Navigating Ontario's Complex Medical Billing Codes: A Physicians First Guide
Ontario’s medical billing system explained through the seemingly straight-forward OHIP Schedule of Benefits, which outlines over 6,000 fee codes for insured services. At Physicians First, we’ve simplified this system for physicians across Ontario, offering a clear, actionable guide to help you avoid costly errors and maximize billing efficiency.
Understanding the Foundations of OHIP Billing
Billing in Ontario is legally based on the Health Insurance Act and Regulation 552. These require that claims be submitted electronically through the Medical Claims Electronic Data Transfer (MCEDT) system.
Annual updates to the OHIP Schedule are negotiated between the Ontario Medical Association (OMA) and the Ministry of Health. In 2024, physician compensation accounted for over 15% of total provincial healthcare expenditures.
Key Steps in the Billing Process
1. Registration and Eligibility:
You must hold a valid Certificate of Registration with the CPSO and apply for an OHIP billing number via the Ministry of Health. This includes submitting proof of registration and a practice address.
2. Electronic Claims Submission:
Use the MC EDT system to submit claims securely. Include required data: patient info, billing code, diagnosis, and any premiums. We recommend using our Claims Concierge service or other professional billing software to reduce rejections.
Deciphering the OHIP Schedule of Benefits
Fee Code Structure:
OHIP billing codes follow a logical format:
A codes – Assessments (e.g., A005: GP consultation)
K codes – Forms (e.g., K035 for medical condition reports)
E codes – Premiums (e.g., E078 for chronic care bonuses)
Virtual Care & Telemedicine:
New virtual billing codes have emerged:
Note: Claims for virtual and in-person care cannot be billed on the same day.
Ensuring Compliance and Audit Preparedness
Common Errors:
According to the OMA, the most frequent issues include:
Unbundling procedures
Missing documentation or incorrect diagnostic codes
Billing ineligible premiums
Physicians using manual systems are 2.5× more likely to face audit-related issues.
DIY vs. Professional Billing
Studies show that practices using DIY billing have higher rejection rates (6.8% vs. 1.2%) and spend more time per claim. Professional billing services can significantly reduce both monetary and time losses, and improve cash flow by ensuring more revenue and approved and paid the first time it’s submitted.
Looking Ahead: Technology & Trends
Machine learning tools are being integrated to suggest accurate codes based on clinical notes, improving claim speed and accuracy. For the most part however, they are rules-based, and OHIP claims are more dynamic than current systems can compensate for. We find Claims Concierge and competent professionals in the space are much better at coding than technology at this point.
FAQ’s
1. What is the OHIP Schedule of Benefits?
The OHIP Schedule of Benefits is a government-published document listing all insured medical services and their corresponding billing codes and fees in Ontario.
2. How do I get an OHIP billing number in Ontario?
You must have a valid CPSO license and apply to the Ministry of Health with your credentials and practice address to receive your six-digit billing number.
3. What is MCEDT in Ontario healthcare?
MCEDT (Medical Claims Electronic Data Transfer) is the platform through which Ontario physicians securely submit billing claims to OHIP.
4. Can I submit claims to OHIP manually?
No. As of current regulations, all claims must be submitted electronically via MCEDT.
5. What are common billing code types in OHIP?
Common types include A-codes for assessments, K-codes for forms, and E-codes for premiums and bonuses.
6. What are the new OHIP virtual care billing codes?
K738 and K739 are used for e-consultations, and B203A is used for direct-to-patient video visits.
7. Can I bill for a virtual and in-person visit on the same day?
No. OHIP rules do not allow billing for both types of services for the same patient on the same calendar day.
8. What causes OHIP claim rejections?
The most common causes include incorrect diagnostic codes, unbundled services, and incomplete documentation.
9. What is the average claim rejection rate for manual billing?
Practices using manual billing see average rejection rates of 5–8%, compared to 1–2% with automated systems.
10. Is professional billing worth the cost for physicians?
Yes. Data shows that professional billing services reduce rejection rates, save staff time, and increase net revenue.
11. How long do I have to submit an OHIP claim?
As of recent updates, claims must be submitted within 90 days of the service date.
12. What is E078 in OHIP billing?
E078 is a premium code used for chronic disease management services, offering additional compensation for qualifying patients.
13. How often is the OHIP fee schedule updated?
The fee schedule is updated annually through negotiations between the Ontario Medical Association and the Ministry of Health.
14. Can I check patient eligibility in real time?
Yes. The MCEDT API allows for real-time eligibility checks and remittance advice access.
15. What’s the difference between DIY and professional billing?
DIY billing is managed in-house and is prone to errors; professional billing uses experienced teams or services to improve accuracy and revenue.
16. Do billing errors impact audit risk?
Yes. Manual errors significantly increase your chances of post-payment audits and penalties.
17. What is a billing premium in OHIP?
Premiums are additional payments for services meeting specific criteria—such as complexity, after-hours timing, or chronic disease care.
18. What documentation do I need to bill OHIP correctly?
You’ll need accurate clinical notes, patient health card info, service codes, and supporting diagnostic data.
19. Can OHIP claims be submitted retroactively?
Yes, for services rendered up to six months before your billing number was issued, though this must be properly documented.
20. How can Physicians First help with OHIP billing?
We offer concierge-level billing support, audits, and ongoing optimization to ensure accuracy, compliance, and improved practice profitability.
