A161 – 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 (a full, relevant history and physical examination of one or more systems).
When to Use
- Bill A161 when managing a patient with a rare autoimmune disorder requiring a detailed review of multiple organ systems and a complex management plan.
- Use A161 for a patient with a newly diagnosed, aggressive malignancy where a thorough history, physical exam, and discussion of complex treatment options are necessary.
- A161 is appropriate for a patient with a severe, undiagnosed neurological condition presenting with a constellation of obscure symptoms requiring extensive system review.
Common Pitfalls
- Billing A161 when a simpler assessment code like A164 (Medical specific re-assessment) would suffice, leading to potential audits.
- Failure to submit a written report of findings and recommendations to the patient's primary care physician will result in the fee being adjusted to a lesser assessment fee.
- Exceeding the limit of 4 combined A161 and A163 (Medical specific assessment) claims per patient per physician within a 12-month period.
Billing Tips
- Ensure the written report to the primary care physician clearly outlines the complexity of the patient's condition and the rationale for the re-assessment.
- If the patient is within three years post-renal transplant and meets E060 criteria, bill A161 with the E060 premium, ensuring the diagnosis code reflects transplant status.
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 findings, opinions, or recommendations in writing to the patient’s primary care physician.
Failure to provide the written report will result in the fee being adjusted to a lesser assessment fee.
The 'Complex' designation is based on the complexity, obscurity, or seriousness of the patient's condition.
The fee for A161 is $83.40 (Specialist fee).
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