Compensation terms for services rendered in the context of the pandemic caused by COVID 19

To follow up on the receipt of the COVID-19 services infoletter, here is some information that will help you understand the new Lettre d’entente 238. As usual, please take note that this communication is published solely to help you understand the Lettre d’entente 238. The original text, in French, prevails.

The Lettre d’entente 238 comes into force retroactively to February 28, 2020 except for telemedicine (March 16, 2020) and the temporary discontinuation of certain medico-administrative and teaching activities (March 23, 2020). You have 120 days from the date of this infoletter (April 23, 2020) to bill for your services.

Six situations COVID-19

1. Physician practicing in an SNT (non-traditional site) or in a clinique désignée

Choice 1 – Standard compensation mode

FEE-FOR-SERVICE:

Visit:
  • Inpatient visit as per specialty
  • COVID-19 related visit (art. 4 LE 238)
Context elements:
  • LE238 – Service rendu dans un SNT non ambulatoire dans le cadre de la COVID-19 #SNTN
  • LE238 – Service rendu dans un SNT ambulatoire ou une clinique désignée dans le cadre de la COVID-19 #SNTA
  • LE238 – Télémédecine à partir d’un cabinet dans le cadre de la COVID-19 #TELC
    (Possible si dans une autre demi-journée non SNT)
  • LE238 – Télémédecine ailleurs qu’à partir d’un cabinet dans le cadre de la COVID-19 #TELA
    (Possible si dans une autre demi-journée non SNT)
Institution:
  • Choose the institution the physician is attached to
Rules:
  • Admission date mandatory, and for outpatients, enter the visit date in the admission date
MIXED REMUNERATION:

  • Activity code: 65320 or 84320 (anesthesiologist) / Secteur : hospitalization 03
  • Institution the physician is attached to
  • Mandatory signature

Meetings regarding pandemic (art. 8 LE 238):
Payable if Fee-for-service and/or Mixed remuneration

Choice 2 – Pandemic-specific Fixed amount (art. 3.1 LE 238)

HOURLY RATE:

Activity code:
  • 290322 (pandemic fixed amount – SNT (non-traditional site) or clinique désignée)
  • Sector: hospitalization 03
  • 20% increase if between 8 p.m. and 8 a.m. / Sector: 46

Rate:
  • 844 $ / per 4 hour period / max. three fixed amounts per day

Rules:
  • Can request a compensation for office costs
  • Cannot receive any other billing, subject to exceptions
  • 20% increase if between 8 p.m. and 8 a.m. (on site)

Laboratory service:
  • A physician practicing in a laboratory must select Choice 2, given the nature of his/her services

Choice 1 – Standard compensation mode

FEE-FOR-SERVICE:

Visit:
  • Inpatient visit as per specialty
  • COVID-19 related visit (art. 4 LE 238)

Context elements:
  • LE238 – Service rendu par un médecin réaffecté dans le cadre de la COVID-19 #REAF
  • LE238 – Médecin réaffecté dans un autre lieu que l’établissement auquel il est rattaché dans le cadre de la COVID-19 #REAFA
  • LE238 – Télémédecine à partir d’un cabinet dans le cadre de la COVID-19 #TELC
  • LE238 – Télémédecine ailleurs qu’à partir d’un cabinet dans le cadre de la COVID-19 #TELA

Institution:
  • Choose the institution the physician is attached to
Rules:
  • If performed as telemedicine: start and end time mandatory
  • If other territory, enter reassignment location in the "Lieu en référence" box
MIXED REMUNERATION:

  • If inpatient: activity code: 65321 or 84321 (anesthesiologist) / Sector: hospitalization 03
  • Elsewhere: activity code: 65328 or 84328 (anesthesiologist) / Sector: hospitalization 03
  • Institution the physician is attached to / Mandatory signature

Meetings regarding pandemic (art. 8 LE 238):
Payable if Fee-for-service and/or Mixed remuneration

Choice 2 – Pandemic-specific Fixed amount (art. 3.1 LE 238)

HOURLY RATE:

Activity code:
  • 290323 (pandemic fixed amount – Physician holding a PEM and is reassigned)
  • Sector: hospitalization 03
  • 20% increase if between 8 p.m. and 8 a.m. / Sector: 46

Rate:
  • $844 / per 4 hour period / max. three fixed amounts per day

Institution:
  • Institution where the services are performed or for which they are performed

Rules:
  • Can request a compensation for office costs
  • Cannot receive any other billing, subject to exceptions
  • 20% increase if between 8 p.m. and 8 a.m. (on site)

Laboratory service:
  • A physician practicing in a laboratory must select Choice 2, given the nature of his/her services
Physicians reassigned can select choices 1 or 2 while physicians not reassigned will have to use choice 2

Choice 1 – Standard compensation mode

FEE-FOR-SERVICE:

Visit:
  • Inpatient visit as per specialty
  • COVID-19 related visit (art. 4 LE 238)

Context elements:
  • LE238 – Service rendu par un médecin infecté dans le cadre de la COVID-19 #INF
  • LE238 – Télémédecine ailleurs qu’à partir d’un cabinet dans le cadre de la COVID-19 #TELA

Institution:
  • Choose the institution the physician is attached to / Sector: Outpatient

Rules:
  • Telemedicine: start and end time mandatory
  • If other territory, enter reassignment location in the "Lieu en référence" box
MIXED REMUNERATION:

  • Activity code: 65325 or 84325 (anesthesiologist)
  • Institution the physician is attached to / Mandatory signature

Meetings regarding pandemic (art. 8 LE 238):
Payable if Fee-for-service and/or Mixed remuneration

Choice 2 – Pandemic-specific Fixed amount (art. 3.1 and 3.2 LE 238))

THOURLY RATE:

Reassigned infected physician:
  • 290329 (Pandemic fixed amount – Reassigned infected physician) $844 / per 4 hour period / max. three fixed amounts per day

Infected physician not reassigned:
  • 290330 (Half-day fixed amount – Non-reassigned infected physician) $372$ / per half-day availability / max. two fixed amounts per day
  • Half-day = minimum of 3h30m availability (bill 1h to get one fixed amount)

Institution:
  • Institution for which the services are performed or to which he/she is attached

Rules:
  • Can request a compensation for office costs
  • Cannot receive any other billing, subject to exceptions

Laboratory service:
  • A physician practicing in a laboratory must select Choice 2, given the nature of his/her services
Physicians reassigned can select choices 1 or 2 while physicians not reassigned will have to use choice 2

Choice 1 – Standard compensation mode

FEE-FOR-SERVICE:

Visit:
  • Outpatient visit as per specialty
  • COVID-19 related visit (art. 4 LE 238)

Context elements:
  • Service rendu par un médecin en isolement préventif dans le cadre de la COVID-19 #ISO
  • LE238 – Télémédecine ailleurs qu’à partir d’un cabinet dans le cadre de la COVID-19 #TELA

Institution:
  • Choose the institution the physician is attached to / Sector: Outpatient

Rules:
  • Telemedicine: start and end time mandatory
  • If other territory, enter reassignment location in the "Lieu en référence" box
MIXED REMUNERATION:

  • Activity code: 65326 or 84326 (anesthesiologist)
  • Institution the physician is attached to / Mandatory signature

Meetings regarding pandemic (art. 8 LE 238):
Payable if Fee-for-service and/or Mixed remuneration

Choice 2 – Pandemic-specific Fixed amount (art. 3.1 and 3.2 LE 238))

HOURLY RATE:

Reassigned segregated physician:
  • 290331 (Pandemic fixed amount – Reassigned segregated physician) $844 / per 4 hour period / max. three fixed amounts per day

Segregated physician not reassigned:
  • 290332 (Half-day fixed amount – Non-reassigned segregated physician)372$ / per half-day availability / max. two fixed amounts per day
  • Half-day = minimum of 3h30m availability (bill 1h to get one fixed amount)

Institution:
  • Institution for which the services are performed or to which he/she is attached

Rules:
  • Can request a compensation for office costs
  • Cannot receive any other billing, subject to exceptions

Laboratory service:
  • A physician practicing in a laboratory must select Choice 2, given the nature of his/her services
Physicians reassigned can select choices 1 or 2 while physicians not reassigned will have to use choice 2

Choice 1 – Standard compensation mode

FEE-FOR-SERVICE:

Visit:
  • Outpatient visit as per specialty
  • COVID-19 related visit (art. 4 LE 238)

Context elements:
  • LE238 – Service rendu par un médecin enceinte dans le cadre de la COVID-19 #ENC
  • LE238 – Télémédecine à partir d’un cabinet dans le cadre de la COVID-19 #TELC
  • LE238 – Télémédecine ailleurs qu’à partir d’un cabinet dans le cadre de la COVID-19 #TELA

Institution:
  • Choose the institution the physician is attached to / Sector: Outpatient

Rules:
  • Telemedicine: start and end time mandatory
  • If other territory, enter reassignment location in the "Lieu en référence" box
MIXED REMUNERATION:

  • At the hospital: activity code: 65327 or 84327 (anesthesiologist))
  • Elsewhere: activity code: 65335 or 84335 (anesthesiologist)
  • Institution the physician is attached to / Mandatory signature

Meetings regarding pandemic (art. 8 LE 238):
Payable if Fee-for-service and/or Mixed remuneration

Choice 2 – Pandemic-specific Fixed amount (art. 3.1 and 3.2 LE 238)

HOURLY RATE:

Reassigned pregnant physician:
  • 290333 (pandemic fixed amount – Reassigned pregnant physician) $844 / per 4 hour period / max. three fixed amounts per day - 20% increase if between 8 p.m. and 8 a.m. / Sector: 46
  • Majoration de 20% si entre 20h et 8h / Secteur : 46

Non-reassigned pregnant:
  • 290334 (Half-day fixed amount – Non-reassigned pregnant physician) $372$ / per half-day availability / max. two fixed amounts per day
  • Half-day = minimum of 3h30m availability (bill 1h to get one fixed amount)

Institution:
  • Institution for which the services are performed or to which he/she is attached

Rules:
  • Can request a compensation for office costs
  • Cannot receive any other billing, subject to exceptions

Laboratory service:
  • A physician practicing in a laboratory must select Choice 2, given the nature of his/her services
The physician can also take advantage of COVID-19 visits, coordination activities as well as telemedicine (see art. 4 and 9 LE 238).

List of new context elements

Context elements
Description
SNTN
Service rendu dans un SNT non ambulatoire dans le cadre de la COVID-19
SNTA
Service rendu dans un SNT ambulatoire ou une clinique désignée dans le cadre de la COVID-19
REAF
Service rendu par un médecin réaffecté dans le cadre de la COVID-19
REAFA
Médecin réaffecté dans un autre lieu que l’établissement auquel il est rattaché dans le cadre de la COVID-19
TELC
Télémédecine à partir d’un cabinet dans le cadre de la COVID-19
TELA
Télémédecine ailleurs qu’à partir d’un cabinet dans le cadre de la COVID-19
INF
Service rendu par un médecin infecté dans le cadre de la COVID-19
ISO
Service rendu par un médecin en isolement préventif dans le cadre de la COVID-19
ENC
Service rendu par un médecin enceinte dans le cadre de la COVID-19

Explanation of the different compensation methods specific to the pandemic

Rémunération différente (Annexe 19 – Régions éloignées)

  • The fixed amounts (forfaits) payable in accordance with the provisions of Lettre d'entente 238 are not subject to the different compensation increase provided for in Appendix 19 of the Framework Agreement.
  • For services performed remotely, the payment in Appendix 19 applies according to the location where the services would normally have been performed (telemedicine).

Forfait spécifique à la pandémie (art. 3.1 LE 238)

  • This fixed amount compensation mode allows all medical activities and meetings relating to the pandemic to be paid, and includes, where applicable, the telemedicine services provided in the context of the COVID-19 pandemic. (Applies to situations 1, 2, 3, 4 and 5)


  • $844 for 4 hours of activities
  • Shorter activity period: this amount is divisible in hours of 60 consecutive minutes
  • Maximum of 3 fixed amounts per day
  • 20% increase between 8 p.m. and 8 a.m. if the services were performed on site at the institution
  • Hourly rate billing type

  • During one day, the physician who chooses the fixed amount compensation specific to the pandemic cannot receive any other compensation provided for in the Framework Agreement during that same day, with the exception of the pandemic-specific fixed amount in the event of non-reassignment (art. 3.2 LE 238), if he or she is eligible and he or she is reassigned for a period of 4 hours or less, and the fixed amounts provided for in Lettre d'entente 239 (Infoletter concerning ICU, not received at the moment), as long as it does not exceed a maximum of 12 hours for the 2 Lettres d'entente.
  • For office expenses, the physician may request a compensation of $200 per day of missed work in the office. To apply, please follow the instructions in the Lettre d'entente.


Note that this fixed amount constitutes an exclusive compensation and therefore includes telemedicine as well as meetings related to COVID-19.

Forfait spécifique à la pandémie en cas de non-réaffectation (art. 3.2 LE 238)

  • This fixed amount applies to the infected physician who is able to perform services, to physicians in preventive segregation and pregnant physicians in preventive withdrawal who are available, but not reassigned or reassigned for a period of 4 hours or less. They can take advantage of a fixed amount payable per half-day


  • $372 for a half-day
  • Monday to Friday except public holidays
  • Available at least 3 h 30, between 7 a.m. and 12 p.m. or between 12 p.m. and 5 p.m.
  • Maximum of 2 fixed amount per day
  • No increase for a different compensation (Appendix 19 – remote regions)

  • During a day, the physician who benefits from this fixed amount cannot receive any other compensation provided for in the Framework Agreement during that same day, with the exception of what is provided for in the 4th paragraph of article 3.1 (pandemic package).
  • For office expenses, the physician may request a compensation of $200 per day of missed work in the office. To apply, please follow the instructions in the Lettre d'entente.

Télémédecine (art. 9 LE 238)

  • The medical specialist may bill for medical services related to COVID-19 which are performed remotely by telephone or by video consultation. The physical examination is not necessary for billing the main visit and the telemedicine consultation. If physical examination is required, the patient should be seen in person.
  • For practice from the office, cabinet pricing must be used. For a practice from any other place, including home, outpatient clinic pricing applies. Outpatient clinic pricing also applies to the physician usually practicing in an office, when the services are rendered from a place other than the office, for example from his or her home.
  • Coming into effect:The provisions relating to telemedicine come into effect retroactively to March 16, 2020 and are valid as long as the state of health emergency is in force.


Maximum payable:

  • Fee-for-service: A medical specialist cannot charge more than $300 per hour of telemedicine. For the last hour, the doctor cannot charge more than $75 per completed 15 minutes of telemedicine.
  • Mixed remuneration: A medical specialist compensated according to the mixed mode of Annexe 38 or Annexe 40 cannot charge more than $195 per hour of telemedicine. For the last hour, the physician cannot bill more than $48.75 per completed 15 minutes of telemedicine. The physician can count his or her time to bill per diem as if he or she were in an institution.


  • Cannot be increased according to rule 14 of the general preamble (emergency care);
  • Cannot be billed the same day as a pandemic-specific fixed amount
  • Payable at all times
  • Increase applicable for different compensation (Appendix 19 - Remote regions)
  • The radiology specialist should not bill according to the telemedicine terms of Lettre d'entente 238, but rather according to the usual procedures for remote interpretation.

Billing instructions:

Increase for different compensation (Appendix 19 – Remote regions):

In all these situations, if the place where the service would normally have been rendered is located in a territory where the rate of increase under Appendix 19 is different from the place of dispensation, the physician must also write:

  • The reference facility type : Where the patient is located (telemedecine)
  • Reference Facility: the location where the service would normally be delivered


1. Office performed services
  • Service: patient visit (for example main visit)
  • Use context element: LE 238 – Télémédecine à partir d’un cabinet dans le cadre de la COVID-19 #TELC
  • Institution: Use your office’s number (location code)
  • Add the service start and end time; Example: P#TELC :0800-0830
2. Services performed at any other location, when the physician is attached to an institution:
  • Service: patient visit (for example main visit)
  • Use context element: LE 238 – Télémédecine ailleurs qu’à partir d’un cabinet dans le cadre de la COVID-19 #TELA
  • Institution: Use the number of the institution you are attached to
  • Sector: Outpatient clinic
  • Add the service start and end time; Example: P#TELC :0800-0830
3. Services performed at any other location, when the physician is not attached to an institution:
  • Service: patient visit (for example main visit)
  • Use context element: LE 238 – Télémédecine ailleurs qu’à partir d’un cabinet dans le cadre de la COVID-19 #TELA
  • Institution: Use the institution number 99111
  • Sector: Outpatient clinic
  • Add the service start and end time; Example: P#TELC :0800-0830

Visites en lien avec la COVID-19 (art. 4 LE 238)

  • When billing, a physician can use one of the following billing codes with the context element that applies to the situation.
  • They can be billed by physicians of each of the specialties. These visits are payable for each of the different possible situations as well as for telemedicine. Start time and end time are not required.


Cohort care unit, non-ambulatory SNT (non-traditional site) or hospitalization
  • 15923 – main visit related to COVID-19 ($95) (55% if RMX)(maximum one per patient, per physician or per physician of the same specialty/week)
  • 15924 – Follow-up visit related to COVID-19 ($35) (55% if RMX)(maximum one per patient, per physician or per physician of the same specialty/day)
NOTICE: To bill these visits (15923 and 15924), use the context element pertinent to your situation (see various situations on the following pages).
Flu clinic, ambulatory SNT (non-traditional site) or outpatient clinic
  • 15925 - main visit related to COVID-19 ($70) (55% if RMX)(maximum one per patient, per physician or per physician of the same specialty/week)
  • 15926 – Follow-up visit related to COVID-19 ($31) (55% if RMX)(maximum one per patient, per physician or per physician of the same specialty/day)
NOTICE: To bill these visits (15925 and 15926), use the context element pertinent to your situation (see various situations on the following pages as well as the context elements related to telemedicine).

Rémunération des tâches de coordination en lien avec la pandémie (art. 8 LE 238)

  • At the request of the authorities in place, the physician who participates in meetings related to the pandemic is paid at an hourly rate of $211/hour. Payment of one hour requires a continuous activity period of 60 minutes.
  • Meetings must be subject to a meeting notification and include an agenda. Attendance must be recorded and minutes must be prepared and given to the members. Notification, agenda, minutes must be prepared and given to the members.
  • The administration of the institution or the MSSS must transmit to the joint committee the names of the medical specialists designated for these functions and the number of authorized hours.
  • This hourly rate also applies to the time devoted to the reassignment of medical personnel in the context of the COVID-19 pandemic, up to a maximum of 4 hours per day, per physician and billable at all times.


Billing instructions (hourly rate form):

Meetings related to the pandemic:
  • Institution: where the service is performed or, if the service is performed remotely, the institution number where it would normally have been performed.
  • Fee-for-service: activity code 290336
  • Mixed remuneration: activity code 290338 (payable at 50%)
Participation to the reassignment of medical personnel (maximum of 4 hours per day, per physician):
  • Institution: where the service is performed or, if the service is performed remotely, the institution number where it would normally have been performed
  • Fee-for-service: activity code 290337
  • Mixed remuneration: activity code 290339 (payable at 50%)

Suspension de certaines activités médico-administratives et d’enseignement

  • Since March 23, 2020 and for the entire duration of the health emergency period announced by the Government of Quebec, in order to avoid regrouping and reduce the risk of transmission, all activities related to the Protocole d’accord relatif à la rémunération de certaines activités médico-administratives accomplies dans un établissement de santé ou au Protocole d’accord relatif à la rémunération de certaines activités d’enseignement effectuées par les médecins spécialistes Partie II : Autres activités d’enseignement et d’évaluation are suspended and are no longer paid. This suspension concerns service, department or committee meetings (activity codes XXX170 to XXX248) as well as teaching at an hourly rate (activity codes XXX249 to XXX254).
  • Only meetings related to the management of the pandemic caused by COVID-19 and the reallocation of medical personnel can be paid in accordance with the provisions of article 8 of Lettre d'entente 238.
  • If applicable, the RAMQ will make the necessary adjustments to billing. For the physicians concerned, the information will appear on a subsequent statement. No action is required from you.