To our colleagues outside of Ontario, please bear with us. This is a huge change that is causing a lot of confusion and stress. It has big financial implications, so appropriate for this group (with the only-applicable-to-Ontario descriptor above).

As promised in another thread, I will review, as best as I can, the major changes to virtual care that are starting December 1st. Please understand that I am merely the messenger and had nothing to do with creating these rules. I sit on an OMA committee tasked with coming up with resources to help interpret the Schedule of Benefits which, as you know, is not an easy read. Those will hopefully be coming out soon and I'm working on some other more simplified materials as well. The new SOB (effective Dec 1st) is available online with the new sections highlighted. The main pages are A64-A73 and Appendix J (J1 - J3). Link here: (Link stopped working - we are looking into this)

What are the major changes?
• The COVID virtual care codes that were introduced in March 2020 (K080, K081, K082 and K083) will expire on November 30, 2022
• Ontario Virtual Care Program (OVCP) will be discontinued and the B203 modifier for OTN will be no longer be used. A "Verified Video Solution" must be used for video visits under the new program.
• There will now be two levels of virtual care services with very different reimbursement structures:
Comprehensive virtual care
Limited virtual care

In order to be able to bill under Comprehensive virtual care, you must have an established "Existing/Ongoing Patient-Physician Relationship" (EOPPR). If you satisfy the requirements for EOPPR, as long as the care is clinically appropriate and you meet the requirements of a code, you can bill your usual corresponding in-person code with a modality modifier (K300 for video, K301 for telephone). Video visits pay at 100% of the regular code fee, most telephone visits pay 85% of the code, except some mental health codes (K007, K005, K197, K198) which pay 95% of the code. Premiums (p. A72) and Management Fees (p. A73) are applied against the virtual rate.

If you do not have EOPPR, your only choice is to bill Limited virtual care codes. These are new and poorly remunerated.
• A101A: Limited Virtual care by Video - $20
• A102A: Limited Virtual Care by Telephone - $15

How is EOPPR established?
There are 4 ways:
1. Patient was seen in-person, at least once, in the preceding 24 months
2. Patient is rostered to that physician or another physician in the same primary care group
3. A video consultation takes place for a new patient OR was provided to a patient in the preceding 24 months
4. A physician has provided any one of the services listed on p. A64-65 of the SOB (15 codes) in the preceding 24 months.

How is EOPPR maintained?
For family physicians with rostered patients - EOPPR is ongoing as long as the patient remains enrolled in the primary care practice.
Specialists, GP Focused Practice or FFS family physicians - when EOPPR is established, it is valid for 24 months. In order to extend/maintain, the physician needs to
- see the patient in-person
- provide any of the 15 services listed on A64-65 of the SOB
- specialists and GP focused practice physicians can provide another video consultation (if receive re-referral from patient's family physician)

So, for example, if I do a pediatric consult for a 5 yo by video (that is clinically appropriate for a virtual-only visit), I would bill A265 (consultation) +K300 (video modality modifier). This would pay at 100% of the in-person rate. The Age Premium of (10%) would be automatically applied.

If I help out at a walk in clinic that does some virtual care and assess a 7yo for a viral illness over video, that would be Limited Virtual Care because I have no EOPPR with the patient. The claim would be A101 - $20.

There are other nuances in the SOB about issues such as the visit needing to be medically necessary, initiated by the patient, etc. There is a lot of emphasis on needing to satisfy the requirements of a code virtually in order for it to be eligible for payment. The common A003 code is not even on the list of virtual care services because the requirements of this code are such that it is impossible to satisfy without an in-person visit with a physical exam.

If, during the course of the visit, it becomes apparent that the service cannot be completed without an in-person visit, the virtual care service is not eligible for payment. If a second visit is required to complete the assesment, only the service with the direct physical encounter is billable.

You can only bill for the modality that was >50% of the visit. So if you connect by video for 2 minutes and then there are technical issues or user issues and you switch to phone for the next 20 minutes, that is considered a telephone virtual service.

There are obviously many challenges. One big one is the administrative burden on family physicians being asked to re-refer patients to specialists or GP focused practice physicians so that the EOPPR is maintained for another 24 months. Another is for any group of physicians that follows patients that are in a non-enrollment model. Other than for rostered patients, there is no regognition of a group for the purposes of EOPPR. The EOPPR is per individual physician.

Once again, I wish I could change many things about this. All I can do is try to help my colleagues understand the new rules. Let's try to keep this thread focused on practical questions rather than debating things we can't change, like how the PSA should have been voted on.

Posted: November 15, 2022 by Cathy Mastrogiacomo
Tags: Virtual Care, Billing practices