What is OHIP billing code J895?

J895 is "Therapeutic study for sleep related breathing disorders", an OHIP Diagnostic and Therapeutic Procedures code from the Ontario Schedule of Benefits (Physician Services).

How do I bill J895 to OHIP?

J895 is submitted through OHIP's MCEDT claims system, either directly or via billing software. SnapBill validates J895 claims against the Schedule of Benefits rules before submission.

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J895

J895 – Therapeutic study for sleep related breathing disorders

OHIP Diagnostic and Therapeutic Procedures Code — DIAGNOSTIC AND THERAPEUTIC PROCEDURES · Schedule of Benefits

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A therapeutic study for sleep related breathing disorders, designated as Level 1. The fee for this service often represents the technical component of the study. The professional component may be billed separately. Payment rules: 1. There is a limit of one therapeutic study per patient during any two consecutive 12 month periods except where prior approval has been given. An additional study may be payable with prior approval when necessary to evaluate a change in treatment modality. 2. J895 rendered to the same patient during the same 12-hour period as J896 or J897 is not eligible for payment. Requirements: A therapeutic study, including repeat studies, is not eligible for payment unless it is preceded by a pre-study assessment by a physician practicing sleep medicine. The request for prior approval for excess studies must be based on this assessment. Exceptions to the pre-study assessment requirement include: a. A therapeutic study that immediately follows an initial or repeat diagnostic study, provided the patient's clinical circumstances are unchanged and the physician has previously documented the plan for the therapeutic study. b. Exceptional circumstances (e.g., a patient traveling a long distance) where a clinical protocol or approved medical directive is used, and the physician can demonstrate to the ministry that CPSO standards are met.

Pre-authorization required

A therapeutic study rendered without a pre-study assessment by a physician practicing sleep medicine is not eligible for payment except under specific circumstances (e.g., immediate follow-up to an initial or repeat diagnostic study, or in exceptional circumstances where a clinical protocol or approved medical directive is used and can be demonstrated to the ministry).

For studies requiring prior approval (e.g., in excess of limits), the request for prior approval must be based on the pre-study assessment by a physician practicing sleep medicine.

The physician submitting a claim for the technical component is responsible for the complete quality assurance process and must maintain documentation describing this process in accordance with professional standards.

The physician must have the necessary training and experience to personally render the technical component of the service.

1. For payment purposes, repeat diagnostic studies or therapeutic studies for indications or in circumstances other than listed above, or in excess of the limits set out above require prior approval.

2. A repeat diagnostic study rendered without the required pre-study assessment by a physician practicing sleep medicine, is not eligible for payment.

3. A therapeutic study rendered without a pre-study assessment by a physician practicing sleep medicine is not eligible for payment except:

a. For the therapeutic study that immediately follows an initial diagnostic or repeat diagnostic study where:

i. the time interval is such that it is unlikely the clinical circumstances of the patient has changed; and

ii. the physician practicing sleep medicine has previously assessed the patient and documented the applicable decisions with respect to the performance of the therapeutic study; or

b. In exceptional circumstances where the physician can demonstrate to the ministry upon request that the CPSO standards are satisfied with the use of a clinical protocol or approved medical directive.

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