C094 – Specific re-assessment
OHIP Surgical Procedures Code — CARDIAC SURGERY (09) · Schedule of Benefits
A service rendered by a specialist (Cardiac Surgery) in a hospital in-patient setting, requiring a full, relevant history and physical examination of one or more systems. This code is typically used for admission assessments when the physician has previously assessed the patient for the same illness within 90 days.
When to Use
- Use C094 for an admission assessment when you have already provided a consultation or assessment for the same cardiac condition within the preceding 90 days.
- Use C094 when performing the major pre-operative assessment for a patient you have previously evaluated for the same surgical indication within the 90-day window.
Common Pitfalls
- Billing C093 instead of C094 when a previous assessment for the same illness exists within 90 days will trigger a rejection or audit recovery.
- Attempting to bill C094 in addition to a consultation code (C095/C096) for the same admission is prohibited, as only one assessment code is payable per admission.
- Billing C094 for an elective surgery patient when a pre-operative assessment was already performed by you within 30 days of the admission date violates the same-day and pre-op restriction rules.
Billing Tips
- Always append the E082 premium to C094 if you are acting as the Most Responsible Physician (MRP) for the admission to increase the claim value by 30%.
- Ensure your clinical notes explicitly document the 'full, relevant history and physical' to satisfy the specific requirements of C094, distinguishing it from a routine subsequent visit.
Effective: June 1, 2025
A. Consultations and Visits
CARDIAC SURGERY (09)
Hospital In-Patient
Assessment
Full, relevant history
Physical examination of one or more systems
Admission assessments are deemed to be a specific re-assessment (C094) if the physician has previously assessed the patient for the same presenting illness within 90 days of the admission assessment.
Admission assessment by the surgeon is not eligible for payment unless it is the major preoperative visit.
If a specialist assesses a patient in the ED/OPD and subsequently admits them, that initial assessment constitutes the admission assessment.
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