Emergency Medicine Billing Basics

The H-prefix system, explained

OHIP has a special set of fee codes reserved for services rendered in an emergency department or Hospital Urgent Care Clinic. These all start with the letter H. Any physician on duty in an ED bills using H codes regardless of specialty, with one exception: an emergency medicine specialist using the specialty-specific consultation code.

The ministry defines an Emergency Department Physician as a doctor working a pre-arranged shift, or an on-call physician whose service does not qualify for a special visit premium. If that is you, you use H codes. If you are a specialist called down from the ward to see one patient in the ED, you are not using H codes - you use your specialty's A-prefix listings plus a special visit premium.

The four assessment codes

Every ED patient encounter is one of four assessment types. The type is defined by what the encounter actually involved, not by how busy the department was or how long the patient waited.

Minor assessment (H1x1 family)

A brief focused assessment for a single, clearly delineated complaint. Minor, ankle sprain, simple non-severe laceration, uncomplicated UTI, medication refill. The classic "easy" presentation.

Multiple systems assessment (H1x3 family)

A detailed history and examination of more than one system, part, or region. This is the workhorse code for most undifferentiated ED presentations where you are evaluating more than one possibility. Abdominal pain, chest pain, shortness of breath, back pain, dizziness - majority of the common presentations that do not require resuscitation.

Comprehensive assessment and care (H1x2 family)

Requires a full history including systems review, past history, medication review, and social or domestic evaluation; a full physical examination and concomitant treatment. Also includes interpretation of labs and imaging, and necessary liaison with the family physician, family, nursing home, CAS, police, and other agencies.

Re-assessment (H1x4 family)

An assessment rendered at least two hours after the original assessment (including appropriate investigation and treatment), indicating further care or investigation is required and performed. Not for discharge assessments. Not if the patient is admitted by the ED physician. Not if the re-assessment leads directly to a consult referral. Limited to three per patient per day and two per physician per patient per day.

The time-of-day grid

The middle digit of each assessment code changes based on when the service was rendered. Same clinical work, four different payments. Get this table memorized or at least pinned to your work monitor.

Fridays from 17:00 onward are now billed at the weekend/holiday H15x rates. Always confirm the current fee from the most recent Schedule of Benefits before submitting.

Build the code in two steps. First, decide what you did - minor (last digit 1), multiple systems (3), comprehensive (2), or a re-assessment (4). Then decide when you did it - weekday daytime (middle digit 0), Monday to Thursday evening (3), Friday evening plus weekends and holidays (5), or overnight (2). Slot the two digits into H1-[when]-[what]: a comprehensive assessment seen on a Saturday is H1-5-2, or H152. Complexity and time of day are the only two decisions you ever make.

Age premiums are easy money you already earn

Comprehensive and multiple-systems assessments get an age-based bonus for young children and seniors.

Consultation codes

A consultation is different from an assessment. It requires a written referral from another physician, nurse practitioner, and a written response back. In the ED there are two consultation codes in regular use.

H065 - Consultation in Emergency Medicine ($95.60)

Used by any ED physician for a consultation rendered in the ED. Requires a referral and a written report back. The report requirement matters: if you were consulted by the family doctor over the phone to see someone in the ED, document the referral source and send a communication back to close the loop.

H055 - ER physician consultation ($125.65, effective April 1, 2026)

Used by specialists in Emergency Medicine (as opposed to a family doctor or other physician working in the ED) for consultations in specific circumstances. If you hold the RCPSC certification in Emergency Medicine, H055 is the code you will use.

In-patient interim admission orders (H105)

H105 pays $29.05 for writing in-patient interim admission orders when you are on-call or on-duty in the ED, pending admission of a non-elective patient by a different most responsible physician. You wrote the admission orders because the admitting team was not there yet, or was tied up.

The rules:

• H105 is payable in addition to the initial consultation or assessment, provided each service is rendered separately by you.
• H105 pays nil if the hospital admission assessment is payable to you as the ED physician.
• Document the orders and the reason you wrote them (the receiving team is tied up, unavailable, etc.).

Procedures and premiums

Most procedures done in the ED (lacerations, fracture reductions, lumbar punctures, chest tubes, and so on) have their own fee codes from the procedures sections of the Schedule. Those can be billed in addition to your assessment code where rules allow. When a procedure is done during premium hours, an ED physician adds a separate procedural premium.

After-hours procedure premiums for ED physicians

These are specific to ED physicians. Non-ED physicians doing procedures have their own (higher) premiums, E409 and E410.

When to use E409 and E410. Only use E409/E410 when billing with a special visit premium (SVP) and A-prefix assessment codes - in other words, when you are not rostered as the ED physician and are attending the ED or hospital as a special visit. While on an ED shift, use E412 or E413 instead.

After-hours premiums (H112, H113, H114)

When assessing patients and performing services such as resuscitation, Form 1, counselling, you can apply the following premium codes. Examples of codes that you can apply this premium to include but are not limited to G395, G391, G521, G523, G522, K623, and K005.

Billing a resuscitation

A true resuscitation — a critically ill or injured patient with threatened or actual failure of one or more vital organ systems — is billed with the life-threatening critical care codes instead of your regular H1xx codes (they cannot be billed together and the ministry will take the lower of the two codes if you try). They are time-based, counted in quarter-hour units, so chart your start and stop times.

G521 — Life-threatening critical care, first quarter hour ($125.10)

The first 15 minutes of resuscitating a patient with critical illness or injury and vital-organ failure. Billed by the first of up to three physicians involved.

What the critical care fee already includes. On a day you bill life-threatening (or other) critical care, these services are not separately billable to the same patient by the same physician: assessment and ongoing monitoring of the patient; intravenous lines; cutdowns; arterial and venous catheters; CVP lines; endotracheal intubation; tracheal toilet; blood gases; nasogastric intubation (with or without anaesthesia or lavage); urinary catheters; and pressure infusion sets and pharmacological agents. Life-threatening critical care also includes defibrillation and cardioversion.

G523 — Second quarter hour ($64.50)

The next 15 minutes of life-threatening critical care.

G522 — Each quarter hour after the first half hour ($42.50)

Every additional 15 minutes beyond the first 30.

G395 — Other critical-care, first quarter hour ($64.70)

This code is billable for the fourth physician providing resuscitation to the critically ill patient above, or when a physician provides critical care or resuscitation to a patient who otherwise does not meet the criteria for G52x above. Colloquially “small G”, for those patients that are still need urgent critical care but are not as severely ill.

G391 — Each subsequent quarter hour ($34.35)

Every additional 15 minutes beyond the first 15 for patients billed with g395.

Stack what you are owed. Critical care time rendered after hours is eligible for the H112, H113, or H114 premium, and a qualifying major-trauma resuscitation is eligible for the E420 trauma premium (below). Document the times and the clinical picture so the claim holds up.

The trauma premium (E420)

For a major trauma patient you can add a 50% premium with E420. It applies when the Injury Severity Score (ISS) is greater than 15 for a patient aged 16 or older, or greater than 12 for a patient under 16, and the service is rendered on the day of the trauma or within the following 24 hours.

E420 attaches to consultations and visits (Section A), the resuscitative critical care codes (G391, G395, G521, G522, G523), surgical procedures (Sections M through Z, and obstetrics), and the anaesthesia and surgical-assistant components of those services. It does not apply to special-visit, after-hours, or age premiums — only to the underlying service fees.

Documentation and submission. The calculated ISS must be recorded in the chart. E420 is not paid automatically: the claim is submitted manually with supporting documentation (the ISS and the trauma details). Keep the ISS calculation on file in case the ministry asks for it.

Emergency department investigative ultrasound (H100)

H100 ($19.65) covers a point-of-care ultrasound performed by an ED physician for a patient clinically suspected of one of five life-threatening conditions:

• Pericardial tamponade
• Cardiac standstill
• Intraperitoneal hemorrhage associated with trauma
• Ruptured abdominal aortic aneurysm
• Ruptured ectopic pregnancy

H100 is only payable when a radiologist is not available to render an urgent interpretation, and when you meet the training and experience standards (the Canadian Emergency Ultrasound Society standards are the reference). You must keep a permanent image and an interpretive report. Max two per patient per day.

The gotcha. If you claim H100, most other ultrasound services on the Schedule are no longer eligible for payment for that encounter. And beyond the five listed conditions, you cannot claim H100 even if your POCUS was clinically valuable. Document exactly which life-threatening diagnosis you were ruling in or out.

Common mistakes I see in ED billing

Undercoding comprehensive assessments

The classic new-grad pattern: a genuinely sick patient consuming hours of your shift gets billed as H103 (multiple systems) because the physician is not sure their note "earns" H102. If you met the elements - full history, full physical, concomitant treatment, intermittent attendance over a period of time, interpretation of investigations - claim comprehensive. Your note should reflect that work regardless.

Billing a re-assessment on the discharge visit

H1x4 is not a discharge assessment. If the re-assessment is the conversation where you tell the patient they are going home, you cannot claim it. The re-assessment has to identify that an investigation or treatment was performed at that time on reassessment.

Missing the consultation documentation

If you are going to bill H065, the referral has to be documented and there needs to be a written response. Verbal consultations that did not generate documentation do not qualify. Put a standard consult note template in your EMR and use it.

Quick reference card

Look up any emergency code, premium, or procedure fee at MedConcierge.ca/emerg.