A164 – Medical specific re-assessment
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A medical specific re-assessment rendered by a specialist in Nephrology. As per page , a medical specific re-assessment is a service rendered by a specialist and requires a full, relevant history and physical examination of one or more systems. An admission assessment is deemed to be a medical specific re-assessment for those patients who have been assessed by a physician and subsequently admitted to the hospital for the same illness by the same physician.
When to Use
- Bill A164 when a Nephrology specialist performs a comprehensive re-assessment of a patient's renal condition, including a detailed history and physical examination of relevant systems, distinct from a routine follow-up.
- Use A164 for a specialist's initial assessment of a patient admitted to hospital for a condition the specialist has already evaluated, provided the specialist is the admitting physician.
- A164 is appropriate when a specialist performs a detailed re-assessment of a patient with complex nephrological issues, requiring a thorough review of multiple organ systems related to the kidney disease.
Common Pitfalls
- Billing A164 for a standard follow-up visit that does not involve a comprehensive history and physical examination of one or more systems, which could be billed as a K005 or K013 instead.
- Submitting A164 when the service is rendered by a non-specialist; this code is exclusively for specialists in Nephrology.
- Claiming A164 for an initial assessment of a patient not admitted to hospital by the same specialist, as this would fall under consultation codes like A001.
Billing Tips
- Ensure documentation clearly outlines the 'medical specific' nature of the re-assessment, detailing the history and physical exam components that justify this higher-level code over a standard visit.
- When billing the Chronic Disease Assessment Premium (K013) with A164, confirm the patient has a documented chronic disease from the approved list (GP26) and the assessment occurs in an office or hospital outpatient clinic setting.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Assessments
If the E060 Post Renal Transplant Assessment Premium is claimed, the purpose of the assessment (post-transplant care) and the patient's status (within the first three years of transplant) must be documented.
If claiming the Chronic Disease Assessment Premium, the patient's medical record must document the established diagnosis of a chronic disease from the approved list on page .
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