A604 – Medical specific re-assessment
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A medical specific re-assessment is a service rendered by a specialist and requires a full, relevant history and physical examination of one or more systems. In addition to the common elements, all services which are described as assessments, or as including assessments (e.g. consultations), include the following specific elements (as described in : A. A direct physical encounter with the patient including taking a patient history and performing a physical examination. B. Other inquiry (including taking a patient history), carried out to arrive at an opinion as to the nature of the patient's condition, (whether such inquiry takes place before, during or after the encounter during which the physical examination takes place) and/or follow-up care. C. Performing any procedure(s) during the same encounter as the physical examination, unless the procedure(s) is(are) separately listed in the Schedule and an amount is payable for the procedure in conjunction with an assessment. D. Making arrangements for any related assessments, procedures or therapy, and/or interpreting results. E. Making arrangements for follow-up care. F. Discussion with, and providing advice and information, including prescribing therapy to the patient or the patient's representative, whether by telephone or otherwise, on matters related to the service and results of related procedures. G. When medically indicated, monitoring the condition of the patient and intervening, until the next insured service is provided. H. Providing premises, equipment, supplies, and personnel for the specific elements of the service except for any aspect(s) that is (are) performed in a hospital or nursing home.
When to Use
- Bill A604 when a specialist performs a focused history and physical examination on a patient with a new or worsening condition, distinct from a general assessment (A007) or a complete consultation (A005).
- Use A604 for a specialist's follow-up assessment of a specific system or condition, where a detailed history and physical examination relevant to that condition are performed, differentiating it from a simple follow-up visit (A003).
- A604 is appropriate when a specialist evaluates a patient for a specific problem requiring a relevant history and physical, even if the patient has other unrelated medical issues.
Common Pitfalls
- Billing A604 when the service provided was a general assessment (A007) or a complete consultation (A005), as A604 requires a focused, system-specific examination.
- Submitting A604 for a brief follow-up visit where a comprehensive history and physical examination were not performed; consider A003 instead.
- Billing multiple A604 codes on the same day to the same patient; only one assessment-type service is payable per day unless specific exceptions apply.
Billing Tips
- Ensure the documentation clearly outlines the specific system(s) examined and the relevant history obtained, justifying the 'medical specific' nature of the re-assessment.
- If a procedure is performed during the same encounter as A604, ensure the procedure is not separately billable or that it meets the criteria for being included within the assessment.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Assessments
All insured services must be documented in appropriate records. The Act requires that the record establish that: 1. an insured service was provided; 2. the service for which the account is submitted is the service that was rendered; and 3. the service was medically necessary.
For services not listed, refer to Internal Medicine section
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