C263 – Medical specific assessment
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A medical specific assessment is a service rendered by a specialist to a non-emergency hospital in-patient. It 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. As a 'C' prefix code, this service is for non-emergency in-patient services in an acute care hospital. See the General Preamble for full requirements for assessments (, ).
When to Use
- Use C263 for a non-emergency, subsequent in-patient assessment when a full history and detailed examination are required for a specific clinical issue.
- Use C263 when the patient's condition necessitates a more comprehensive review than a standard subsequent visit (C661) but does not meet the criteria for a formal consultation (C264).
Common Pitfalls
- Billing C263 on the same day as psychotherapy or psychiatric care codes is a common rejection unless you document a distinct, unrelated diagnosis.
- Exceeding the maximum number of medical specific assessments per patient per year will trigger an automatic payment adjustment to a lower-valued assessment fee.
- Confusing C263 with A263; remember that 'C' codes are strictly for hospital in-patients, whereas 'A' codes are for office or emergency department settings.
Billing Tips
- If the patient meets the specific trauma criteria (ISS > 15 for adults or > 12 for pediatrics), ensure you append E420 to the C263 claim to capture the 50% premium.
- Ensure your documentation clearly distinguishes the C263 assessment from routine daily rounds (C661) by highlighting the specific diagnostic or functional assessment performed.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Hospital and Institutional Consultations and Assessments, Assessments
A direct physical encounter with the patient is required, including taking a patient history and performing a physical examination.
Must include a full history of the presenting complaint.
Must include 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.
The 'C' prefix indicates this service is for non-emergency hospital in-patient services.
For emergency calls and other special visits to in-patients, use General Listings ('A' prefix codes) and Premiums when applicable.
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