A256 – Special ophthalmologic assessment
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A Special Optometrist-Requested Assessment is an assessment in which the ophthalmologist provides all the elements of an Optometrist-Requested Assessment (A253) and spends a minimum of 50 minutes in direct contact with the patient, exclusive of time spent rendering any other separately billable intervention to the patient.
When to Use
- Bill A256 when an optometrist requests an assessment for a complex condition like advanced glaucoma requiring extensive discussion and patient education, exceeding the scope of a standard A253.
- Use A256 for suspected retinal detachment or macular degeneration where the optometrist needs a detailed, prolonged ophthalmologic evaluation beyond a routine consult.
- A256 is appropriate when a patient presents with a rare or obscure ocular condition, necessitating a comprehensive 50+ minute assessment by the ophthalmologist as requested by the optometrist.
Common Pitfalls
- Billing A256 without a written request from the optometrist on file will result in a reduced payment, as per submission instructions.
- Failing to document the start and stop times of direct patient contact in the chart can lead to audit issues, as the 50-minute minimum is a strict requirement.
- Submitting A256 when the patient encounter was less than 50 minutes of direct contact, or included significant time for other billable procedures, will lead to rejection or clawback.
Billing Tips
- Ensure the written report is sent to both the referring optometrist and the patient's PCP/NP to avoid payment adjustments.
- Verify that the optometrist's request specifies a complex, obscure, or serious nature for the patient's problem to justify the A256 assessment.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultations and Visits
Assessment
The ophthalmologist must submit findings, opinions, and recommendations in writing to both the requesting optometrist and the patient’s primary care physician or nurse practitioner (if applicable).
Urgent or emergency requests may be initiated verbally but must be documented in writing.
The written request from the optometrist must be retained in the patient's permanent medical record.
Start and stop times of the service must be recorded in the patient's permanent medical record.
The calculation of time for A256 excludes time devoted to any other service or procedure for which an amount is payable in addition to the assessment.
The calculation of time excludes non-patient-facing time (e.g., reviewing charts, imaging, or documentation).
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