OADM29798
Class 9
Review: General Surgery, Assistant and Anaesthesiologist Health Claims
New material: After Hours Surgical Procedure Premiums
Obstetrics Review
• Who is our doctor?
• Dr. Spriggs – speciality is Obstetrics & Gynaecology
• Where to we find Dr. Spriggs’s codes in the Schedule of Benefits?
• 4 sections:
• Obstetrics
• Consultations and Visits > Obstetrics & Gynaecology
• Diagnostic and Therapeutic Procedures
• Female Genital Surgical Procedures
Obstetrics Review
Obstetrics Review
How will this be billed?
Obstetrics Review
How will this be billed?
Obstetrics Review
• What about when Dr. Spriggs is the surgeon and Dr. Plunkett is the
assistant?
• Apply the same basic concepts as billing for the General Surgeon and
Assistant …
The Surgical Team
• Who are the members of a Surgical Team?
The Surgical Team consists of:
A) The Surgeon
B) The Surgical Assistant
C) The Anesthetist
… A, B and C are the suffixes we use to identify these individuals when
billing OHIP.
EXAMPLE
A patient has an Appendectomy with or without perforation:
For the Surgeon, bill S207A
For the Assistant, bill S207B
For the Anaesthetist, bill S207C
How is the Surgeon’s fee different from fees
for the Anesthetist and Assistant?
• The surgeon’s (A suffix) fee is listed as a dollar amount in the
Schedule of Benefits;
• Fees for the Assistant (B suffix) and Anesthetist (C suffix) must be
calculated using a formula.
Calculating the Assistant’s Fee
(Basic Units + Time Units) x the Basic Unit Fee
The basic rules for Assistant Billing are found in the General Preamble of
the Schedule of Benefits.
The basic rules for Anesthetist Billing are also found here.
Calculating the Anesthetist Fee
• The formula is the same as for the Assistant
• The UNIT FEE is different
• The BASIC UNITS can be different
• Calculation of time units is also slightly different
What is the Basic Unit Fee?
(Basic Units + Time Units) x the Basic Unit Fee
• This is a Constant
• It is found in the General Preamble of the Schedule of Benefits
• For the Assistant, it is always $12.51
• For the Anesthetist, it is always $15.49
What are Basic Units?
(Basic Units + Time Units) x the Basic Unit Fee
• Found in the Schedule of Benefits, next to the Surgeon’s Fee
Where do we find the Basic Units?
B A C
What about the Time Units?
(Basic Units + Time Units) x the Basic Unit Fee
Where in the Schedule of Benefits can we
find the time units …
Some questions about surgical billing …
Entering Assistant Billing to YorkMed
1. Manually change the “A” suffix to “B”
2. Enter the start and stop time for the procedure
3. Fill in the rest of the required information
• i.e. Diagnostic Code, SLI Code, Master Number, etc.
IMPORTANT: when billing for multiple doctors, triple check
you are billing to the correct doctor
Bill the surgical codes (“A”) to the surgeon, bill the assistant
codes (“B”) to the assistant
To indicate it is Assistant Billing …
Manually change the A to B
To enter time units
Click the arrow next to number of
services, then enter the START and
STOP times for the procedure
General Surgery Billing (03)
• General Surgeons may operate on a wide range of organs and body
systems.
• Dr Thomas is our General Surgeon.
• When looking up Surgical Procedure codes in the Schedule of
benefits, how do you find surgical codes for the general surgeon?
• Remember to search and read carefully – no need to use bookmarks,
but you must be very careful with spelling and reading the code
descriptions to ensure they match!
Work from last Class
• Activity 8-3: Schedule and code for Dr. Thomas (Surgeon)
• Activity 8-4: Schedule and code (Dr Plunkett, Assisting Dr Thomas)
Activity 8-3: Billing Journal
Activity 8-4: Billing Journal
After Hours Procedure Premiums
What are they?
• When a surgeon commences a case after hours, a premium
can be added to the procedure claim.
• The amount added will depend on WHEN the case
COMMENCES
• Cases commencing between 5:00 PM and Midnight (17:00h
– 24:00h) are eligible for one code (worth an additional 50%
of the fee claimed)
• Cases commencing after Midnight but before 7:00 AM
(00:00h – 07:00h) are eligible for a different code (worth an
additional 75% of the fee claimed)
• Similar fees exist for the Surgical Assistant and Anesthetist.
For the surgeon
• The codes are E409A & E410A
• You can find these in the Schedule of Benefits by searching “After
Hours Procedure Premiums”
For the assistant (con’t)
• For the Assistant, the codes are E400B & E401B
Order matters.
• When adding these premiums to procedures for the
Surgeon or the Assistant, the claims must be entered
to YorkMed Medical Desktop in the following order:
1. Enter the main Surgical Claim first (i.e. S206A)
2. Next, enter any additional claims that may apply
3. Add the After Hours Procedure Premium last
Why does order matter?
• The after hours procedure premiums are percentage based
• If not applied last, the fee will not be calculated correctly.
• i.e. 50% of $100 is $50, but 50% of $200 is $100 …
• And 50% of $0 is $0. If you bill the premium first, this is the way it will
calculate.
When billing after hours procedure premiums
for the assistant …
• Bill the surgery, then click “Add to”
• Don’t forget to change “A” to “B” for the after hours code
• Confirm that the base units and time units are accounted for by
looking at the “# of Services” field. This should not change after
clicking “Add to” …
For next class…
• Test 3 (15%)
• General Surgery, Assistant and Anaesthesiologist Health Claims
• After Hours Procedure Premiums
• Complete Activities 9-1 & 9-2
• Check SLATE for answer keys
• Complete Activity 9-3 (Check SLATE for updates)
• Review material and activities from last class and this class
• New topic: Multiple and Bilateral Major Operative Procedures
Assignment #2 (10%)
Obstetrics & Gynaecology Billing AND
General Surgery, Assistant & Anaesthesiologist Billing
• This assignment must be completed individually. Anyone found in violation of that may
be penalized as per the OA Policies and Procedures Guidelines.
• This assignment allows the use of the SOB (Schedule of Benefits) and the Diagnostic
Manual only.
• Please close all other applications/windows, including York-Med and all websites
(except SLATE ), when completing this assignment.
• Note: There are 20 questions on this assignment and you will be given 75 minutes to
complete and submit the assignment.
• In previous terms, 50 minutes has been the limit for this assignment. The additional time is being
included to account for technical issues and to ensure everyone has ample time to finish the
assignment.
~~Please note that CORRECT SUFFIXES MUST BE ENTERED for all service codes, so be sure
to enter full 5-character service codes in order for your answers to be marked as
correct.~~
Example: A003A = correct | A003 = incorrect (suffix missing)
