A181 – 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 medical specific re-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.
When to Use
- Bill A181 when a patient presents with a complex, obscure, or serious condition requiring a detailed history and physical examination of one or more systems, distinct from a routine re-assessment (K005).
- Use A181 for a follow-up assessment of a patient with a newly diagnosed, serious condition that requires significant physician input and detailed documentation, differentiating it from a simple follow-up visit (K005).
- A181 is appropriate when a patient's condition has significantly changed, presenting new complexities or seriousness that necessitate a comprehensive re-evaluation beyond what is covered by a standard re-assessment code.
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 A181 for conditions that do not meet the criteria for complexity, obscurity, or seriousness may lead to claims being adjusted or denied.
- Exceeding the combined usage limit for medical specific assessments (A180) and complex medical specific re-assessments (A181) without meeting specific criteria will result in payment adjustment.
Billing Tips
- Ensure the written report to the primary care physician clearly outlines the complexity of the patient's condition and the physician's specific findings, opinions, and recommendations.
- A181 can be billed with E078 (Chronic Disease Assessment Premium) if the physician has an eligible specialty and the patient has a qualifying chronic disease diagnosis, provided the service is rendered in an office or hospital out-patient setting.
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 or the amount payable for the service will be adjusted to a lesser assessment fee.
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