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Error code

D5 — Procedure already paid - visit fee adjusted

Visit reduced for procedure

A procedure for this patient was already paid, so OHIP reduced or zeroed the visit fee billed with it.

What to do: Look at what was paid for the procedure and visit together; if the rules don't allow both, nothing to fix.

Code
D5
Description
Procedure already paid - visit fee adjusted

Explanation

Updated October 26, 2026

OHIP had already paid a procedure for this patient, so it reduced the visit fee billed with it. Check the visit and procedure together before acting.

What it means

D5 means a procedure had already been allowed (paid) when OHIP assessed the visit, so it adjusted the visit fee. The procedure stays paid and the visit line is reduced or paid $0. It appears on the Remittance Advice (RA); it is not an Error Report rejection.

It is the mirror image of D3 and D4. With D3 or D4 the procedure line is cut because of the visit. With D5 the visit line is cut because of the procedure.

The Schedule of Benefits has several rules that limit a visit billed with a procedure. A surgical fee includes preparing the patient and post-operative care up to the first post-operative visit, but not the major pre-operative visit where the decision to operate is made (SP1, SP2). On the day of a Z-code procedure (an independent operative procedure), if the major pre-operative visit was in the previous 12 months, the only assessment payable before the procedure is a minor assessment for a family physician or a partial assessment for a specialist (SP4). A minor procedure plus an unrelated, significant problem in another body system at the same visit can be billed as both (SP4).

Common causes

  • A visit billed on the same day as a procedure whose fee already covers that visit
  • A full assessment billed before a Z-code procedure when the major pre-operative visit was in the previous 12 months
  • A routine pre-operative or follow-up visit billed separately from a surgical fee that includes it
  • The procedure and the visit billed on separate claims, so the procedure was paid first

How to fix it

  1. Look at what was paid for the procedure and the visit together, not just the D5 line.
  2. Check the Schedule of Benefits payment rules for the procedure, including the section preamble.
  3. If the rules don't allow the full visit fee with that procedure, there is nothing to fix. Resubmitting won't change the result.
  4. If the visit was for a separate, significant problem in another body system, or was the major pre-operative visit, send a Remittance Advice Inquiry (RAI) through eSubmit, or on form 0918-84, within 7 months of the RA date. Explain why the visit is payable in addition to the procedure.

Don't resubmit if

  • The visit is on the RA. Changes to a processed claim go through an RAI, not a new claim.
  • The visit was part of the care the procedure fee already includes.

How APEX handles it

APEX has no correction rule for D5. Because the procedure was paid, the patient's visit that day usually isn't listed in the Correction Centre. A reduced visit line is marked Underpaid, or Settled when it is the only fee code on its claim, so you can decide whether an RAI is worth sending. See how APEX works · Pricing

Related codes: D3, D4, V3, S7

Sources