C053 – Subsequent visits - Nursing home or home for the aged
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A medical specific assessment rendered by a specialist in Community Medicine for a non-emergency hospital in-patient. This service requires a full history of the presenting complaint and a detailed examination of the affected part(s), region(s), or system(s) needed to make a diagnosis, and/or exclude disease, and/or assess function. In addition to the common elements, all assessments include the following specific elements as per : - A direct physical encounter with the patient including taking a patient history and performing a physical examination. - 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. - 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. 'Procedure' in this context includes obtaining specimens, preparation of the patient, interpretation of results and, unless otherwise specified, all diagnostic (including laboratory) and therapeutic (including surgical) services. - Making arrangements for any related assessments, procedures or therapy, and/or interpreting results. - Making arrangements for follow-up care. - 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. - When medically indicated, monitoring the condition of the patient and intervening, until the next insured service is provided. - 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
- Use C053 for a comprehensive medical-specific assessment of a nursing home patient when the clinical complexity exceeds a standard follow-up visit but does not meet the criteria for a full consultation.
- Select C053 when performing a periodic medical-specific reassessment of a long-term care resident to adjust chronic disease management plans or address a new, distinct clinical issue.
Common Pitfalls
- Billing C053 in conjunction with a Special Visit Premium (Table IV) will result in a rejection; you must use the corresponding 'A' prefix assessment code from the General Listings for these encounters.
- Exceeding the combined limit of 4 assessments (C051/C053) per patient per physician per 12 months will trigger an automatic payment adjustment to a lower fee schedule.
- Attempting to bill C053 more than twice in a 12-month period without documenting a distinct, unrelated diagnosis or ensuring the 90-day interval for hospital admission assessments is met will lead to claim rejection.
Billing Tips
- Ensure your documentation clearly distinguishes the C053 assessment from routine follow-up visits by highlighting the 'medical specific' nature of the examination and the complexity of the decision-making involved.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Assessments, Hospital and Institutional Consultations and 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.
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