C004 – General re-assessment
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A general re-assessment includes all the services listed for a general assessment, with the exception of the patient’s history, which need not include all the details already obtained in the original assessment. It is typically used as a hospital admission assessment when the physician has seen the patient for the same illness within the previous 90 days.
When to Use
- Use C004 for a hospital admission assessment when you have provided a general assessment (C003) or consultation (C005) for the same condition within the preceding 90 days.
- Use this code when admitting a patient from the ED or OPD if you have already established a clinical history for the patient within the 90-day window.
Common Pitfalls
- Billing C004 on the same day as a subsequent hospital visit (C122 or C123) will result in a rejection; the admission assessment is intended to cover all physician services for that calendar day.
- Attempting to bill C004 for a patient transfer within the same hospital facility is ineligible, as the initial admission assessment remains valid for the duration of the stay.
- Submitting C004 when the patient has not been formally admitted to an inpatient bed will lead to audit recovery, as this code is strictly restricted to hospital in-patient status.
Billing Tips
- Always verify if the patient is 65 or older to automatically append the 15% age premium, as this is frequently missed on admission billing.
- If performing an urgent, non-elective admission outside of routine rounds, ensure you attach the appropriate C960-C964 special visit premiums to maximize the claim value.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Hospital In-patient
Assessment
If a patient is transferred within the same hospital, an additional admission assessment is not eligible for payment.
Excess assessments beyond the 'one per admission' limit will be adjusted to a lesser fee.
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