A411 – Complex Medical Specific Re-Assessment
OHIP General Listings Code — Gastroenterology (41) · 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. It includes all the requirements of a medical specific re-assessment (a full, relevant history and physical examination of one or more systems).
When to Use
- Bill A411 when a patient with known Crohn's disease (555) presents with a new, severe complication requiring a detailed re-evaluation and a written report to the PCP.
- Use A411 for a patient with advanced cirrhosis (571) who requires a complex re-assessment of their multi-system involvement, including a physical exam and written recommendations to the referring physician.
- A411 is appropriate for a patient with a severe, obscure malabsorption issue (579) that necessitates a thorough re-assessment beyond a standard visit, with formal documentation sent to the primary physician.
Common Pitfalls
- Failure to submit a written report to the patient's primary care physician will result in the claim being downgraded to A414.
- Billing A411 more than 4 times per patient per year, even when combined with A413, will lead to claims being adjusted to the lower fee code (A414).
- Submitting A411 without one of the specified diagnostic codes (263, 555, 556, 571, 579) will cause the claim to be rejected.
Billing Tips
- Ensure the written report to the primary care physician is comprehensive, detailing findings, opinions, and recommendations, to justify the A411 fee.
- When providing virtual care for A411, append the 'A' suffix to the billing code.
Effective: June 1, 2025
Consultations and Visits
Gastroenterology (41)
Consultations and Visits
Assessment
Physicians in hospital but not on duty in the emergency department when seeing patients in the emergency or OPD should use General Listings (A-prefix codes).
Gastroenterology (41) is NOT an eligible specialty for the Chronic Disease Assessment Premium (E078).
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