C163 – Nephrology medical specific assessment
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A medical specific assessment rendered by a Nephrology specialist 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. As defined on page , in addition to the common elements, all services which are described as assessments include the following specific elements: - 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. - 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. - 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. - When medically indicated, monitoring the condition of the patient and intervening, until the next insured service is provided.
When to Use
- Use C163 for a non-emergency, scheduled follow-up assessment of an admitted nephrology patient when the patient's condition requires a comprehensive review of systems and physical exam.
- Use C163 when performing a medical specific assessment for a patient transferred to your service from another department where a formal consultation (C162) has already been completed by your group.
- Use C163 for routine inpatient management where the complexity of the renal condition exceeds the scope of a simple subsequent visit (C164).
Common Pitfalls
- Billing C163 more than 4 times per patient per 12-month period will trigger an automatic payment adjustment to a lower-valued assessment fee.
- Attempting to bill C163 for emergency inpatient visits; these must be billed using 'A' prefix codes with applicable Special Visit Premiums.
- Failing to distinguish C163 from C164 (subsequent visit); C163 requires a detailed examination and full history of the presenting complaint, whereas C164 is for routine daily monitoring.
Billing Tips
- If the patient is located in an ICU or CCU, ensure you append the C101 premium to the C163 claim to capture the additional value for the intensive care setting.
- Monitor your annual volume of C163 and C165 claims per patient to avoid exceeding the 4-service annual limit, which triggers automatic fee reductions.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Assessments, Hospital and Institutional Consultations and Assessments
In addition to common medical record requirements (see ), the record must include 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 as per .
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