A263 – Medical specific assessment
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A service rendered by a specialist in Paediatrics requiring 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 A263 for a detailed assessment of a specific pediatric condition, such as a new diagnosis of asthma, requiring a focused history and physical exam, distinct from a general assessment (A007).
- Bill A263 when a specialist performs a comprehensive evaluation of a specific pediatric neurological issue, like suspected epilepsy, necessitating a detailed neurological exam and history, differentiating it from a general consultation (A001).
- A263 is appropriate for assessing a specific pediatric orthopedic problem, such as a complex fracture follow-up requiring a detailed musculoskeletal examination and functional assessment, rather than a simple follow-up visit (A003).
Common Pitfalls
- Billing A263 more than once in 12 months for the same patient and condition without meeting the criteria for a second assessment (e.g., unrelated diagnosis or 90-day gap with hospital admission) will lead to claim rejection or adjustment.
- Submitting A263 for a patient over 18 years of age without clear justification based on the specialist nature of the assessment can lead to audit scrutiny, as it's typically for pediatric patients.
- Failure to document the detailed history and examination findings specific to the presenting complaint in the patient's chart can result in claim audits if the service is questioned.
Billing Tips
- When a second A263 is billed within 12 months due to a clearly different, unrelated diagnosis, ensure the new diagnosis code reflects this distinct condition to support the claim.
- If A263 is performed as a special visit, remember to add the appropriate K-code premium (K960-K999) and document the time of the visit to justify the premium.
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)
Direct physical encounter (unless virtual suffix A is used)
Discussion and advice to the patient or representative
A263 is not eligible for the age-based percentage premiums (which apply to consultations, not assessments).
Excess services beyond the 12-month limit are adjusted to a lesser assessment fee.
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