A163 – Medical specific assessment
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A medical specific assessment is a service rendered by a specialist in Nephrology (16) in a place other than a patient’s home. It requires a full history of the presenting complaint and a 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
- Use A163 for a new patient presenting with a chief complaint of unexplained edema and requiring a full history and detailed physical exam of the renal system to establish an initial diagnosis.
- Bill A163 when a patient with previously undiagnosed hypertension requires a comprehensive renal assessment, including history and examination, to rule out secondary causes.
- Employ A163 for a patient referred for evaluation of abnormal urinalysis findings, necessitating a detailed history and focused physical examination of the renal system.
Common Pitfalls
- Billing A163 when the patient has already received an A163 from the same physician within the last 12 months, unless the second assessment is for a clearly different diagnosis or at least 90 days have passed and it's a hospital admission assessment.
- Claiming A163 for a patient already assessed under A160 (Comprehensive nephrology consultation) within the same 12-month period, as the comprehensive consultation typically suffices for initial complex workups.
- Submitting A163 for an inpatient assessment; use C163 (Medical specific assessment - In-patient) instead for hospital-based services.
Billing Tips
- Ensure the assessment involves a detailed physical examination of the affected renal system, not just a review of previous records or a brief check-up.
- Remember that A163 is limited to one per patient per physician per 12 months, with specific exceptions for unrelated diagnoses or significant time intervals and hospital admissions.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Medical specific assessment
Assessment
The amount payable for assessments in excess of the 12-month limits will be adjusted to a lesser assessment fee.
A163 is not eligible for the Chronic Disease Assessment Premium as Nephrology (16) is not an eligible specialty for that premium.
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