A511 – Complex physiatry assessment
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
This service is an assessment in relation to traumatic brain injury, stroke (hemorrhagic and ischemic), or spinal cord injury where the complexity of the condition requires the ongoing management by a physical medicine and rehabilitation specialist.
When to Use
- Bill A511 for a patient with a recent CVA requiring detailed assessment of new spasticity and functional deficits, distinct from a general neurological assessment (A007).
- Use A511 when managing a patient with a high spinal cord injury (e.g., ASIA A or B) experiencing autonomic dysreflexia and requiring a comprehensive review of their neurological status and management plan.
- A511 is appropriate for a patient with a moderate traumatic brain injury who is exhibiting significant cognitive and motor impairments, necessitating a specialized physiatric re-assessment beyond a standard medical re-assessment (A310).
Common Pitfalls
- Billing A511 for uncomplicated conditions like a mild concussion or a patient with normal motor and sensory function post-spinal cord injury (e.g., ASIA E) will lead to claim rejection or adjustment.
- Exceeding the limit of 6 A511 services per patient per physician within a 12-month period will result in the excess claims being adjusted to a lesser assessment fee.
- Billing A511 on the same day as E078 (Physiatry assessment) is not permitted and will result in the E078 claim being ineligible for payment.
Billing Tips
- When billing A511 for virtual care, ensure the 'A' suffix is appended (A511A) to indicate the service was provided remotely in an office or out-patient setting.
- For hospital in-patients requiring this service, use C511, and for long-term care patients, use W511, to ensure correct facility-specific billing.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Specialist Assessment
Assessment
Must include the elements of a medical specific re-assessment (full, relevant history and physical examination of one or more systems).
If the elements of a medical specific re-assessment are not met, the fee will be adjusted to a lesser assessment fee.
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