C264 – Medical specific re-assessment - Paediatrics
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A medical specific re-assessment is a service rendered by a Paediatrics specialist (26) for a non-emergency hospital in-patient. It requires a full, relevant history and physical examination of one or more systems. The patient's history need not include all the details already obtained in the original assessment. See for the general definition. This service is used for follow-up care in a hospital setting and is subject to the rules for non-emergency hospital in-patient services outlined in to .
When to Use
- Use C264 for the daily follow-up of a hospitalized paediatric patient where a focused physical exam and history are required to manage an active medical issue.
- Use C264 when transitioning a patient from a higher level of care to a general ward status where a comprehensive re-assessment is necessary to establish a new management plan.
Common Pitfalls
- Billing C264 when only a brief 'check-in' or nursing update occurs; this code requires a documented physical examination of at least one system.
- Attempting to bill a special visit premium with C264; premiums are only payable with 'A' prefix codes, so you must use A264 if you are called in for an urgent assessment.
Billing Tips
- Ensure your documentation explicitly notes the physical exam findings for the system(s) assessed to justify the 're-assessment' status over a lower-level supportive care code.
- If you are managing a patient in the ICU, remember to add C101 to your C264 claim to capture the additional premium for the intensive care setting.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Hospital and Institutional Consultations and Assessments
Requires documentation of a full, relevant history and physical examination of one or more systems in the patient's medical record. (Source: ).
All insured services require documentation in the medical record to establish that the service was provided, medically necessary, and is the service for which the account is submitted. (Source: ).
All insured services include keeping and maintaining appropriate medical records as a common element. (Source: ).
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