Samir Gupta

The applicant physician appealed OHIP's denial of payment for fee codes Z428 and E628, which he billed for extracting pacemaker leads during a cardiac transplant surgery without using extraction sheaths.

OHIP argued the codes required the use of extraction sheaths and that the extraction was an inherent component of the transplant procedure.

The Physician Payment Review Board, assisted by a peer physician advisor, found that pacemaker lead extraction is an ancillary procedure with independent risks and that the fee code's use of the word 'including' does not make extraction sheaths a mandatory condition for payment.

The Board ordered OHIP to pay the applicant for the submitted fee codes.

The applicant physician appealed OHIP's decision to deny payment for fee codes Z428 and E628 for pacemaker lead extraction performed during a cardiac transplant surgery.

OHIP argued the codes were not payable because extraction sheaths were not used and the extraction was an inherent component of the transplant procedure.

The Physician Payment Review Board, assisted by a peer physician advisor, found that pacemaker lead extraction is an ancillary procedure with independent risks and is separately billable.

The Board interpreted the fee code descriptor 'including' as non-restrictive, concluding that the use of extraction sheaths is not a mandatory condition for payment.

The Board ordered OHIP to pay the applicant for the claims.

The General Manager of OHIP alleged that the applicant physician misrepresented the nature of services by billing fee code K070 multiple times for the same patient when modifying home care medical orders.

The applicant appealed to the Physician Payment Review Board, arguing his billing practice was consistent with the Schedule of Benefits.

The Board found that the wording of fee code K070 does not expressly limit its use to the initial home care application.

The Board concluded that the applicant's practice of billing K070 when submitting a fresh home care services request form to modify medical orders was a reasonable interpretation and did not constitute misrepresentation under s. 18(2) of the Health Insurance Act.

The General Manager of OHIP brought a motion to dismiss a physician's appeal for lack of jurisdiction, arguing the decision to demand repayment was made under s. 37.1(7) of the Health Insurance Act due to an absence of records, which is subject only to judicial review.

The physician argued the dispute concerned the interpretation of a fee code, granting the Physician Payment Review Board jurisdiction under s. 18.

The Board dismissed the motion, finding that the essential character of the dispute concerned the interpretation of a fee code, and that the General Manager's correspondence satisfied the notice requirements of s. 18.

The Board concluded it had jurisdiction to hear the appeal.