ONTARIO · ARTICLE
Ten premiums we most often see left off Ontario claims: why each gets missed, and what has to be on the claim for it to pay.
By Robin, Expert Biller, ResolvMD · 6-minute read
Premiums are the easiest revenue to miss. They sit on top of a service you’re already billing (an add-on code, a percentage, a few dollars here and there), and because nothing rejects when you leave them off, they’re invisible. The claim goes through; the premium just doesn’t. Over a year, the codes below add up to more than most physicians expect.
This guide covers the premiums we most often see omitted in Ontario, why each gets missed, and what has to be on the claim for it to pay. Special Visit Premiums (the K, H, C and U families) are a category of their own, covered in a separate guide.
Quick reference
| Code(s) | Premium | Where it’s missed |
|---|---|---|
| E078 | Chronic disease assessment (+50%) | Chronic-condition outpatient assessments billed without the qualifying diagnostic code |
| E083 / E084 | Most Responsible Physician (MRP) | Premium not added to the qualifying subsequent inpatient visit |
| E409 / E410 / E412 / E413 | After-hours procedure premiums | Procedures done evenings, nights, weekends or holidays billed without the premium |
| H112 / H113 / H114 | Emergency department after-hours premiums | ED procedures such as critical care, done overnight, on weekends and holidays, or on weekday evenings, billed without the premium |
| Q012 | After-hours premium, rostered patients | Services before 08:00 or after 17:00 for rostered patients |
| C101 | Intensive care premium ($9.10 per patient) | ICU/CCU visits, especially post-op, with no other service fee |
| E542 | Tray fee (procedure supplies) | Clinic procedures (such as G370, G371, G271) billed without the tray fee |
| K730 / K731 | Physician-to-physician phone consultation | Claim submitted without the referring physician |
| K002 / K015 | Family counselling and interviews | Family discussions of 20+ minutes not documented or billed |
| K034 / K035 | Mandatory reporting | Communicable disease and Medical Condition Reports completed but not billed |
E078Chronic disease
E078 adds a 50% premium to eligible outpatient assessment fees (not consultations) to recognize the added complexity of managing chronic disease. To qualify, the service must be an outpatient assessment by an eligible specialist and carry a qualifying diagnostic code for a chronic condition.
Where it’s missed: the assessment is billed without the qualifying diagnostic code, so the premium has nothing to attach to. E078 isn’t payable for admitted inpatients, long-term care residents, or emergency department visits.
E083 / E084Most Responsible Physician
The MRP premiums recognize the physician coordinating an admitted patient’s care. E083 must be billed with a qualifying subsequent inpatient visit (C122, C123 or C124, but not C121) to pay. E084 is the weekend and holiday version.
Where it’s missed: the visit code is billed on its own and the premium is never added. If the qualifying visit isn’t on the same claim, the premium won’t pay.
E409–E413After-hours procedure premiums
These premiums add a percentage to the procedure fee when an eligible procedure is performed after hours. E409 (evenings, weekends and holidays) and E410 (nights) apply to non-emergency physicians; E412 and E413 are the emergency department equivalents.
Where it’s missed: the procedure is billed at the standard fee with no premium, or the premium for the wrong time block is used. Check the time of service against the premium before submitting.
H112–H114Emergency department after-hours premiums
These premiums are paid to the emergency physician on duty, on top of a procedure performed after hours. They’re billed extra to procedures, such as critical care, not to assessments or consultations, and can be billed alongside the E412 and E413 after-hours procedure premiums.
| Code | When it applies | Premium |
|---|---|---|
| H112 | Overnight, every day: 00:00 to 08:00 | $50.95 |
| H113 | Saturdays, Sundays and holidays, 08:00 to 24:00, and Friday evenings, 17:00 to 24:00 | $32.20 |
| H114 | Weekday evenings, Monday to Thursday, 17:00 to 24:00 | $23.65 |
Where it’s missed: the procedure is billed without the premium, especially on weekday evenings (H114 is new, so it’s easy to overlook) and on Friday evenings, which now fall under H113 rather than the weekday codes.
Q012After-hours care for rostered patients
Q012 compensates for medically necessary services to rostered patients before 08:00 or after 17:00.
Where it’s missed: after-hours services to rostered patients billed without Q012.
C101Intensive care
C101 is a flat $9.10 for each patient seen during an ICU or CCU visit. It’s payable when no other separate service fee is claimed for the visit (post-operative care is the classic example) and isn’t eligible alongside team fees such as Critical Care, Ventilatory Care, Comprehensive Care, Acquired Brain Injury Management or Neonatal Intensive Care.
Where it’s missed: post-op ICU visits where no other fee is billed and the per-patient premium is left off.
E542Tray fee
E542 is a tray fee that covers the cost of supplies for certain procedures performed in an outpatient clinic. It’s most commonly billed with G370, G371 and G271, and isn’t claimed for procedures done in hospital, where supplies are covered by the hospital.
Where it’s missed: clinic procedures billed without the tray fee.
K730 / K731Physician-to-physician phone consultations
K730 and K731 cover telephone consultations between physicians and aren’t included in monthly management fees.
Where it’s missed: the claim goes in without the referring physician, and it won’t pay.
K002 / K015Family counselling and interviews
K002 and K015 compensate for counselling or interviews with a patient’s family or representatives about the patient’s care. They’re time-based, typically with a 20-minute minimum, and documentation carries the claim: record who attended and what was discussed.
Where it’s missed: family discussions happen but aren’t documented or billed.
K034 / K035Mandatory reporting
K035 covers the Medical Condition Report, the mandatory report on patients whose condition makes driving dangerous. K034 covers immediate telephone reporting of specified communicable diseases to the local Medical Officer of Health; it’s limited to one claim per physician, per patient, per reportable disease, per 12 months, and must be personally rendered by the physician.
Where it’s missed: the report is completed but the fee isn’t billed.
The pattern behind all of these
Every premium here is missed the same way: the base service is billed correctly, the add-on is forgotten, and nothing rejects to tell you. The fix isn’t memorizing ten codes. It’s a submission process that checks for them every time.
Official sources
Every premium, on every claim
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