A481 – Complex medical specific re-assessment
OHIP General Listings Code — CONSULTATIONS AND VISITS · 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
- Use A481 for a patient with a complex autoimmune condition like lupus or rheumatoid arthritis requiring ongoing management, where the physician performs a detailed history and physical exam of multiple systems.
- Bill A481 when a patient with a severe neurological disorder, such as advanced multiple sclerosis, needs a re-assessment due to new or worsening symptoms, necessitating a comprehensive review beyond a standard follow-up.
- A481 is appropriate for managing a patient with a complicated endocrine disorder, like poorly controlled diabetes with multiple complications, where a thorough re-assessment of affected systems is required.
Common Pitfalls
- Billing A481 for an initial patient assessment or for uncomplicated conditions like osteoarthritis or simple back pain, which should be billed under codes like A483 or A484.
- Failing to submit a written report of findings, opinions, or recommendations to the patient's primary care physician will result in the claim being adjusted to a lesser assessment fee.
- Exceeding the limit of 4 A481 claims per patient per physician within a 12-month period; subsequent claims will be adjusted to a lower fee code.
Billing Tips
- Ensure the patient's primary care physician receives a written report detailing the findings and recommendations to justify the A481 fee.
- Verify that the patient has a documented chronic disease to be eligible for the E078 chronic disease assessment premium when billing A481 in an office or approved out-patient clinic setting.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultations and Visits
Assessment
Must include all elements of a medical specific re-assessment: a full, relevant history and physical examination of one or more systems.
The physician must report findings, opinions, or recommendations in writing to the patient’s primary care physician.
A481 is intended for the ongoing management of complex disorders and is not for the initial evaluation of a patient.
If the usage limit of 4 per 12 months is exceeded, the fee is adjusted to a lesser assessment fee.
A481 is distinct from A480 (Complex rheumatology assessment), which is reserved for specific diseases like systemic vasculitides and has different limits and rules.
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