Effective June 4, 2001
Hospital in-patient
The WSIB pays for standard ward accommodation. The only exception may be where the attending physician or surgeon states that for medical reasons, a semi-private or private accommodation is required. Reasons for preferred accommodation must be stated on the account at the time of submission. Where a patient requests non-standard ward accommodation, this may be provided if the patient is advised, in advance, that the WSIB will not cover the additional cost.
Hospital out-patient
Emergency care
Initial visit
This is the first hospital emergency treatment following a work-related injury. This includes all necessary x-rays and treatments including emergency room minor surgery and fracture room use.
Follow-up visit
This is a follow-up visit after an initial visit for procedures such as:
- suture removal
- minor dressing
- follow-up fracture care/fracture clinic
- splint removal and dispensing of slings
- injection of steroids to joint or bursa
Follow-up visit with specific additional treatment
This applies in cases where a more extensive procedure has been provided. Some examples of more extensive procedures are:
- urethral dilation
- extensive complicated dressings with or without associated suture removal
- removal or change of plaster cast
- nerve blocks as listed in the Ministry of Health and Long Term Care (MOHLTC) Schedule of Fees for Physician Services
- lumbar puncture
- minor procedure under local anaesthetic
- review of complicated ophthalmological trauma which requires specialized attention
- burn debridement.
Day Surgery
Day surgery is an admission to hospital for out-patient operating room services and includes:
- x-rays
- dressings
- facility use
Haemodialysis
Haemodialysis is considered an out-patient service.
Imaging studies
Imaging studies include CT scans and MRIs of the head, body, neck, and thorax.
Photocopying of medical records
Copies of hospital medical records should be submitted only when specifically requested by the WSIB.
X-rays
X-rays should not be billed separately when the person is seen for the initial emergency visit. X-rays in these circumstances are considered part of the person’s initial out-patient care and are included in the initial visit fee. Necessary imaging studies associated with subsequent visits can be billed separately.
Use of hospital facilities
Physicians who are not on staff but use hospital facilities for diagnostic procedures do not bill the WSIB directly. In these cases, the technical and professional component should be billed by the hospital and the hospital reimburses the doctor for the professional portion of the fee.
Hospitals should not bill the WSIB for the use of hospital facilities by physicians who conduct non-economic loss assessments in a hospital. These assessments do not require use of hospital diagnostic procedures and cannot be billed to the WSIB by a hospital.
Ambulance
On the date of the accident, the employer pays for the ambulance service from the site of the incident to the hospital. Ambulance service from the injured or ill person’s home to hospital or transfers between hospitals is paid by the WSIB only where transportation is deemed medically necessary for the work-related injury/ illness.
Hospital Out-Patient Services
| Services included | Service code | Fee |
|---|---|---|
| Initial visit | 3100 | $95.83 |
| Follow-up with specific additional treatment | 3120 | $68.67 |
| Normal follow-up | 3110 | $23.96 |
| Services included | Service code | Fee |
|---|---|---|
| Day care surgery | 3130 | $332.05 |
| CAT Scan | MOH | $381.10 |
| Haemodialysis | MOH | $381.10 |
| Services included | Service code | Fee |
|---|---|---|
| Photocopy of medical records (when requested by WSIB) | 3150 | $48.15 |
Hospital billing instructions
Hospital in-patient
In-patient services are paid according to the Ministry of Health and Long Term Care (MOHLTC) inter-provincial authorized rates for public hospitals as these are approved by the WSIB. All necessary nursing services are included in the hospital per diem rate. Hardware/prosthetic implants required for operative procedures are also included in the per diem rate.
Hospitals may bill for a full day on the day of admittance, but not on the day of discharge.
Hospital out-patient
Fees listed in the WSIB Hospital Out-Patient Fee Schedule include all supplies (e.g., coban tape, tensor bandages, etc.) associated with the service and no additional charges should be billed to either the WSIB or the person with a work-related injury or illness.
Laboratory and x-ray services are paid by the WSIB based on the Schedule of Benefits for Physician Services under the Health Insurance Act.