C313 – Subsequent visits - Nursing home or home for the aged
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A medical specific assessment for a non-emergency hospital in-patient, as indicated by the 'C' prefix. According to , this service is rendered by a specialist and requires a full history of the presenting complaint and a detailed examination of the affected part(s), region(s), or system(s) to make a diagnosis, exclude disease, or assess function. This service is listed under the Physical Medicine & Rehabilitation specialty.
When to Use
- Use C313 for a scheduled, non-emergency medical specific assessment of a patient admitted to a nursing home or home for the aged when you are acting as the attending specialist.
- Select C313 when performing a detailed examination and history for a patient requiring a formal assessment of a specific system or region, distinct from routine supportive care.
Common Pitfalls
- Billing C313 when the patient is in an acute care hospital rather than a nursing home or home for the aged, which will trigger a rejection as the code is facility-specific.
- Exceeding the 4-visit annual limit for combined medical specific assessments and re-assessments, which results in an automatic downward adjustment to a lower-valued assessment fee.
- Failing to account for the 90-day rule when performing a hospital admission assessment, which may cause the claim to be downgraded to a re-assessment code like C314.
Billing Tips
- Ensure your documentation explicitly reflects a full history and detailed examination of the affected systems to satisfy the 'medical specific' requirement, as this is the primary target for OHIP audits.
- If you have already billed a consultation or assessment for the same patient within the last 90 days for the same illness, bill C314 instead to avoid automatic payment adjustments.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Hospital and Institutional Consultations and Assessments, Assessments
In addition to the common elements of an insured service, a medical specific assessment requires documentation of a direct physical encounter with the patient, including a full history of the presenting complaint and a detailed examination of the affected part(s), region(s), or system(s).
The medical record must establish that an insured service was provided, the service for which the account is submitted is the service that was rendered, and the service was medically necessary.
The 'C' prefix indicates a non-emergency hospital in-patient service. See to for rules on non-emergency hospital in-patient services.
For emergency calls and other special visits to in-patients that require a premium, use the corresponding General Listings ('A' prefix) code. See .
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