A053 – Medical Specific Assessment
OHIP General Listings Code — Community Medicine (05) · Schedule of Benefits
A service rendered by a specialist in Community Medicine in a place other than a patient’s home, requiring a full history of the presenting complaint and detailed examination of the affected part(s), region(s), or system(s) needed to make a diagnosis, and/or exclude disease, and/or assess function.
When to Use
- Bill A053 for a specialist in Community Medicine performing a comprehensive assessment of a patient's new infectious disease outbreak in a community setting, distinct from a routine follow-up.
- Use A053 when a Community Medicine specialist conducts a detailed assessment of a patient's complex environmental exposure history and its impact on their health, requiring a full diagnostic workup.
- A053 is appropriate for a specialist in Community Medicine assessing a patient with a newly diagnosed chronic condition requiring a full history, detailed examination, and initial management plan, differentiating it from a re-assessment code like A054.
Common Pitfalls
- Billing A053 more than once per patient per physician within a 12-month period without meeting the criteria for a second assessment (unrelated diagnosis or 90-day interval with hospital admission) will result in payment adjustment to a lesser fee.
- Claiming A053 in combination with E078 is incorrect, as Community Medicine (specialty 05) is not an eligible specialty for the Chronic Disease Assessment Premium.
- Submitting A053 on the same day as another assessment code (e.g., A058, A051, or another A053) for the same patient by the same physician will lead to rejection of the claim.
Billing Tips
- Ensure your documentation clearly outlines the specific findings, diagnosis, and follow-up plan for the patient's condition, as this is a requirement for A053.
- When a second A053 is billed within 12 months, confirm that either a new, unrelated diagnosis was made or that 90 days have passed and the second service relates to a hospital admission assessment.
Effective: June 1, 2025
Consultations and Visits
Community Medicine (05)
Consultations and Visits
Assessment
Documentation of findings, diagnosis, and follow-up plan in the medical record.
Used for 'special visits' to long-term care in-patients when applicable.
Excessive claims beyond the 12-month limit will be adjusted to a lesser assessment fee (e.g., partial assessment).
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