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E414
E414 – High risk obstetrical premium
OHIP Surgical Assists Code — OBSTETRICS · Schedule of Benefits
Payable in addition to labour and delivery procedures when at least one of the following conditions are present: - fetal prematurity (<32 weeks gestational age) - severe pregnancy induced hypertension - intrauterine growth retardation (IUGR) less than 10th percentile - significant placental insufficiency as demonstrated by absent umbilical vessel flow or reverse systolic/diastolic (S/D) ratio.
When to Use
- Use E414 when managing a vaginal delivery or C-section for a patient with confirmed IUGR below the 10th percentile, as documented in the prenatal record or ultrasound reports.
- Apply this premium during the delivery of a fetus at less than 32 weeks gestational age, ensuring the exact gestational age is clearly noted in the delivery summary.
- Bill this code when the patient presents with severe pregnancy-induced hypertension requiring active management during the labour and delivery process.
Common Pitfalls
- Do not bill E414 for routine high-risk conditions like gestational diabetes or mild hypertension, as it is strictly limited to the four specific clinical criteria defined in the Schedule of Benefits.
- Avoid billing E414 as a standalone service; it must be submitted in conjunction with the primary labour and delivery procedure code to be valid.
- Ensure the diagnosis code submitted with the claim matches the specific high-risk condition (e.g., IUGR or severe hypertension) to avoid automated rejections.
Billing Tips
- Always link the E414 premium to the primary delivery procedure code (e.g., P003 or P004) on the same claim to ensure the system recognizes the association.
- Maintain precise documentation of the specific qualifying condition—such as the S/D ratio or the specific percentile for IUGR—within the hospital delivery record to support the claim in the event of a post-payment audit.
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