C461 – Complex medical specific re-assessment
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A complex medical specific re-assessment rendered by a specialist in Infectious Disease (46) for a non-emergency hospital in-patient. This service is a re-assessment of a patient because of the complexity, obscurity, or seriousness of the patient's condition and includes all the requirements of a medical specific re-assessment as outlined in the Schedule. The physician must report his/her findings, opinions, or recommendations in writing to the patient's primary care physician. If this report is not provided, the amount payable for the service will be adjusted to a lesser assessment fee.
When to Use
- Use C461 for a complex, non-emergency inpatient re-assessment by an Infectious Disease specialist when the patient's condition is obscure or serious enough to warrant a higher level of review than a standard A461 assessment.
- Use this code when performing a comprehensive re-evaluation of a complex infectious process that requires a formal written report to the primary care physician to justify the higher complexity fee.
Common Pitfalls
- Claiming C461 more than 4 times per patient per 12-month period will trigger an automatic adjustment to a lower assessment fee.
- Failing to send a formal written report to the primary care physician will result in the claim being downgraded to a standard assessment fee upon audit.
- Attempting to bill C461 for emergency visits; these must be billed using A461 combined with the appropriate Special Visit Premium.
Billing Tips
- Ensure your documentation clearly highlights the 'complexity, obscurity, or seriousness' of the case to defend the use of the complex code over the standard A461.
- If the patient is in the ICU or CCU, remember to append the C101 premium to the C461 claim to maximize the value of the inpatient visit.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Hospital and Institutional Consultations and Assessments, Assessments
The physician must report his/her findings, opinions, or recommendations in writing to the patient's primary care physician or the amount payable for the service will be adjusted to a lesser assessment fee.
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