C161 – Complex medical specific re-assessment
OHIP Surgical Procedures 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, which requires a full, relevant history and physical examination of one or more systems.
When to Use
- Use C161 when managing a hospitalized patient with a multi-system failure or diagnostic obscurity that requires a comprehensive re-evaluation beyond the scope of a standard C164 re-assessment.
- Select C161 when the patient's clinical status has significantly deteriorated, necessitating a full history and physical examination to adjust a complex treatment plan that was previously established.
Common Pitfalls
- Billing C161 more than 4 times in a 12-month period will trigger an automatic adjustment to a lower-valued assessment code, as it shares the limit with C163.
- Failure to send a formal written report to the referring primary care physician will result in the claim being downgraded to a lower assessment fee during an audit or manual review.
- Attempting to add Special Visit Premiums to C161 is a common error; these premiums are strictly prohibited for all C-prefix hospital in-patient codes.
Billing Tips
- Ensure your documentation explicitly highlights the 'complexity' or 'obscurity' of the case to justify the C161 fee over the standard C164 re-assessment.
- Track your annual count of C161 and C163 services closely to avoid exceeding the 4-service threshold, which automatically triggers a fee reduction.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Hospital In-patient
Assessment
The physician must report his/her findings, opinions, or recommendations in writing to the patient’s primary care physician.
Requires a full, relevant history and physical examination of one or more systems.
The amount payable for services in excess of the 12-month limit will be adjusted to a lesser assessment fee.
If the required written report to the primary care physician is not provided, the amount payable will be adjusted to a lesser assessment fee.
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