Q043A – New Patient Fee Abnormal Colorectal Cancer (CRC)/ Increased Risk
OHIP Critical Care Code — APPENDIX Q · Schedule of Benefits
The Q043A New Patient Fee is for patients with an abnormal colorectal cancer (CRC) test or who are at increased risk. The payment amount is tiered based on the patient's age: - $150.00 for patients up to 64 years of age - $170.00 for patients aged 65 to 74 years - $230.00 for patients 75 years of age and older This service is only eligible for physicians participating in the following models: CCM, FHG, FHN, FHO, RNPGA, BSM, GHC, SJHC, SEAMO, WHA. For complete billing information and minimum requirements, physicians must refer to the Primary Health Care Fact Sheets and INFOBulletin 4723. This code is listed in Appendix Q (), which is provided for informational purposes and is not part of the formal Schedule of Benefits.
When to Use
- Use Q043A when a new patient presents with a positive FIT test result requiring follow-up assessment and management.
- Use Q043A for patients with a documented family history of colorectal cancer that qualifies them for increased risk screening protocols.
- Use Q043A for patients with a personal history of adenomatous polyps or inflammatory bowel disease who require initiation of high-risk surveillance.
Common Pitfalls
- Billing Q043A for a standard annual physical or routine screening in an average-risk patient, which should instead be billed as a standard K030A or equivalent.
- Attempting to bill Q043A in conjunction with a standard A007A or A001A assessment, as the Q-code is intended to be a comprehensive new patient fee that often replaces or bundles standard assessment fees.
- Failing to verify that your specific practice model (e.g., FHO, FHG) is eligible for Appendix Q codes, leading to automatic rejections.
Billing Tips
- Ensure the patient's chart clearly identifies the 'increased risk' status or the abnormal test result, as this is the primary audit trigger for this specific code.
- Review INFOBulletin 4723 to confirm the specific visit requirements, as Q043A often requires a more detailed management plan than a standard office visit.
Effective: April 1, 2025
AQ. Appendix Q
APPENDIX Q
Other
Other Premiums (including After Hours Procedure Premiums)
For minimum requirements to claim Q043A please see INFOBulletin 4723.
Fee of $150.00 applies to patients up to 64 years of age.; or Fee of $170.00 applies to patients from 65 to 74 years of age.; or Fee of $230.00 applies to patients 75 years of age and older.
Appendix Q does not form part of the Schedule of Benefits: Physician Services under the Health Insurance Act and is for your information only.
Please Refer to the Primary Health Care Fact Sheets for complete billing information.
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