A264 – Medical specific re-assessment
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A medical specific re-assessment is a service rendered by a specialist in Paediatrics (26) that requires a full, relevant history and physical examination of one or more systems.
When to Use
- Use A264 for a specialist pediatrician performing a focused reassessment of a child's chronic condition, such as asthma exacerbation, requiring a detailed history and physical exam of the respiratory system.
- Bill A264 when a pediatric specialist re-evaluates a patient's complex neurological disorder, necessitating a targeted history and examination of the neurological system, distinct from a general assessment (A263).
- A264 is appropriate for a pediatric specialist reassessing a child's developmental delay after initial interventions, focusing on specific developmental domains with a relevant history and physical.
Common Pitfalls
- Billing A264 more than twice per patient per physician within 12 months, unless it's for a hospital admission assessment, will lead to claims being adjusted to a lesser assessment fee.
- Using A264 for a patient over 18 years old is incorrect, as this code is specifically listed under the Paediatrics (26) section and typically applies to patients under 18.
- Submitting A264 on the same day as another assessment code (e.g., A261, A262, A263) without meeting the specific criteria for separate billing will result in rejection.
Billing Tips
- When a patient is admitted to the hospital for the same illness they were recently assessed for by the same physician, A264 can be billed as an admission assessment, bypassing the usual frequency limits.
- Ensure documentation clearly outlines the specific system(s) examined and the relevant history obtained to justify the 'medical specific' nature of the reassessment, differentiating it from a general reassessment (A263).
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultations and Visits
Assessment
Requires a full, relevant history.
Requires a physical examination of one or more systems.
Admission assessments are deemed to be a specific re-assessment or medical specific re-assessment under either of the following circumstances: 1. for those procedures prefixed with a “Z” or noted as an IOP, by a surgical specialist who has assessed the patient prior to admission in respect of the same illness; or 2. for those patients who have been assessed by a physician and subsequently admitted to the hospital for the same illness by the same physician.
A264 is listed under the Paediatrics (26) section of the Schedule.
Ready to bill this code?
SnapBill makes OHIP billing simple — auto-filled codes, validation, and batch submission.