K996 – First Person Seen
OHIP Consultation & Visit Premium Codes Code — GENERAL PREAMBLE · Schedule of Benefits
K996 is a 'First Person Seen' special visit premium for a non-elective service rendered in an Emergency Department. This premium is applicable when the service is provided during night hours, from 00:00h to 07:00h. It is not payable to physicians defined as 'Emergency Department Physicians' (see ). The visit must be initiated by or on behalf of the patient for a non-elective service. Claims for this premium must be submitted with an appropriate A-prefix assessment code from the General Listings. The time of the visit must be documented in the patient's medical record as per .
When to Use
- Use K996 when you are a non-ED physician called in to the Emergency Department between 00:00 and 07:00 for an urgent, non-elective patient assessment.
- Apply this code when you are the first patient seen during an unscheduled visit to the ED, provided you do not meet the definition of an Emergency Department Physician under GP67.
Common Pitfalls
- Billing K996 as an ED physician or while on a scheduled ED shift will result in automatic rejection, as this premium is strictly for physicians not on duty in the ED.
- Failure to document the exact time of the visit in the medical record is a primary cause for clawbacks during OHIP audits, as per GP69 requirements.
- Submitting K996 for subsequent patients seen during the same visit is incorrect; subsequent patients must be billed using the H-prefix codes.
Billing Tips
- Always pair K996 with an A-prefix assessment code (e.g., A007) to ensure the claim is processed correctly as a special visit premium.
- Verify your status against GP67 definitions before billing to avoid claiming premiums restricted to non-ED staff.
Effective: April 1, 2026
GP. General Preamble
GENERAL PREAMBLE
Premium
Special Visit Premiums (Table I - Emergency Department)
For fee codes listed in Table I, the time at which the special visit takes place must be documented on the medical record.
Submit claims using the appropriate A-prefix assessment fee from the 'General Listings' for an assessment rendered in conjunction with a special visit premium.
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