A425 – Comprehensive Physical Medicine and Rehabilitation Consultation
OHIP General Listings Code — Physical Medicine & Rehabilitation (31) · Schedule of Benefits
A comprehensive physical medicine and rehabilitation consultation is a consultation in which the physician provides all the elements of a consultation and spends a minimum of 75 minutes in direct contact with the patient, exclusive of time spent rendering any other separately billable intervention to the patient.
When to Use
- Bill A425 when a patient requires a complex assessment for rehabilitation needs following a major trauma, and the physician spends at least 75 minutes directly with the patient discussing their functional limitations and developing a comprehensive management plan.
- Use A425 for an initial assessment of a patient with a newly diagnosed neurological condition impacting mobility, where the physician conducts an in-depth history, performs a detailed physical examination, reviews all prior investigations, and spends over 75 minutes formulating a rehabilitation strategy.
- A425 is appropriate for a patient referred for evaluation of chronic, severe musculoskeletal pain unresponsive to standard treatments, necessitating a prolonged, detailed assessment to identify underlying causes and guide specialized interventions.
Common Pitfalls
- Billing A425 when the total direct patient contact time is less than 75 minutes will result in payment being reduced to a lesser assessment fee, as per submission instructions.
- Failure to document the start and stop times of the patient encounter in the medical record can lead to payment reduction, even if the 75-minute duration was met.
- Not sending a comprehensive written report with findings, opinions, and recommendations to the referring provider can invalidate the A425 claim and lead to rejection or recoupment.
Billing Tips
- Ensure the written request for consultation is retained in the patient's chart, clearly identifying the referring provider, patient, and the reason for referral, unless common medical records are maintained.
- A425 can be billed in conjunction with the E078 Chronic Disease Assessment Premium if the patient has a documented chronic disease and the assessment is performed in an eligible setting (e.g., office).
Effective: June 1, 2025
Consultations and Visits
Physical Medicine & Rehabilitation (31)
Consultations and Visits
Consultation
The physician must provide all elements of a consultation (history, examination, review of relevant data).
Minimum of 75 minutes in direct contact with the patient.
The start and stop time must be recorded in the patient’s permanent medical record.
A written report (including findings, opinions, and recommendations) must be prepared and sent to the referring provider.
A copy of the written request for the consultation, signed by the referring physician, nurse practitioner or dental surgeon must be kept in the consulting physician’s medical record, except in the case of a consultation which occurs in a hospital, long-term care institution or multi-specialty clinic where common medical records are maintained. In such cases, the written request may be contained on the common medical record.
The request identifies the consultant by name and/or the specialty being consulted, the referring physician, nurse practitioner or dental surgeon by name and billing number, and identifies the patient by name and health number.
The written request sets out the information relevant to the referral and specifies the service(s) required.
Calculation of time excludes non-patient-facing time such as time spent reviewing charts, imaging, or documentation.
If consultation requirements are not met, the amount payable will be reduced to a lesser assessment fee.
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