Three things define paediatric billing. The assessment ladder — A265A consultation at $190.35 down to A262A at $50.20 — where picking the right rung is most of the money. The premiums E078A at add 50% and E082A and E083A at add 30%, which are percentages rather than fees and are easy to forget because of it. And the additional-persons codes for hospital rounds, where the amount depends on the time of day and ranges from $20.55 to $102.80.
IntelAGENT offers the eligible age, time and diagnosis premiums on the visit rather than expecting you to remember them. See how →
Paediatrics is not a high-volume-procedure specialty; the revenue is in assessments and in the premiums that attach to them, which means it is a specialty where what you do not bill matters more than what you bill wrongly.
The codes and what they pay
| Code | Description | Fee |
|---|---|---|
| A265A | Consultation | $190.35 |
| C997A | Hospital in-patient, additional persons — weekday nights | $102.80 |
| A263A | Medical specific assessment | $95.75 |
| H261A | Newborn care in hospital or home | $82.90 |
| U999A | Hospital out-patient, additional persons — Sat/Sun/holiday | $77.10 |
| U995A | Hospital out-patient, additional persons — weekday evenings | $61.70 |
| C995A | Hospital in-patient, additional persons — weekday evenings | $61.70 |
| A262A | Level 2 paediatric assessment | $50.20 |
| H113A | Sat/Sun/holiday and Friday evening premium | $32.20 |
| U991A | Hospital out-patient, additional persons — weekday daytime | $20.55 |
| C991A | Hospital in-patient, additional persons — weekday daytime | $20.55 |
| E078A | Chronic disease assessment premium | add 50% |
| E082A | MRP admission assessment premium | add 30% |
| E083A | MRP subsequent visit premium | add 30% |
Fees are from the OHIP Schedule of Benefits and are the ministry's, not ours. Which assessment code applies, the eligibility conditions for each premium, and the rules for the additional-persons codes are all in the current Schedule. Check it before billing a code you have not used. These fees are from the Schedule effective July 1, 2026 (PDF).
The assessment ladder
The gap between A265A at $190.35 and A262A at $50.20 is larger than most procedures in the specialty, so the single most consequential decision on a paediatric claim is which assessment code applies.
The rungs are defined by what the service was, not by how long it took or how complex it felt. A consultation requires a referral and has requirements about what the consultation includes and what is communicated back; the assessment codes below it have their own definitions. Billing a consultation where the criteria were not met is a refusal; billing an assessment where a consultation was performed is money left behind.
Two practical points:
- The referring physician is mandatory on a consultation, and a missing or invalid one is among the most common rejections in the specialty. It is also entirely preventable before submission.
- Repeat consultations on the same patient have rules. A second consultation for the same condition within a defined period is not a fresh consultation. Where it is refused, the refusal is usually correct.
The premiums are percentages, not fees
E078A, E082A and E083A have no dollar amount of their own. The Schedule lists E078A as add 50% and the two MRP premiums as add 30%, so each is worth a proportion of the service it attaches to. On a $95.75 medical specific assessment, E078A is the largest single line on the claim after the assessment itself.
The practical consequence is that a per-claim expected amount is more than a convenience in this specialty. If you do not compute what the percentage should have produced, a premium that quietly failed to apply is invisible — the base service simply paid less than you assumed. See reading a Remittance Advice.
E078A depends on the diagnostic code. The chronic disease assessment premium is payable only for a defined set of conditions, so the diagnostic code you submit is what decides whether it applies. A clinically defensible code that is not on the premium's list means no premium, with nothing on the RA saying why. How diagnostic codes work covers this failure mode.
The additional-persons codes
Seeing more than one patient on the same hospital visit is billed with the additional-persons codes: the U99x series for out-patients and the C99x series for in-patients. The code within each series depends on when the visit happened, and the spread is wide — $20.55 on a weekday daytime, $61.70 in the evening, $102.80 overnight, $77.10 on a weekend or holiday.
Because the amount is set by the clock rather than by the work, two things matter:
-
The time has to be right
A night round billed with the daytime code is a real loss and a silent one, because the claim is perfectly valid and pays without complaint.
-
The series has to match the setting
U99x for out-patients, C99x for in-patients. Using the wrong series produces a refusal rather than a quiet underpayment, so it is the less expensive mistake.
H113A, the Saturday, Sunday, holiday and Friday evening premium at $32.20, applies alongside eligible services on those days and is the other commonly missed clock-driven code.
What gets missed
-
The chronic disease and MRP premiums
Not prompted by the base code, and with no headline fee to make them look worth claiming — which is exactly backwards, since 50% of an assessment is the biggest thing on the claim.
-
The wrong rung of the assessment ladder
Usually downward — an assessment billed where a consultation was performed.
-
Time-of-day on the additional-persons codes
Billed at the daytime rate regardless of when the round happened.
-
H113A on weekend and Friday evening work
Small, frequent, and entirely a function of the calendar.
-
Newborn care
H261A for care delivered around a delivery someone else billed.
Billing paediatrics in IntelAGENT
Paediatric premiums depend on the age, the time and the diagnosis at once, which is why they are the most commonly missed part of the specialty.
- Premium prompting on eligible visits. E078A, E082A and E083A are offered where the visit qualifies rather than remembered.
- Diagnosis-aware premiums. Where a premium depends on the diagnostic code, the dependency is known rather than discovered from an underpayment.
- Time-driven codes picked from the actual time. The U99x and C99x rung follows the recorded time of the visit, not a default.
- Referring physician enforced on consultations. The largest rejection family in the specialty is caught before submission.
- Expected against settled, per claim. The only way to see a folded premium that did not apply.
- Mobile entry on rounds. Billing from the phone app during the round, which is when the times and the patient list are still accurate.
Three months free, then 0.25% of paid claims, capped at $39.99 a month. IntelAGENT has submitted OHIP claims since 2016 for more than 2,000 Ontario physicians.
Frequently asked questions
What is the OHIP code for a paediatric consultation?
A265A, $190.35 effective July 1, 2026. A263A is the medical specific assessment at $95.75 and A262A the level 2 paediatric assessment at $50.20. Which applies depends on the service rendered and the referral, both of which are defined in the Schedule of Benefits.
What is the OHIP code for newborn care?
H261A covers newborn care in hospital or at home, $82.90 effective July 1, 2026. It is distinct from the assessment codes and from the additional-persons codes used for hospital rounds.
What are the paediatric premium codes worth?
It depends on the service they attach to, because the Schedule states them as percentages rather than fees: E078A adds 50% to the assessment, and E082A and E083A each add 30%. A 50% premium on a $95.75 medical specific assessment is worth more than most of the codes it sits beside.
What are the U99x and C99x codes?
They are additional-persons codes for seeing more than one patient on the same hospital visit — U99x for out-patients and C99x for in-patients — with the amount depending on whether the visit was a weekday daytime, an evening, a night, or a weekend or holiday.
Related reading
Diagnostic codes
Why E078A turns on the diagnostic code you submit.
GuideReading a Remittance Advice
Telling a correctly applied premium from one that silently did not.
SpecialtiesAll specialties
Billing patterns by specialty.
ProductIntelAGENT on mobile
Billing from rounds, with the premiums offered as you go.