A486 – Complex rheumatology assessment
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A complex rheumatology assessment is for the ongoing management of complex disorders of the musculoskeletal system, where the complexity of the condition requires the continuing management by a rheumatologist. It is not intended for the evaluation and/or management of uncomplicated rheumatologic disorders (e.g. osteoarthritis, bursitis/tendonitis, neck and back pain).
When to Use
- Bill A486 for ongoing management of a patient with established systemic vasculitis, such as polyarteritis nodosa, requiring detailed assessment of multiple organ systems.
- Use A486 for continued care of a patient diagnosed with an inflammatory myopathy (e.g., polymyositis) where regular reassessments of muscle strength, function, and treatment efficacy are necessary.
- A486 is appropriate for managing pediatric patients with diagnosed vasculitis, necessitating specialized ongoing care and monitoring beyond a general assessment.
Common Pitfalls
- Claiming A486 for the initial evaluation of a patient with a new diagnosis of osteoarthritis or bursitis; these conditions are explicitly excluded.
- Billing A486 for a patient with uncomplicated neck or back pain, which should be billed under a general assessment code like A484 or A485.
- Exceeding the 6-visit per patient per physician limit within a 12-month period without justification, leading to payment adjustment.
Billing Tips
- Ensure your documentation clearly details the 'elements of a medical specific re-assessment,' including a full, relevant history and physical examination of one or more systems, to support the A486 claim.
- A486 is for *ongoing* management of *complex* rheumatologic disorders; use A485 or A590 for initial consultations or evaluations of less complex cases.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultations and Visits
Assessment
Must include the elements of a medical specific re-assessment (full, relevant history and physical examination of one or more systems), or the amount payable will be adjusted to a lesser assessment fee.
Examples of systemic vasculitides include Churg-Strauss angiitis, polyarteritis nodosa, Wegener’s granulomatosis, Takayasu’s vasculitis, microscopic polyangiitis, and temporal arteritis.
A consultation or assessment service, as appropriate, may be claimed for the initial evaluation of a patient.
This service is not eligible for payment to a physician for the initial evaluation of the patient by that physician.
Ready to bill this code?
SnapBill makes OHIP billing simple — auto-filled codes, validation, and batch submission.