health insurance week1

Week 1 Content:
- Class Overview includes:
- Obstetrical Billing
- Obstetrical Care
- Labour & Delivery Codes
- Post-natal Care Codes
- Newborn Care Codes
- Premium Codes
- Scenarios

Definition: Obstetrical care involves the care of mother and baby during:
- Pregnancy
- Labour
- Delivery
- Immediately after delivery
Eligible Providers:
- Obstetricians: Specialists in pregnancy and childbirth.
- Family/General Physicians: Can claim for obstetrical care under specific conditions:
- They are only eligible to claim for normal pregnancies and deliveries.
- Can claim for newborn care of healthy babies.

Included Activities:
- Assessment of the patient at the time of admission.
- Attendance at labour.
- Delivery of the baby.
- Care of the mother and baby immediately after delivery.
Key Codes:
- P006A: Vaginal Delivery
- Physician attends the mother during labour only; does not attend the delivery.
- P038A: Attendance at Labour
- Physician attends the mother during both labour and delivery, but another physician performs the delivery.
- P009A: Attendance at Labour and Delivery
- Physician attends the mother during labour and delivery.

Overview: Flat fees are established for post-natal visits to the mother following delivery:
- P007A: Post-natal care in the hospital
- P008A: Post-natal care in the office (post-natal examination).

Billed Activities:
- Covers all hospital visits for a healthy baby.
Key Codes:
- H001: General newborn care visit.
- H002: Low birth weight baby care - initial visit.
- H003: Low birth weight baby care - subsequent visit.
- H007: Attendance at maternal delivery for the care of high-risk baby/babies.

Sole Delivery:
- Billed anytime during a 24-hour day.
- Maximum of 25 claims per physician per 12-month period.
- Fee of 100% of the procedure fee applicable only for:
- Codes: P006A, P009A, P038A, P041, P018, P020, and E414 (last four applicable only for Obstetricians).
Specific Codes:
- E411A: Sole Delivery
- For deliveries performed in the evening (17:00 to 24:00) with a fee of 50% of the procedure fee.
- E409A: Evening Delivery (After hours procedure)
- For deliveries performed during the night (24:00 to 07:00) with a fee of 75% of the procedure fee.
- C989A: Sacrifice of Office Hours
- Billed for the first patient seen for obstetrical delivery, limited to one per calendar day.

Example 1: Taken from a bulletin issued by the Ministry of Health (MOH) and Ontario Medical Association (OMA).
Example 2: Also from a bulletin issued by MOH and OMA.
Reference: PDF version of these bulletins available in the Home page on Blackboard.

Scenario 1:
- Situation: A Family Doctor is called to the hospital upon the admission of her gestational patient. The doctor arrives and delivers the baby at 08:00.
- Billing Eligible Codes:
- P006A: Vaginal delivery.
- E411A: Sole delivery premium.
  - Justification: The sole delivery premium is eligible as this is the only delivery for the doctor on that day.
Scenario 2:
- Situation: An Obstetrician performs a post-natal care examination on a patient 6 weeks following her delivery, at the doctor’s office.
- Billing Eligible Code:
- P008A: Post-natal care in the office.
  - Justification: Flat fee for the post-natal care examination of the mother in the office.
Scenario 3:
- Situation: An Obstetrician performs an admission assessment and attends during a patient's labour, delivering the baby at 04:00.
- Billing Eligible Codes:
- P006A: Vaginal delivery.
- E410A: Night premium.
  - Justification: The baby is delivered between 24:00 and 07:00 qualifying the physician for the night premium on top of the delivery.

Practice Exercise: Located within the Week 1 folder under the Weekly Learning Material section. Not graded.