved at zero’ means K229A was claimed without a consultation or genetic care service for the same patient and therefore will pay $0.

Since there’s a low volume of claims that are affected by the K229A changes, all adjustments will be done internally through OHIP and will appear on future Remittance Advices (RAs).

New Fee Schedule Codes effective April 1st, 2020

1. R766A: In-situ saphenous vein arterial bypass-tibial-two Vascular Surgeons-first surgeon.
2. R767A: In-situ saphenous vein arterial bypass-tibial-two Vascular Surgeons-second surgeon.

Claims Processing-R766A/B/C and R767A Changes

1. You’re only eligible to claim R766A and R767A if you’re a vascular surgeon with a specialty designation in General Surgery (03) or Vascular Surgery (17).
2. Error code ‘D7 Not allowed in addition to other procedure’ means you can’t claim R766A and R767A with R804A (if you do, R804A will be paid and R766A and R767A will be paid at $0).
3. If you try and claim R766A/B and R767A on the same date for the same patient then only R766A/B will be paid. R767A will come back paid at ‘0’ and you’ll get error code ‘D7 Not allowed in addition to other procedure’.
4. If you submit a claim for R766A/B  and there’s history that you’ve already previously submitted  R767A  for the same patient, on the same service date then you’ll get error code ‘D7 Not allowed in addition to other procedure’ and the claim will be paid at 0. (the same is true but for the reversed situation see point 5).
5. If you submit a claim for R767A and there’s history that you’ve already previously submitted R767A/B for the same patient, on the same day, then you’ll get error code D7 Not allowed in addition to other procedure’ and the claim will be paid at 0.
6. Only one physician can be paid for R766 within a surgical assistant unit.
7. R766C can be claimed for automated anesthesia age premiums.
8. If you’re an R766C-Anaesthesiologists refer to page GP95 of the Schedule (page 109) to bill extra units.
9. Error code ‘A3F-No Fee for Service’ means R767B/C was rejected.

R766A/R767A Medical Claims Adjustments 

While these new rules came into effect starting January 1st, 2021, all fee codes R766A and R767A claims will be backdated starting from April 1st, 2020. This means: 

• Previously paid claims submitted for R766A and R767A services between April 1, 2020 and December 31, 2020 are subject to the adjustments. If changes are made, you’ll see adjustments on your February 2021 Remittance Advice (RA) report.
  
• If a claim gets adjusted then the entire claim is selected for reprocessing. If a claim has multiple fee schedule codes, all codes will be reprocessed.
•  On your adjustments, if you see ‘55-This deduction is an adjustment on an earlier account’ or ’57-This payment is an adjustment on an earlier account’ it simply means there is no change in payment for claims that were reprocessed. 

Knowing the eligibility and changes to these codes will help improve the efficiency of your processing claims. If you have any questions don’t hesitate to get in touch with our team.

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