E088 – Congestive heart failure premium
OHIP Surgical Assists Code — CONSULTATIONS AND VISITS · Schedule of Benefits
Congestive heart failure premium is payable in addition to the amount payable for an assessment by a cardiology specialist (60) when all of the following criteria are met: a. The assessment is a: i. medical specific assessment; ii. medical specific re-assessment; iii. complex medical specific re-assessment; or iv. partial assessment. b. The assessment is rendered in an office setting or an out-patient clinic located in a hospital, other than an emergency department. c. The patient has an established diagnosis of congestive heart failure, documented in the patient's medical record.
When to Use
- Use E088 when performing an A603 or A604 medical specific assessment for a patient with a confirmed diagnosis of CHF in your office.
- Apply this premium when billing an A601 or A608 for a follow-up visit in an outpatient hospital clinic for a patient with established heart failure.
Common Pitfalls
- Billing E088 for patients seen in the emergency department or as hospital inpatients, which will trigger an automatic rejection.
- Claiming the premium for assessments performed in a long-term care facility, as the premium is strictly limited to office or outpatient hospital settings.
- Failing to ensure the diagnosis of CHF is explicitly documented in the chart, as this is the primary requirement for audit compliance.
Billing Tips
- Ensure the E088 is submitted on the same claim as the qualifying assessment code (A601, A603, A604, or A608) to ensure the premium is correctly linked to the service.
Percentage Premium: 0.5%
This code applies a percentage increase to the base procedure fee
Effective: April 1, 2023
A. Consultations and Visits
CONSULTATIONS AND VISITS
PercentageIncrease
Other Premiums (including After Hours Procedure Premiums)
The patient has an established diagnosis of congestive heart failure, documented in the patient's medical record.
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