X040 – Sternum - two or more views
OHIP Laboratory Code — DIAGNOSTIC RADIOLOGY · Schedule of Benefits
A diagnostic radiology service for two or more views of the sternum. The fee is comprised of a technical component (H-fee) and a professional component (P-fee). The P-fee covers the physician's interpretation of the images and the report. The H-fee covers the cost of the facility, equipment, and staff to perform the imaging. This service must be documented in the patient's medical record. As per and , this service includes all common elements such as reviewing patient history, obtaining consents, and maintaining records. Payment for the technical component is subject to specific rules, particularly regarding the service location (e.g., not payable outside a hospital or for in-patients, see ).
When to Use
- Use X040 when performing a standard radiographic assessment of the sternum requiring at least two distinct projections (e.g., PA and lateral) to evaluate for fracture or pathology.
- Select X040 for diagnostic imaging of the sternum in an outpatient setting where the professional interpretation is provided by the radiologist.
Common Pitfalls
- Billing the technical component (H-fee) for hospital in-patients, which is strictly prohibited under GP11 and will result in automatic claim rejection.
- Attempting to bill X040 for a single-view sternum study, as the code specifically requires two or more views to meet the service definition.
- Submitting the technical component for services rendered outside of a hospital facility, which violates the Health Insurance Act requirements for diagnostic imaging.
Billing Tips
- Ensure the referral source is clearly documented as a physician, nurse practitioner, or oral maxillofacial surgeon to satisfy the mandatory referral requirement.
- When providing urgent, non-elective interpretations in a hospital setting, verify eligibility for C108, C109, or C110 premiums to maximize the professional component value.
Effective: April 1, 2025
D. Diagnostic Radiology
DIAGNOSTIC RADIOLOGY
Diagnostic
Diagnostic Radiology
The physician submitting a claim for the technical component is responsible for the complete quality assurance process for all elements of the technical component of the service, including data acquisition, reporting, and record keeping.
The physician must be able to demonstrate upon request by the MOH that they have the necessary training and experience to personally render the technical component and maintain documentation describing the process by which the physician monitors quality assurance in accordance with professional standards.
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