Billing K030 and Q040: a guide to OHIP diabetes management codes
Updated 2026-09-30
For a family physician, a patient with diabetes is worth up to $248.70 a year in continuing-care billing on top of ordinary visits: four K030 assessments at $45.75 each, and one Q040 incentive at $65.70. Most of that money is lost to counting, not to clinical work. A fourth K030 is never billed because nobody knew it was the fourth, or a Q040 is never claimed because nobody noticed the patient had three K030s this year.
Fees below are from the Schedule of Benefits effective July 1, 2026.
K030: diabetic management assessment ($45.75)
- Limit: four per patient per 12-month period.
- It replaces the visit code; it doesn't add to it. K030 is all-inclusive. The Schedule doesn't pay it on top of another consultation or visit by the same physician on the same day, so bill K030 instead of the visit code, not beside it.
- It has content requirements. The patient's diabetic flow sheet must be maintained, covering lipids, HbA1c, urinalysis, blood pressure, fundal examination, peripheral vascular examination, weight or BMI, and medications. If the visit didn't touch those elements, it's a regular visit, not a K030.
- Virtual K030s depend on an in-person one. A K030 delivered virtually is only payable if the patient had an in-person K030 in the preceding 12 months.
Q040: diabetes management incentive ($65.70)
- Limit: one per patient per 12-month period.
- It needs three K030s first. Q040 is only payable once the same physician has billed at least three K030s for the same patient in the same 12-month period.
- It's for the most responsible physician. Q040 is claimed by the family physician who is most responsible for the patient's diabetes care, with the Diabetes Canada elements documented for the previous 12 months.
Q040 is where most of the unclaimed money sits: it exists only if someone counts K030s.
Counting the 12 months
Count back 12 months from the date of the visit you're about to bill, not from January 1. For each tracked patient, keep:
- How many K030s were billed in the last 12 months, and on what dates.
- The date the oldest of those drops out of the window. That's when a patient at four becomes eligible again.
- Whether any of them were in person, if the next one will be virtual.
- Whether Q040 has been billed in the last 12 months, and whether three K030s now unlock it.
Only claims OHIP actually accepted should count. A K030 that was rejected and never corrected doesn't use up the limit, and a K030 billed through a different system still does.
The common mistakes
| Mistake | What happens |
|---|---|
| A fifth K030 inside 12 months | The claim is refused. |
| K030 billed alongside a visit code the same day | The combination doesn't pay more than K030 alone. |
| Virtual K030 with no in-person K030 in the last year | Not payable. |
| Three K030s billed, Q040 never claimed | $65.70 per patient per year, never billed. |
| Waiting until the patient is "due" to plan the visit | The flow-sheet elements weren't done, so the visit can't be billed as a K030. |
That last row is the one to fix first. Knowing before the visit that a K030 is available is what lets you do the foot exam and order the HbA1c that make it billable.
Doing this without a spreadsheet
Med Copilot tracks patients by health number, counts K030s and Q040 over the rolling 12-month window, and shows a recall list of which patients are due, what each visit is worth, and when a capped patient becomes eligible again. It includes codes you billed outside Med Copilot. It's advisory only: you make the call on every claim.
This guide summarises the Schedule of Benefits for convenience. The Schedule itself, and the ministry's bulletins, are what OHIP applies.