E078 – Chronic Disease Assessment Premium
OHIP Surgical Assists Code — Chronic Disease Management · Schedule of Benefits
The chronic disease assessment premium is payable in addition to the amount payable for an assessment when all of the following criteria are met: a. The assessment is a medical specific assessment; medical specific re-assessment; complex medical specific re-assessment; partial assessment; or level 2 paediatric assessment. b. The service is rendered by a physician registered with OHIP as having one of the following specialty designations: 07(Geriatrics), 15(Endocrinology & Metabolism), 18(Neurology), 26(Paediatrics), 28(Pathology), 31(Physical Medicine), 34(Therapeutic Radiology), 44(Medical Oncology), 46(Infectious Disease), 47(Respiratory Disease), 48(Rheumatology), 61(Haematology), 62(Clinical Immunology). c. The assessment is rendered in an office setting or an out-patient clinic located in a hospital, other than an emergency department. d. The patient has an established diagnosis of a chronic disease, documented in the patient’s medical record.
When to Use
- Use E078 when performing a standard office-based medical specific assessment (A007) for a patient with a documented chronic condition like diabetes or rheumatoid arthritis.
- Apply this premium during a complex medical specific re-assessment (A005) for a patient with an established chronic disease, provided you hold one of the eligible specialty designations.
- Use this for a level 2 paediatric assessment (A013) when the child has a chronic diagnosis and you are a registered paediatrician.
Common Pitfalls
- Billing E078 for patients seen in an emergency department or long-term care facility will trigger an automatic rejection.
- Submitting the premium for general assessments that do not fall under the specific list of eligible assessment codes (e.g., A001 or A003) is a common audit error.
- Attempting to bill E078 when your specialty designation is not on the approved list of 13 specialties will result in a claim rejection.
Billing Tips
- Ensure the chronic disease diagnosis is clearly documented in the chart for every encounter to satisfy audit requirements for this premium.
- Always append E078 to the primary assessment code on the same claim to ensure the premium is triggered correctly alongside the base assessment fee.
Percentage Premium: 0.5%
This code applies a percentage increase to the base procedure fee
Effective: January 1, 2023
Assessments
Chronic Disease Management
PercentageIncrease
Other Premiums (including After Hours Procedure Premiums)
The patient has an established diagnosis of a chronic disease, documented in the patient’s medical record.
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