A111 – Complex medical specific re-assessment
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A complex medical specific re-assessment is a re-assessment of a patient because of the complexity, obscurity, or seriousness of the patient’s condition and includes all the requirements of a medical specific re-assessment.
When to Use
- Billing for a complex re-assessment of a patient with a rare neurological disorder requiring extensive history, examination, and consultation with specialists, where the condition is obscure and serious.
- Using A111 when a patient with a newly diagnosed, complex autoimmune disease requires a comprehensive re-evaluation beyond a standard medical specific re-assessment (A114), involving multiple system reviews.
- Billing for a critically ill patient in the ICU (not on duty) who requires a complex medical specific re-assessment due to the seriousness and obscurity of their multi-organ failure, distinct from critical care codes G521-G523.
Common Pitfalls
- Failing to submit a written report of findings, opinions, or recommendations to the patient's primary care physician will result in the service being adjusted to the lesser fee of A114.
- Billing A111 more than 4 times per patient per 12-month period, either alone or in combination with A713, will lead to subsequent claims being adjusted to a lesser assessment fee.
- Billing A111 on the same day as life-threatening critical care (G521, G522, G523) when the assessment is part of ongoing monitoring, leading to claim rejection or adjustment.
Billing Tips
- Ensure the patient's condition truly meets the criteria for complexity, obscurity, or seriousness; otherwise, consider billing A114 (Medical specific re-assessment).
- If the A111 service is rendered to an in-patient, use C111 instead to ensure correct payment.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultations and Visits
Assessment
Requires a full, relevant history and physical examination of one or more systems.
The physician must report his/her findings, opinions, or recommendations in writing to the patient’s primary care physician or the amount payable for the service will be adjusted to a lesser assessment fee.
A111 is the specific complex re-assessment code for Critical Care Medicine (11).
Eligible for Special Visit Premiums (e.g., Travel and First Person Seen) when the criteria for a special visit are met (non-elective, travel required, etc.).
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