X167 – Fistula or sinus
OHIP Laboratory Code — DIAGNOSTIC RADIOLOGY · Schedule of Benefits
A diagnostic radiology examination for a fistula or sinus tract. This service is comprised of a professional component ('P') for the physician's interpretation, and a technical component ('H') for the facility's costs. The technical component ('H') fee is intended for services rendered in an Independent Health Facility (IHF). When the service is rendered in a hospital, the technical component is funded through the hospital's budget and is not payable as a fee-for-service claim. The professional component ('P') is payable to the physician who interprets the examination. As per , the technical component ('H') is not eligible for payment if the service is rendered to a hospital in-patient, or to an out-patient who is admitted to hospital within 24 hours for the same condition for which the service was rendered.
When to Use
- Use X167 when performing a contrast study specifically to delineate a fistula or sinus tract, rather than a general gastrointestinal or urinary tract imaging study.
- Use this code for the professional interpretation component when the imaging is performed in an Independent Health Facility (IHF) or private clinic setting.
Common Pitfalls
- Billing the 'H' (technical) component for services performed within a hospital, which is ineligible as hospital technical costs are covered by global budgets.
- Attempting to claim the 'H' component for an outpatient who is subsequently admitted to the same facility within 24 hours for the same clinical condition.
- Submitting X167 without a valid referring physician or nurse practitioner, as this diagnostic service strictly requires a formal referral per GP111.
Billing Tips
- Ensure the claim clearly distinguishes between the professional component (P) and the technical component (H) to avoid automatic rejections based on the facility type.
- If providing urgent, non-elective interpretation in a hospital setting, ensure you are correctly appending the appropriate C-series special visit premiums (C102-C110) rather than attempting to bill technical components.
Effective: April 1, 2025
D. Diagnostic Radiology
DIAGNOSTIC RADIOLOGY
Diagnostic
Diagnostic Radiology
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