A131 – 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. It includes all the requirements of a medical specific re-assessment, which 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.
When to Use
- Use A131 when a patient presents with a complex, obscure, or serious condition requiring a detailed history and physical examination of one or more systems, and a written report to the primary care physician is necessary.
- A131 is appropriate for re-evaluating a patient with a chronic, poorly controlled condition that has significantly changed or worsened, necessitating a comprehensive reassessment beyond a standard follow-up.
- Consider A131 when managing a patient with multiple comorbidities where the interplay of these conditions creates diagnostic or therapeutic complexity, requiring a specialized assessment.
Common Pitfalls
- Failure to submit a written report of findings, opinions, or recommendations to the patient's primary care physician will result in payment adjustment to a lesser assessment fee.
- Billing A131 more than 4 times per patient per physician within a 12-month period, or exceeding the combined total of 4 for A131 and A133 (medical specific re-assessment), will lead to payment adjustment.
- Using A131 for routine follow-up visits or for conditions that do not meet the criteria for complexity, obscurity, or seriousness can lead to claim rejection or audit.
Billing Tips
- Ensure the written report to the primary care physician clearly outlines the complexity of the patient's condition, the findings of the history and physical, and the physician's specific opinions or recommendations.
- When billing A131, be prepared to demonstrate through documentation that the assessment involved a full, relevant history and physical examination of one or more systems, justifying the 'complex' designation.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Assessments
The physician must report his/her findings, opinions, or recommendations in writing to the patient's primary care physician.
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