C173 – Specific assessment
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A specific assessment rendered by a specialist for a non-emergency hospital in-patient. Definition As per , a specific assessment is a service rendered by a specialist, in a place other than a patient's home, and requires a full history of the presenting complaint and 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. Specific Elements of an Assessment As per , in addition to the common elements, all assessments include: - A direct physical encounter with the patient including history taking and physical examination. - Other inquiry to arrive at an opinion as to the nature of the patient's condition. - Performing any procedure(s) during the same encounter unless separately payable. - 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 to the patient or representative. - Monitoring the condition of the patient and intervening, when medically indicated, until the next insured service. - Providing premises, equipment, supplies, and personnel for the service elements, except for aspects performed in a hospital or nursing home.
When to Use
- Use C173 for a scheduled, non-emergency follow-up assessment of an existing hospital inpatient where a consultation (C003) is not required.
- Use C173 when performing a subsequent visit for a patient already under your care in a non-emergency hospital setting to assess progress or adjust a treatment plan.
- Use C173 for a specialist-level assessment of a patient transferred to a non-acute ward where the urgency does not meet the criteria for emergency 'A' prefix codes.
Common Pitfalls
- Billing C173 alongside a consultation (C003) for the same patient on the same day will result in the rejection of the assessment code.
- Attempting to bill C173 for emergency department visits or urgent 'special calls' to the hospital, which must be billed using 'A' prefix codes and applicable premiums.
- Exceeding the maximum number of allowed assessments per patient, which triggers an automatic payment adjustment to a lower fee code.
Billing Tips
- Ensure the documentation clearly reflects a 'detailed examination' of the specific system or region to satisfy the GP23 requirement, as generic progress notes often fail audit scrutiny.
- If the patient requires significant active monitoring immediately following the assessment, append K001 to the claim to capture the additional time spent beyond the standard assessment scope.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Assessments, Hospital and Institutional Consultations and Assessments
A full history of the presenting complaint and 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 must be documented in the patient's medical record.
This is a non-emergency hospital in-patient service. See to for rules on hospital and institutional services.
For emergency calls and other special visits to in-patients, use General Listings ('A' prefix codes) and Premiums when applicable. See to .
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