K125 – Intellectual and Developmental Disability Primary Care
OHIP Consultation & Visit Premium Codes Code · Schedule of Benefits
Primary care of patients with intellectual and developmental disabilities which includes any combination of common elements and specific elements of any insured service listed under “Family Practice & Practice In General” in the “Consultations and Visits” section and, in all cases, includes the same minimum time period requirements described for counselling in the General Preamble . When a physician submits a claim for rendering any other consultation or visit to the same patient on the same day for which the physician submits a claim for Intellectual and Developmental Disability Primary Care, the Intellectual and Developmental Disability Primary Care service is included (in addition to the common elements) as a specific element of the other insured service. Unit means ½ hour or major part thereof - see General Preamble , for definitions and time-keeping requirements.
When to Use
- Use K125 for comprehensive, time-intensive primary care visits for patients with a qualifying diagnosis (e.g., 299, 319) that require significant coordination or assessment beyond a standard A007.
- Use K125 when managing complex medication adjustments or multi-system health reviews for patients with cerebral palsy (343) or Down's syndrome (758) where the visit duration meets the minimum 30-minute threshold.
Common Pitfalls
- Billing K125 on the same day as an A007 or other office visit code will result in a rejection or clawback, as K125 is intended to be the primary service code for that encounter.
- Failing to meet the minimum 30-minute time requirement (GP58) is a frequent audit trigger; time spent on charting or reviewing records does not count toward the unit requirement.
- Submitting K125 without one of the five mandatory diagnostic codes (299, 319, 343, 741, 758) will cause an automatic claim rejection.
Billing Tips
- Ensure your clinical notes explicitly document the start and end times of the face-to-face encounter to substantiate the unit-based billing requirement.
- If you provide counselling during the same encounter, you may bill eligible K-codes (like K013) alongside K125, provided the total time spent is clearly segmented and documented.
Effective: April 1, 2026
Primary Care
Assessment
The service must meet the minimum time period requirements described for counselling (/).
A diagnostic code corresponding to the patient’s condition must accompany the claim for payment purposes.
Time units must be calculated based upon consecutive time spent rendering the service.
Calculation of time excludes non-patient-facing time (e.g., charting, reviewing imaging).
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