A243 – Specific assessment
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
Specific assessment and medical specific assessment are services rendered by specialists, in a place other than a patient’s home, and require a full history of the presenting complaint and 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
- Bill A243 for a specialist's detailed assessment of a new, complex dermatological condition requiring a full history and targeted examination, distinct from a general consultation (A245).
- Use A243 when a specialist performs a focused assessment on a specific neurological deficit, including a detailed history of the onset and progression and a thorough examination of the affected neurological system, differentiating it from a broader consultation.
- A243 is appropriate for a specialist's in-depth assessment of a specific orthopedic injury, involving a comprehensive history of the injury mechanism and a detailed examination of the affected joint or limb to determine diagnosis and treatment, rather than a general visit code.
Common Pitfalls
- Billing A243 for a patient encounter that primarily involves managing multiple, unrelated, minor complaints rather than a single, specific presenting complaint requiring detailed assessment.
- Submitting A243 when the documentation only supports a brief history and limited physical examination, which would be more appropriately billed as a partial assessment (A244).
- Receiving payment adjustments to A244 when the physician bills A243 more than twice in a 12-month period for the same patient without documenting a clearly different and unrelated second diagnosis.
Billing Tips
- Ensure documentation clearly outlines the specific presenting complaint, the detailed history obtained, and the targeted examination performed to justify the 'specific assessment' nature of A243.
- When a second, unrelated diagnosis necessitates another specific assessment within 12 months, explicitly document the second, unrelated diagnosis to support the second A243 claim.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultations and Visits
Assessment
Full history of the presenting complaint.
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.
Must be rendered in a place other than a patient’s home.
Ready to bill this code?
SnapBill makes OHIP billing simple — auto-filled codes, validation, and batch submission.