C164 – Medical specific re-assessment
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A medical specific re-assessment is a service rendered by a specialist to a non-emergency hospital in-patient. It requires a full, relevant history and physical examination of one or more systems, as defined in . It includes all the specific elements of an assessment listed in (e.g., history, physical examination, arranging follow-up) and the common elements of all insured services (-). This code is used for services provided in an acute care hospital for non-emergency in-patients (). This service may constitute a hospital admission assessment if the physician has previously assessed the patient for the same presenting illness within 90 days of the admission ().
When to Use
- Use C164 for a scheduled, non-emergency follow-up assessment of an existing hospital inpatient where a full history and physical examination of one or more systems is required.
- Use C164 as the admission assessment fee if you have already provided a consultation or assessment for the same presenting illness within the previous 90 days.
Common Pitfalls
- Billing C164 more than twice in a 12-month period per patient per physician will trigger an automatic payment adjustment to a lower assessment fee.
- Confusing C164 with C002 (Medical Specific Assessment); C164 is specifically for re-assessments, whereas C002 is for the initial hospital assessment of a patient.
Billing Tips
- Ensure your documentation explicitly includes the specific elements of a full history and physical exam to justify the C164 fee over a lower-valued subsequent visit code.
- If the patient is in the ICU or CCU, remember to append the C101 premium to the C164 claim to maximize the value of the visit.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Hospital and Institutional Consultations and Assessments, Assessments
Requires documentation of a full, relevant history and physical examination of one or more systems.
All insured services must be documented in the medical record to establish that the service was provided, was medically necessary, and matches the service claimed ().
The medical record must include all specific elements of an assessment as defined in .
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