X123 – Operative pancreatogram or ERCP
OHIP Laboratory Code — DIAGNOSTIC RADIOLOGY · Schedule of Benefits
An operative pancreatogram or Endoscopic Retrograde Cholangiopancreatography (ERCP). This diagnostic radiology service is comprised of two components with separate fees as listed in the Schedule: - Technical Component (H Fee): For the use of the facility, equipment, supplies, and personnel. - Professional Component (P Fee): For the physician's service of performing and/or interpreting the procedure and providing a report. Payment for the technical component is subject to specific rules outlined in the Schedule of Benefits (see :). Specifically, the technical component is not payable when the service is provided to a hospital in-patient, or if the patient is admitted to the hospital within 24 hours of the service for the same condition. The technical component is also not payable when rendered outside of a hospital setting.
When to Use
- Use X123 for the professional component when performing or interpreting an ERCP or operative pancreatogram in a hospital setting.
- Use X123 when the service is provided to an out-patient who is not subsequently admitted to the hospital within 24 hours for the same condition.
Common Pitfalls
- Billing the technical component (H fee) for hospital in-patients, which is strictly prohibited under GP11.
- Billing the technical component for patients admitted to the hospital within 24 hours of the procedure for the same condition, as this triggers an automatic rejection.
- Attempting to bill the technical component for services rendered outside of a hospital facility, such as in a private clinic or via remote PACS interpretation.
Billing Tips
- Ensure your documentation includes the required quality assurance process description to support the technical component claim when eligible.
- If performing an urgent, non-elective procedure after hours, pair X123 with the appropriate C-series special visit premium (e.g., C104 or C110) to maximize reimbursement.
Effective: April 1, 2025
D. Diagnostic Radiology
DIAGNOSTIC RADIOLOGY
Diagnostic
Diagnostic Radiology
For the technical component, the physician must maintain documentation that describes the process by which the physician monitors quality assurance in accordance with professional standards.
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