OPPRB 2016

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 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.