A413 – Medical Specific Assessment
OHIP General Listings Code — Gastroenterology (41) · Schedule of Benefits
A medical specific assessment is a service rendered by a specialist in a place other than a patient’s home. It requires 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, exclude disease, and/or assess function.
When to Use
- Bill A413 for a new patient presenting with undiagnosed abdominal pain requiring a detailed history and physical examination to differentiate between conditions like Crohn's disease (diagnostic code 555) or ulcerative colitis (diagnostic code 556).
- Use A413 when a gastroenterologist performs a comprehensive assessment for a patient with suspected celiac disease (diagnostic code 263), including a focused history and examination of gastrointestinal symptoms and nutritional status.
- A413 is appropriate for a specialist assessment of a patient with chronic liver cirrhosis (diagnostic code 571) to evaluate disease progression and management needs, distinct from a routine follow-up.
Common Pitfalls
- Billing A413 more than once per patient per 12 months without meeting the criteria for a second assessment (unrelated diagnosis or hospital admission >90 days later) will result in claim adjustment.
- Submitting A413 for a service performed in the patient's home is incorrect; A413 is defined as a service rendered in a place other than the patient's home.
- Failure to include a full history and detailed examination of the affected system in the documentation can lead to claim rejection or audit findings, as these are explicit requirements for A413.
Billing Tips
- Consider billing the Gastroenterology chronic disease assessment premium (E098) in addition to A413 if the patient has an established diagnosis of Crohn's disease, ulcerative colitis, malnutrition, celiac disease, or chronic liver cirrhosis and the service is rendered in an office or outpatient clinic setting.
- Ensure the claim includes one of the specified diagnostic codes (263, 555, 556, 571, or 579) to support the medical necessity of the A413 assessment.
Effective: June 1, 2025
Consultations and Visits
Gastroenterology (41)
Consultations and Visits
Assessment
Requires a full history of the presenting complaint.
Requires a detailed examination of the affected part(s), region(s), or system(s) needed to make a diagnosis, exclude disease, and/or assess function.
Must be rendered in a place other than a patient’s home.
Claims in excess of the 12-month limits will be adjusted to a lesser assessment fee.
Eligible for Special Visit Premiums in the Emergency Department (Table I), Out-Patient Department (Table II), and Office (Table VIII) if criteria for non-elective travel/sacrifice of office hours are met.
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