Optimizing Respiratory Monitoring Billing: Tips for Specialists in Ontario

Respiratory specialists, working in both hospitals or community clinics, play a vital role in diagnosing and managing conditions like COPD, asthma, and sleep-related disorders. Accurate billing through the Ontario Health Insurance Plan (OHIP) is a challenge as these codes are dynamic and complex. Working closely with respirology doctors across Ontario, we’ve found a few common themes and wanted to share some insights to hopefully help you along the way.

Essential OHIP Billing Codes for Respiratory Monitoring

To maximize revenue, specialists must know the key codes for respiratory testing. These include:

1. G550 – Spirometry Testing

Useful for both hospital outpatient services and community clinics. Document pre- and post-bronchodilator results when performed.

2. G555 – Complete Pulmonary Function Testing

Ideal for comprehensive assessments. This code can be billed when spirometry, lung volume measurements, and diffusion studies are performed together.

3. G700 – Nocturnal Oximetry

For sleep monitoring in patients with suspected hypoxemia or sleep apnea. Community-based respirologists should leverage this code for eligible patients to complement hospital-based sleep studies.

4. G702/G703 – Polysomnography or Sleep Latency Testing

These codes apply to diagnostic sleep studies. Ensure the required preauthorization is obtained when billing for hospital-based sleep studies.

Hospital settings often require coordination with other departments, while community-based practices must rely on clear workflows for documentation and follow-up. Both environments demand meticulous coding and justification to avoid claim rejections, and in both settings it’s always best pracfice to chart and code before you leave after your list.

Challenges Unique to Hospital vs. Community Settings

1. Hospital-Based Specialists

Coordination Across Teams: Hospital settings often involve multidisciplinary teams. Ensure that respiratory services are documented separately from general care to capture billable services like spirometry or oximetry.

Internal System Limitations: Billing systems in hospitals may lack the flexibility to highlight specific respirology services. It’s likely best and most effective to coordinate with hospital administrators or a third party claims management service like us to ensure accurate claim submission.

2. Community-Based Specialists

Resource Constraints: Smaller teams may lack the expertise to manage complex billing requirements, and often lack the tools to properly oversee or manage their claims. Using a specialized billing resource, or outsourcing the service, can alleviate administrative burdens.

Patient Education: Ensure patients understand the purpose and value of respiratory tests to improve compliance and reduce no-shows, which can affect billing. Remember as well that everything not expressed as covered in the Schedule of Benefits is not covered by OHIP, and by extension can be charged privately at OMA rates.

Common Pitfalls in Respiratory Billing

1. Missed Codes for Ancillary Services

Specialists frequently overlook consultation codes for pre-test assessments or follow-ups. These services are integral to patient care and represent legitimate billing opportunities.

2. Documentation Gaps

OHIP requires detailed notes to justify tests like spirometry or polysomnography. Failing to link test results with a clear diagnosis or treatment plan may lead to rejections.

3. Underutilization of Sleep Monitoring Codes

In both hospitals and community clinics, specialists often miss opportunities to bill for sleep studies, particularly nocturnal oximetry.

Tips to Improve Billing Practices

1. Invest in Education for Multidisciplinary Teams

Informing colleagues about the importance of capturing respiratory services in the billing process is important, as is your knowing your own best practice for billing. For community practices, train administrative staff on documentation and coding and register for our free OHIP webinars.

2. Integrate Billing Workflows

Whether in a hospital or clinic, streamline workflows to ensure respiratory services are captured and submitted promptly. Using electronic medical records (EMRs) with built-in billing features can help track services in real time.

3. Track and Analyze Metrics

Regularly review metrics such as claim acceptance and error rates and revenue per code. This helps identify issues and refine billing strategies.

4. Use Chronic Disease Management Codes

Chronic respiratory conditions like COPD and asthma qualify for ongoing care billing under OHIP. Combine these codes with monitoring services for comprehensive revenue capture. Our Concierge services can help with this.

5. Pre-Authorize High-Value Services

For hospital-based sleep studies or community-level MSLTs, ensure pre-authorization is obtained to avoid rejections. Keep clear records of authorization numbers.

6. Engage Billing Specialists

Community practices can benefit from outsourcing billing to specialists familiar with OHIP. Hospital-based respirologists should work with hospital billing departments to ensure respiratory-specific codes are captured.

Why Effective Billing is Essential

Billing optimization directly impacts revenue and patient care quality. For community-based specialists, improved cash flow supports better staffing and equipment. Hospital-based specialists benefit from funding for department growth and increased recognition of their contributions.

For respiratory specialists in Ontario, effective billing is more than just a financial task—it’s a means to sustain high-quality care. By mastering OHIP codes, avoiding common pitfalls, and leveraging technology, both hospital-based and community-based practices can improve efficiency and profitability.

Start with a free review of your current billing practices. Are you capturing all eligible services? Are claims being rejected for avoidable reasons? Making these changes will set your practice on a path to success.