If you operate in hospital, some of the visits your office has been billing since April were probably reduced or paid at $0.00, even though the rules said they should have been paid in full. On September 1, the OHIP claims system finally caught up. INFOBulletin 260901, issued September 4, confirms that pre-operative and post-operative visits are now paid separately from the surgical fee, retroactive to April 1, 2026. A retroactive payment adjustment is coming, but it will only fix what your office actually submitted.
Why This Happened
The 2024 Physician Services Agreement between the Ministry of Health and the Ontario Medical Association made permanent changes to physician payments effective April 1, 2026. One of those changes was “surgical unbundling”: pre-operative and post-operative care and visits were separated from the surgical benefit, so they could be billed and paid on their own.
The problem is timing. The ministry is loading these changes into the OHIP claims system in stages, and the surgical unbundling rules were not added until September 1. For five months, the claims system kept applying the old bundling rules to visits that were, on paper, already unbundled. It is the same staged-rollout pattern behind the emergency medicine fee code correction we covered in September: the rule changes on one date, the system changes months later, and a Medical Claims Adjustment (MADJ) is used to settle the difference.
What Changed on September 1
INFOBulletin 260901 describes three claims processing changes, all effective for eligible services rendered on or after April 1, 2026.
1. In-hospital pre-operative assessments
Pre-operative assessments in hospital are now paid in full when they are provided by the physician performing the surgery within one to two days before the procedure. Before this change, those visits were sometimes treated as part of the surgery and paid at a reduced rate, with explanatory code SB (normal pre/post op visits included in surgical fee, surgical fee adjusted) or S7 (normal preoperative and postoperative care included in surgical fee).
2. Subsequent visits on the date of surgery
Subsequent visit codes C122A, C123A, C124A, C142A, C143A, E083A and E084A are now payable alongside a surgical procedure code when they are billed by the same physician, for the same patient, on the same date of service, as long as all other Schedule of Benefits requirements are met. Before, these claims were reduced or paid at $0.00 with SB, S7, or SV (MRP visit not allowed during post operative period, fee reduced to subsequent visit fee).
3. Post-operative visits within two weeks of surgery
In-hospital concurrent care visits and subsequent visits within two weeks of post-operative care are now paid in full. Before, they were reduced or paid at $0.00 with F5 (two weeks aftercare included in fracture fee) or S7.
What did not change
Assessments on the same day as the surgery itself are still bundled into the surgical benefit and are not paid separately, except where specific terms and conditions in the surgical preamble are met. If your billing team hears “unbundling” and starts billing every same-day assessment, those claims will still be reduced.
New Codes for Double Balloon Enteroscopy
The same bulletin added two new codes to the claims system, also effective April 1, 2026:
- Z588A, Double Balloon Enteroscopy. This is an all-inclusive code. Other than E250A, no other surgical or procedural service is payable with Z588A for the same provider, patient and date. If another surgical code is billed alongside it, one pays in full and the other pays $0.00 with explanatory code D7.
- E250A, Digestive System Surgical Time Modifier. Billed in 15-minute units, with the final unit rounded to the nearest 15 minutes. The bulletin’s own examples: a 63-minute procedure is billed as Z588A plus 4 units of E250A; a 68-minute procedure is Z588A plus 5 units.
Two rules catch people out. E250A only pays when Z588A is billed by the same provider for the same patient on the same date, either on the same claim or after the Z588A claim has been processed. If E250A arrives first, it pays $0.00 with explanatory code DF. And when additional procedures are done under the same anaesthesia, the total time for all of them is billed as Z588A plus E250A units. Time starts when the physician is first in attendance with the patient in the procedure room and ends when they leave.
What This Means for Your Practice
The MADJ is the good news. The ministry has confirmed it will re-run all impacted claims submitted between April 1 and September 1, 2026, and pay them under the corrected rules. Timing will be announced in a future INFOBulletin.
The catch is the word “submitted.” A MADJ adjusts claims that were sent to OHIP. It cannot pay for a visit that was never billed. In practice, many offices respond to a string of SB, S7 or SV reductions by quietly stopping. A billing clerk sees the same pre-op visit come back reduced three months in a row and stops entering it. A surgeon’s billing template is set to suppress subsequent visits on surgical days because “they never pay.” Those visits are invisible to the MADJ.
This bulletin also applies to Integrated Community Health Services Centres, so surgeons working in community surgical and diagnostic centres should run the same check.
What You Should Do
- Pull your remittance advice from April through August. Filter for explanatory codes SB, S7, SV and F5 on in-hospital visits and the seven subsequent visit codes listed above. This is your list of claims the MADJ should correct. Keep it so you can reconcile when the payment lands.
- Look for the visits that are missing, not just the ones that were reduced. Compare your OR schedule against billed visits. Pre-op assessments done one to two days before surgery, same-day subsequent visits, and in-hospital visits in the two weeks after surgery should all have claims.
- Check your submission window. OHIP’s regular three-month stale-dating rules still apply. Visits from recent months that were never submitted because your team assumed they were bundled may still be inside the window. Prioritize those now.
- Fix the rule, not just the claims. Update billing templates, EMR billing rules and any staff cheat sheets so these visits are billed going forward.
- Document procedure time for Z588A. If you perform double balloon enteroscopy, make sure start and end times are recorded in a way that supports the E250A units you bill.
- Watch for the MADJ bulletin. When it arrives, reconcile the adjustment against your April to August list so you can confirm every affected claim was corrected.
How MAP Can Help
Staged rollouts like this one are where revenue quietly goes missing: the rule changes, the system lags, and the visits that were never billed never come back. MAP’s OHIP Billing team reconciles remittances against the latest INFOBulletins so corrections like this MADJ are captured in full. Learn more at maphcm.com.