Case Conference and Multidisciplinary Cancer Conference Codes INTRODUCTION What is the Education and Prevention Committee (EPC)? The Ministry of Health and Long-Term Care and the Ontario Medical Association (OMA) have jointly established the Education and Prevention Committee (EPC). The EPC’s primary goal is to educate physicians about submitting OHIP claims that accurately reflect the services provided and that are in compliance with the law.
What is an Interpretive Bulletin? Interpretive Bulletins are prepared jointly by the Ministry and the OMA to provide general advice and guidance to physicians on specific billing matters. They are provided for education and information purposes only, and express the Ministry’s and OMA’s understanding of the law at the time of publication. The information provided in this Bulletin is based on the April 1, 2011, Schedule of Benefits – Physician Services (Schedule). While the OMA and Ministry make every effort to ensure that this Bulletin is accurate, the Health Insurance Act (HIA) and Regulations are the only authority in this regard and should be referred to by physicians. Changes in the statutes, regulations or case law may affect the accuracy or currency of the information provided in this Bulletin. In the event of a discrepancy between this Bulletin and the HIA or its Regulations and/or Schedule under the regulations, the text of the HIA, Regulations and/or Schedule prevail. EPC Bulletins are available on the OMA website (http://www.oma.org/Resources/Pages/EPCbulletins.aspx). The Schedule is available on the Ministry website (http://www.health.gov.on.ca/english/providers/program/ohip/sob/sob_mn.html).
• • • • •
This Bulletin provides information to physicians on case conference fee codes, including revisions to two existing codes (K121 and K124), the introduction of several new case conference codes (K700, K701, K702, K703, K704), as well as multidisciplinary cancer conference codes (K708, K709), which came into effect on October 1, 2010.
Case conferences are time-based services: • The Long-Term Care/CCAC patient case conference (K124) is payable in time units of 30-minute increments (or major part thereof). The time chart on page GP45 illustrates the eligible units for K124. • All other case conference codes are payable in time units of 10-minute increments (or major part thereof), as shown in the chart on page A21.
Case Conferences What is a case conference? As defined on page A21 of the Schedule, “a case conference is a pre-scheduled meeting, conducted for the purpose of discussing and directing the management of an individual patient.” Specific case conference fee codes are available for: • Palliative care outpatients (K700); • Mental health outpatients (K701);
OntariO Medical review
Bariatric outpatients (K702); Geriatric outpatients (K703); Paediatric outpatients (K704); Hospital inpatients (K121); and Long-Term Care/Community Care Access Centre (CCAC) patients (K124).
General payment requirements Each of these case conferences may have specific payment
requirements listed in the Schedule under the individual fee code (pages A23 to A26); however, the following conditions apply to all case conferences: • The case conference must be pre-booked; • There must be at least three eligible participants (see “Who is an Eligible Participant,” below) attending either in person, by videoconference or by telephone (for K124, the participants must all attend in person); • A minimum of 20 consecutive minutes for a long-term care/CCAC patient (K124), or a minimum of 10 consecutive minutes of patient discussion for a hospital inpatient (K121) and all outpatient case conferences; and • The patient’s common medical or case conference record must include all of the following: - patient identification (e.g., name, health number); - eligible participant identification; - start time and stop time of the discussion (as well as separate start time and stop time for a physician not participating for the entire conference) regarding the patient (signed or initialled by all physician participants; the conference chairperson may sign for a physician participating via teleconference); and - the outcome or decision of the case conference.
• When the maximums per patient per day, and per patient per year have been exceeded; or • If another case conference or telephone consultation has already been paid for the patient on that day. Note: no other insured service rendered during a case conference is eligible for payment.
Payment requirements for an individual physician participating in a case conference In addition to the general payment requirements, in order for an individual physician to be eligible for payment of a case conference, he or she must be actively participating and the participation must be evident in the medical record. Furthermore, if the physician does not participate for the entire conference, the physician’s individual start time and stop time must be noted separately on the record, and meet the minimum time requirement for the case conference.
Who is an eligible participant? To be an “eligible” participant, the physician or non-physician must be someone who is involved, or about to be involved, in the care and/or treatment of the patient. For all case conferences, there must be one physician participating and at least two other additional participants. The other two participants may include regulated health professionals, physicians, or additional participants specific to fee codes K701, K702, K704 and K124, as illustrated in the chart below:
If the above conditions, and any other requirements for a specific case conference code, are not met, the service is not eligible for payment. Furthermore, a case conference is not eligible for payment: • Where a physician claiming the service remunerates other participants who are necessary to meet the minimum participant requirement; • To a physician who is receiving funding from another program, other than fee-for-service, to provide the service (e.g., salary, stipend, sessional fee, primary care, alternate payment or alternate funding program, where funding includes the provision of the service); • If it is an included element of another service (e.g., chronic dialysis team fees, community treatment orders); • For radiation treatment planning services listed in the Radiation Oncology section (applies to K121 and K700); • For services described in the Team Care in Teaching Units section (applies to K121); • For educational purposes, such as rounds, journal club, group learning sessions or continuing professional development or any other meeting, where the purpose is not for discussing and directing the management of an individual patient;
Ontario Medical Review
Fee Code Eligible Participant
Personnel employed by a mental health community agency funded by the Ministry of Health and Long-Term Care
Members of the Bariatric Regional Assessment Treatment Centre (RATC) team involved with the patient’s care (e.g., social worker, psychologist)
Educational professionals and/or personnel employed by an accredited centre of Children’s Mental Health Ontario
Note: while medical students and/or residents and/or fellows may participate, these individuals do not count as eligible participants.
For K124, the patient (or their relative, representative or caregiver) may or may not be present during the conference. This is a change from the previous Schedule which required the patient to be present.
Maximums For case conferences, with the exception of K124, a physician is limited to a maximum of • Four services (claims) for a patient in a 12-month period; and • Eight time units for a patient in a single day. For K124, a physician is limited to a maximum of • Two services (claims) for a patient in a 12-month period. Claims in excess of two per year should be submitted using the manual review indicator, with supporting documentation demonstrating that an additional case conference is necessary for the patient under the circumstances. Claims with a manual review indicator are reviewed to determine payment eligibility.
Palliative care outpatient
K700 K701 K702
Mental health adult outpatient
Outpatient registered with a Bariatric RATC for the purpose of pre-operative evaluation and/or post-operative follow-up medical care
Physicians identified to the Ministry as working in a Bariatric RATC
Geriatric outpatient at least 65 years old or under 65 with dementia
K704 Paediatric outpatient less Paediatrics (26) than 18 years of age and Psychiatry (19) K121 Hospital inpatient in an All acute care, chronic care or rehabilitation hospital
Multiple patients discussed at one case conference Where more than one patient is discussed at a case conference, the case conference is eligible for payment for each patient provided all payment requirements are met for each individual patient (see “General Payment Requirements”).
Long-term care institution All in-patient
(an endocrinologist) and Dr. C (a surgeon) for 16:30 that afternoon to discuss patient Z’s complex medical condition. Nurse J also attends. Dr. B calls in from his home. The conference ends at 16:48; however, Dr. B leaves the conference at 16:40. The start time and stop time is recorded in the patient’s medical record and initialled by both Dr. A and Dr. C. Dr. B records his individual participation time in the record when he is at the hospital next on Friday.
Keep in mind the minimum time requirements for each patient, and that each eligible participant must be involved in the care and/or treatment of the patient for which a claim is being submitted.
Eligible patients and eligible OHIP specialties Each case conference is applicable to a specific patient, and some are only eligible for payment to certain OHIP specialties. The following chart (above, right) illustrates the eligible patient and specialty for each fee code.
What is eligible for payment? As at least three physicians or paramedical staff participated for a minimum of 10 minutes: • Dr. A is eligible for 2 units of K121 • Dr. B is eligible for 1 unit of K121 • Dr. C is eligible for 2 units of K121
Examples Example 1 (K121) After seeing patient Z, a hospital inpatient, at 08:00 on Wednesday, Dr. A books a case conference with Dr. B
After seeing patient Z, a hospital inpatient, at 08:00 on Wednesday, Dr. A books a case conference with Dr. B (an endocrinologist) and Dr. C (a surgeon) for 16:30 that afternoon to discuss patient Z’s complex medical condition. Dr. B does not attend, and the conference ends at 16:45. Nurse J was also scheduled to attend, but was detained by a new admission to the ward and did not arrive until 16:50.
K708 and K709 are only eligible for payment when: • The MCC meets the minimum standards, including attendance requirements established by CCO (see Internet link above); • There is a minimum of 10 minutes discussion regarding the patient (for a participant or chairperson making a claim); • The MCC is pre-booked; and • The medical record includes all of the following: - identification of the patient (e.g., name, health number); - identification of the participants; - start time and stop time of the discussion regarding the patient; and - the outcome or decision of the case conference.
What is eligible for payment? Only two physicians participated; therefore, no one is eligible for payment of K121.
Example 3 (K124) Patient Y is a long-term care inpatient seen by Dr. A. A case conference is booked for Thursday afternoon to discuss patient Y. In attendance is Dr. A, Nurse N, and Mr. P, a physiotherapist on salary at the home. The conference begins at 13:00 and ends at 13:25 with all three participants in attendance as well as patient Y’s daughter. Nurse N records the start time and stop time in the patient’s medical records, and it is initialled by all attendees.
K708 (participant) is limited to a maximum of: • Five services per patient per day for any physician (i.e. no more than five physicians are eligible for payment of K708 for an individual patient on the same day); and • Eight claims per physician per day (i.e. no more than eight different patients per physician per day).
What is eligible for payment?
K709 (chairperson) is limited to a maximum of: • One per patient per day (by all physicians); and • Eight claims per physician per day.
Dr. A is eligible for payment of one unit of K124. Note: no other insured service rendered during an MCC is eligible for payment.
Multidisciplinary Cancer Conferences What is a multidisciplinary cancer conference (MCC)?
When are K708 and K709 not eligible for payment?
As stated on page A20, a multidisciplinary cancer conference is a service where a physician is in attendance at a conference in accordance with the defined roles and minimum standards established by Cancer Care Ontario (CCO). These are found on the Internet at: www.cancercare.on.ca/ common/pages/UserFile.aspx?fileId=14318.
K708 and K709 are not eligible for payment: • To the same physician on the same day for the same patient; • To a physician who receives payment other than by feefor-service for the preparation and/or participation in the MCC (e.g., salary, stipend, sessional fee, primary care model, alternate payment or alternate funding program model); or • To physicians in the OHIP specialties of Radiation Oncology (34) and Laboratory Medicine (28).
There must be at least 10 minutes of patient discussion, and each participant must participate for a minimum of 10 minutes in order to be eligible for payment of the service. Participation may either be in person, by telephone or by videoconference. The MCC codes are: • K708 – participant; and • K709 – chairperson
Your feedback is welcomed and appreciated! The Education and Prevention Committee welcomes your feedback on the Bulletins in order to help ensure that these are effective educational tools. If you have comments or questions on this Bulletin, or suggestions for future Bulletin topics, etc., please submit them in writing to: Physician Services Committee Secretariat 150 Bloor Street West, 9th Floor Toronto, Ontario M5S 3C1 Fax: 416.340.2961; E-mail: [email protected] Dr. Jane MacNaughton, Co-Chair Dr. Larry Patrick, Co-Chair Education and Prevention Committee The PSC Secretariat will anonymously forward all comments/suggestions to the Co-Chairs of the EPC for review and consideration.
For specific inquiries on Schedule interpretation, please submit your questions IN WRITING to: Health Services Branch Physician Schedule Inquiries 370 Select Drive, P.O. Box 168 Kingston, Ontario K7M 8T4