A473 – Medical specific assessment
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A medical specific assessment is a service rendered by a specialist in respiratory disease (specialty 47) 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 A473 for the initial assessment of a patient presenting with new-onset shortness of breath requiring a detailed respiratory examination and history to establish a diagnosis, distinguishing it from a general consultation (A475).
- Use A473 when a specialist in respiratory disease evaluates a patient with a suspected new condition like interstitial lung disease, which requires a focused history and examination beyond a partial assessment (A478).
- A473 is appropriate for the first assessment of a patient with a new diagnosis of COPD, differentiating it from subsequent follow-up visits billed as A474 or A471.
Common Pitfalls
- Billing A473 for a follow-up visit when the patient's condition has been previously assessed; these should be billed as A474 or A471.
- Submitting A473 when the service is provided in a hospital inpatient setting, which requires C473 instead.
- Exceeding the one-per-physician-per-12-month limit without meeting the criteria for a second assessment (unrelated diagnosis or 90 days elapsed for hospital admission), leading to fee adjustment.
Billing Tips
- Ensure the documentation clearly supports a 'full history of the presenting complaint' and a 'detailed examination' specific to the respiratory system to justify A473 over a less comprehensive code.
- A473 can be billed with the E078 Chronic Disease Assessment Premium if the patient has a documented chronic respiratory disease and the assessment meets all E078 criteria, including being rendered in an office or out-patient clinic.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultations and Visits
Assessment
If the 12-month limit is exceeded, the fee is adjusted to a lesser assessment fee (e.g., partial assessment).
For services not listed in the Respiratory Disease section, refer to the Internal Medicine section.
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