C416 – Repeat consultation
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A medical specific re-assessment is a service rendered by a specialist that requires a full, relevant history and physical examination of one or more systems. The 'C' prefix indicates this service is for a non-emergency in-patient in an acute care hospital, as defined on page of the Schedule of Benefits. As per page , an admission assessment can be deemed a medical specific re-assessment if a physician assesses a patient and subsequently admits them to the hospital for the same illness, or if a surgical specialist assesses the patient prior to admission for an In-Office Procedure (IOP) or 'Z'-prefix procedure. This service includes all the specific elements of an assessment and - common elements of all insured services.
When to Use
- Use C416 when you are the attending specialist performing a repeat assessment on an inpatient for a previously diagnosed condition that requires a new, comprehensive history and physical.
- Use C416 when you assess a patient in your office and subsequently admit them to the hospital for the same illness, provided the assessment meets the full requirements of a medical specific re-assessment.
- Use C416 for a surgical specialist who assesses a patient prior to admission for a 'Z'-prefix procedure or an In-Office Procedure (IOP) related to the same illness.
Common Pitfalls
- Billing C416 more than twice in a 12-month period for the same patient will trigger an automatic payment adjustment to a lower assessment fee unless the service is linked to a hospital admission.
- Submitting C416 for a routine follow-up visit that lacks a full, relevant history and physical examination of one or more systems will result in a rejection or audit recovery.
- Confusing C416 with a subsequent visit code (C016) when the clinical requirements for a full re-assessment have not been met.
Billing Tips
- Ensure your documentation explicitly records the full history and physical examination elements to justify the 'medical specific re-assessment' designation over a standard subsequent visit.
- Always link the C416 to the hospital admission date in your billing software to ensure the system recognizes the exemption from the two-per-year frequency limit.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Hospital and Institutional Consultations and Assessments, Assessments
All insured services must be documented in appropriate records that establish: 1. an insured service was provided; 2. the service for which the account is submitted is the service that was rendered; and 3. the service was medically necessary.
Specific re-assessment and medical specific re-assessment are services rendered by specialists and require a full, relevant history and physical examination of one or more systems.
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