G394

PDF page 65 / GP51

Definition/Required Elements of Service:
  Monthly Management of a Nursing Home or Home for the Aged Patient is the provision by the most
  responsible physician (MRP) of routine medical care, management and supervision of a patient in a
  nursing home or home for the aged for one calendar month. The service requires a minimum of two
  assessments of the patient each month, where these assessments constitute services described as
  "W" prefix assessments.
  The requirements above are subject to the exceptions as described in payment rule #8.
         [Commentary:
         As with all services described as assessments, direct physical encounter with the patient is
         required.]
  In addition to the common elements, this service includes the provision of the following services by
  any physician to the same patient during the month.
  A. Services described by subsequent visits (e.g. W003, W008).
  B. Services described by additional visits due to “intercurrent illness” (W121) except if the conditions
     described in Payment rule #7 are satisfied.
  C. Services described by palliative care subsequent visits (e.g. W872).
  D. Services described by admission assessments (e.g. W102, W104, W107).
  E. Services described by periodic health visit or general re-assessments (e.g. W109, W004).
  F. Services described by visit for pronouncement of death (W777) or certification of death (W771)
     except if the services are performed in conjunction with a special visit.
  G. Service described by anticoagulation supervision (G271).
  H. Completion of home care referral form and home care supervision (K070, K071, K072).
  I. Services described by the following diagnostic and therapeutic procedures – venipuncture (G489),
     injection (G372, G373), immunization (G538, G590, G849), collection of cervical cancer screening
     specimen(s) (G365, G394, E430, E431), intravenous (G379), and laboratory test codes (G001,
     G002, G481, G004, G005, G009, G010, G011, G012, G014).
  J. All medication reviews.
  K. All discussions with the staff of the institution related to the patient’s care.
  L. All telephone calls from the staff of the institution, patient, patient’s relative(s) or patient’s
     representative in respect of the patient between the hours of 0700 hours and 1700 hours Monday
     to Friday (excluding holidays).
  M.Ontario Drug Benefit Limited Use prescriptions/forms or Section 8 Ontario Drug Benefits Act
    requests.

PDF page 72 / GP58

COUNSELLING
  Definition/Required elements of service:
  Counselling is a patient visit dedicated solely to an educational dialogue with a physician. This service
  is rendered for the purpose of developing awareness of the patient’s problems or situation and of
  modalities for prevention and/or treatment, and to provide advice and information in respect of
  diagnosis, treatment, health maintenance and prevention.
                                          [Commentary:
                                          1.Advice given to a patient that would ordinarily constitute part of a consultation, assessment,
                                            or other treatment, is included as a common or constituent element of the other service, and
                                            does not constitute counselling.
       2.Detention time may be payable following a consultation or assessment when a physician is
         required to spend considerable extra time in treatment or monitoring of the patient. See
         GP29 for further information.]
  Payment rules:
    1. With the exception of the codes listed in the below, no other services are eligible for payment
       when rendered by the same physician the same day as any type of counselling service:
       E080, G010, G039, G040, G041, G042, G043, G202, G205, G365, G372, G384, G385, G394,
       G462, G480, G489, G482, G538, G590, G593, G840, G841, G842, G843, G844, G845, G846,
       G847, G848, G849, H313, K002, K003, K008, K014, K015, K031, K035, K036, K038, K682,
       K683, K684, K730
                    2. Individual and group counselling services are limited to 3 units per patient per physician per
                       year at the higher fee (K013 or K040 respectively); the amount payable for services rendered in
                       excess of this limit will be adjusted to a lesser fee (K033 or K041 respectively).
                    3. If the patient does not have a pre-booked appointment, the amount payable for this service will
                       be adjusted to a lesser assessment fee.
  A. Individual Counselling
  Definition:
  Individual counselling is counselling rendered to a single patient.
  B. Group Counselling
  Definition:
  Group Counselling is counselling rendered to two or more patients with a similar medical condition or
  situation.
  Payment rules:
     1. Group counselling is only eligible for payment when all of the following conditions are fulfilled:

PDF page 461 / J47

DIAGNOSTIC AND THERAPEUTIC PROCEDURES
 GYNAECOLOGY
                                                                                           Fee
+ G394 Collection of additional cervical cancer screening specimen(s)
         for any of the following purposes:
         - Follow-up test once after low grade cytology results,
           where the follow-up specimen(s) are collected between
           March 3, 2025 and September 30, 2026; or
         - Once every 3 years for patients who are
           immunocompromised; or
         - Follow-up test once, a minimum of 24 months after testing
           human papillomavirus (HPV)-positive for other high risk
           subtype as defined by Ontario cervical cancer screening
           guidelines with normal/low grade cytology results; or
         - Follow-up test once, a minimum of 24 months after
           discharge from colposcopy when increased screening is
           recommended by Ontario cervical cancer screening
           guidelines; or
         - Repeat after an invalid HPV test or an unsatisfactory
           cytology test; or
         - Post-hysterectomy vaginal vault testing for patients with
           histologic evidence of dysplasia in the cervix at the time of
           hysterectomy; or
         - Where the physician is of the opinion that the patient is a
           member of a vulnerable group that may have difficulty
           accessing the services within the specified time period...                       12.00
  E431   - when cervical cancer screening specimen(s) are collected
           outside of hospital or ICHSC, to G394....................... add                 11.95
          [Commentary:
          E430 is payable when the requirements for G365 are met. E431 is payable when the
          requirements for G394 are met.]
          Payment rules:
          1. For G365 services provided between March 3, 2025 and March 31, 2028, G365 is limited to
            once per patient per 33 month period. For G365 services provided on or after April 1, 2028,
            G365 is limited to one per patient per 54 month period.
          2. G365 is uninsured for patients less than 25 years of age.
          3. G394 is limited to once per patient per lifetime for vaginal vault testing post-hysterectomy for
            patients with histologic evidence of dysplasia in the cervix at the time of hysterectomy.
          4. G365 and G394 are not eligible for payment when performed in conjunction with a
            consultation, repeat consultation, general or specific assessment or reassessment or routine
            post-natal visit when a pelvic examination is a normal part of the foregoing services. One of
            the add-on codes E430 or E431 is eligible for payment in addition to these services when an
            insured collection of cervical cancer screening specimen(s) is performed outside of hospital
            or ICHSC.
          5. G365 and G394 are not eligible for payment when performed in conjunction with an insured
            colposcopy service. One of the add-on codes E430 or E431 is eligible for payment in addition
            to these services when an insured collection of cervical cancer screening specimen(s) is
            performed outside of hospital or ICHSC.

PDF page 462 / J48

DIAGNOSTIC AND THERAPEUTIC PROCEDURES
GYNAECOLOGY
                                                                                                      Fee
      Medical record requirements:
      Physicians claiming G394 must document the clinical indication for the service in the patient’s
      medical record. G394 is not eligible for payment if this documentation is not present.
      [Commentary:
      1.Collection of cervical cancer screening specimen(s) in excess of the specified limits are not
        insured.
      2.Cervical cancer screening is generally not recommended for patients over 70 years of age.
      3.Ontario cervical cancer screening Guidelines can be found at https://
        www.cancercareontario.ca
      4.The Ontario cervical cancer screening guidelines define the immunocompromised screening
        population as people who:
          a.Have a cervix; and
          b.Are, or have ever been, sexually active; and
          c.Are asymptomatic; and
          d.Are part of any of the following populations at higher risk of pre-cancer and cervical
            cancer:
             • People who are living with human immunodeficiency virus (HIV)/acquired
                  immunodeficiency syndrome (AIDS), regardless of viral load
             • People with congenital (primary) immunodeficiency
             • Transplant recipients (solid organ or allogeneic stem cell transplants)
             • People requiring treatment (either continuously or at frequent intervals) with
                  medications that cause immune suppression for three years or more
             • People who are living with systemic lupus erythematosus (SLE), regardless of
                  whether they are receiving immunosuppressant treatment
             • People who are living with renal failure and require dialysis.]

PDF page 746 / V6

FEMALE GENITAL SURGICAL PROCEDURES
CERVIX UTERI
                                                                                                       Asst         Surg         Anae
    ENDOSCOPY
  Z731 Initial investigation of abnormal cervical cancer screening test
           or lesion of the lower genital tract, including vulva under
           colposcopic technique with or without biopsy(ies)..............        53.50
  Z787 Follow-up colposcopy with biopsy(ies) ...................................  53.50
  Z730 Follow up colposcopy without biopsy......................................  28.35
      Payment rules:
      1.Z731, Z787 and Z730 include collection of cervical cancer screening specimen(s) for
        cytology and/or endocervical curetting if performed.
         2.Z731, Z787 and Z730 include collection of cervical cancer screening specimen(s) for HPV
           testing if performed for cervical cancer screening related indications.
         3.G394 or G365 are not eligible for payment with Z731, Z787 and Z730.
         4.Z720 is not eligible for payment with Z731, Z787 or Z730.
         5.A screening colposcopy is included in the assessment.
         [Commentary:
         Colposcopy recommendations for people with abnormal cervical cancer screening results are
         available at https://www.cancercare.on.ca/.]

Master, record 2105. Record Layout PDF, page 1.

G39420250401999999990000012000000000000000000000000000000000000000000000000

Auxiliary master fields are preserved as raw scaled values. The linked layout calls them zero-filled, but this edition contains non-zero values. They are not presented as final dollar fees or PDF units.