A480 – Complex rheumatology assessment
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A complex rheumatology assessment is an assessment for the ongoing management of specific complex disorders of the musculoskeletal system where the complexity of the condition requires continuing management by a rheumatologist. It is not intended for the evaluation and/or management of uncomplicated rheumatologic disorders such as osteoarthritis, bursitis/tendonitis, or neck and back pain.
When to Use
- Bill A480 for the ongoing management of a patient with established polymyalgia rheumatica requiring regular rheumatologist follow-up.
- Use A480 for follow-up visits for patients with diagnosed inflammatory myopathies, where the complexity necessitates continued specialist care.
- A480 is appropriate for managing patients with systemic vasculitides, such as Wegener's granulomatosis, requiring ongoing rheumatologic intervention.
Common Pitfalls
- Billing A480 for initial evaluations; use A590 (Comprehensive rheumatology consultation) or an appropriate assessment code (e.g., A483) instead.
- Claiming A480 for uncomplicated conditions like osteoarthritis or bursitis, which are explicitly excluded by the code's description and patient restrictions.
- Failure to document a full, relevant history and physical examination of one or more systems will result in payment adjustment to A484.
Billing Tips
- Ensure the patient's diagnosis is one of the specified complex conditions (vasculitides, inflammatory myopathies, polymyalgia rheumatica, or paediatric vasculitides) to justify A480.
- Remember that A480 is limited to 6 claims per patient, per physician, per 12-month period; exceeding this limit will lead to payment adjustment.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Specialist Assessment
Assessment
Must include the elements of a medical specific re-assessment: a full, relevant history and physical examination of one or more systems.
Not for patients with uncomplicated disorders like osteoarthritis, bursitis, tendonitis, or neck/back pain.
Examples of systemic vasculitides include Churg-Strauss angiitis, polyarteritis nodosa, Wegener’s granulomatosis, Takayasu’s vasculitis, microscopic polyangiitis, and temporal arteritis.
If the service does not meet the requirements of a medical specific re-assessment, it will be adjusted to a lesser fee.
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