C243 – Specific assessment
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
C243 is a specific assessment for the specialty of Otolaryngology (specialty 24) rendered to a non-emergency in-patient of an acute care hospital, as indicated by the 'C' prefix ().
As defined in the Schedule on page , a specific assessment requires a full history of the presenting complaint and a detailed examination of the affected part(s), region(s), or system(s) necessary to make a diagnosis, exclude disease, and/or assess function.
This service includes all the specific elements of assessments outlined on page , which encompass:
- A direct physical encounter with the patient, including history and examination.
- Performing procedures during the same encounter unless separately payable.
- Arranging for related assessments, procedures, or therapy.
- Arranging for follow-up care.
- Discussing findings and providing advice to the patient or their representative.
- Monitoring the patient's condition as medically indicated.
When to Use
- Use C243 for a non-emergency, subsequent in-patient follow-up visit where a detailed examination of the ENT system is required to monitor progress or adjust a treatment plan.
- Use C243 when performing a specific assessment on an in-patient who has already been seen by the specialist for the current admission, provided it does not meet the criteria for a consultation (C245) or supportive care (C248).
Common Pitfalls
- Billing C243 when the service provided is actually supportive care (C248); C243 requires a detailed examination and active management, whereas C248 is for routine monitoring.
- Attempting to bill a procedure code separately when it is considered an 'included' element of the C243 assessment under the General Preamble GP15 rules.
- Submitting C243 for an emergency in-patient visit; emergency visits must be billed using the 'A' prefix codes combined with the appropriate special visit premium.
Billing Tips
- If you are attending the patient for an emergency, switch to an 'A' prefix code (e.g., A243) to allow for the attachment of special visit premiums that are not compatible with 'C' prefix codes.
- Ensure the medical record clearly differentiates the C243 assessment from routine daily rounds; the documentation must reflect a specific, detailed examination of the ENT system to justify the specific assessment fee.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Hospital and Institutional Consultations and Assessments
All insured services must be documented in the patient's medical record to establish that the service was provided, was medically necessary, and is the service for which the account is submitted.
The medical record for a specific assessment 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.
See General Preamble to for Non-Emergency Hospital In-Patient Services.
For emergency calls and other special visits to in-patients, use General Listings and Premiums when applicable - see General Preamble to .
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