A601 – 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 A601 when a patient presents with a new, complex neurological condition requiring a detailed history and physical examination of the neurological system, and a written report is sent to the primary care physician.
- Bill A601 for a patient with a previously diagnosed but poorly controlled autoimmune disorder that has acutely worsened, necessitating a comprehensive re-evaluation of multiple systems and a report to the referring physician.
- A601 is appropriate for a patient with a serious, undiagnosed cardiac issue that requires a thorough cardiac history and physical, and a detailed written opinion to the primary care physician.
Common Pitfalls
- Billing A601 when a simpler assessment code like A007 (General Assessment) or A604 (Medical Specific Re-assessment) would suffice, as A601 requires a higher threshold of complexity, obscurity, or seriousness.
- Failing to submit a written report of findings, opinions, or recommendations to the patient's primary care physician will result in the fee being adjusted to a lesser assessment fee, potentially leading to underpayment.
- Submitting A601 on the same day as another assessment code (e.g., A603, A604) by the same physician is not permitted and will lead to rejection of one of the claims.
Billing Tips
- Ensure the patient's condition truly meets the criteria of complexity, obscurity, or seriousness; document the specific factors that elevate the assessment beyond a standard re-assessment (A604).
- When applicable, append the E088 (Congestive Heart Failure Premium) to A601 if the patient has a documented diagnosis of CHF and the assessment is performed in an office or hospital outpatient clinic setting (not ED or inpatient).
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultations and Visits
Assessment
Requires 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.
The service must be necessitated by the complexity, obscurity, or seriousness of the patient's condition.
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