X213 – Scapula - three or more views
OHIP Laboratory Code — DIAGNOSTIC RADIOLOGY · Schedule of Benefits
A radiological examination of the scapula which includes three or more views. This service is comprised of a technical component (performing the X-ray) and a professional component (interpretation). Per , the technical component is only payable to physicians in specific non-hospital settings (e.g., Independent Health Facilities) and not in a hospital, where it is funded through the hospital's budget. The professional component is payable to the interpreting physician regardless of setting.
When to Use
- Use X213 when a patient requires a dedicated scapular series consisting of at least three views, such as an AP, lateral, and axillary view, to evaluate for fracture or dislocation.
- Do not use X213 for a standard shoulder series; use X049 if the scapula is only incidentally visualized as part of a general shoulder examination.
Common Pitfalls
- Billing X213 in a hospital setting and attempting to claim the technical component; the technical component is only payable to non-hospital facilities like Independent Health Facilities.
- Failing to use the correct suffix when billing in an eligible non-hospital setting; you must submit the technical component with suffix B and the professional interpretation with suffix C.
Billing Tips
- Ensure your documentation explicitly lists the three or more views performed to justify the use of X213 over lower-complexity codes.
- If performing this service in a hospital during urgent after-hours scenarios, ensure you meet the specific criteria for Special Visit Premiums (e.g., C109, C108, C110) as these are not payable for routine elective imaging.
Effective: April 1, 2025
D. Diagnostic Radiology
DIAGNOSTIC RADIOLOGY
Diagnostic
Diagnostic Radiology
All insured services must be documented in the patient's medical record, establishing that the service was provided, medically necessary, and is the same service for which the account is submitted.
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 this upon request by the MOH.
The physician must have the necessary training and experience to personally render the technical component of the service.
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