C474 – Medical specific re-assessment
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A medical specific re-assessment is a service rendered by a specialist for a hospital in-patient. As defined in the Schedule of Benefits, it requires a full, relevant history and physical examination of one or more systems. The 'C' prefix designates this service for non-emergency hospital in-patients. This service may also be billed as an admission assessment for a patient who has been assessed by the physician for the same illness within the previous 90 days (see ).
When to Use
- Use C474 when you are the attending specialist performing a subsequent assessment on an inpatient for the same illness within 90 days of your previous assessment.
- Use C474 as the admission assessment code when you have already assessed the patient for the same illness in your office or clinic within the 90-day window prior to hospital admission.
- Use C474 for a comprehensive re-assessment of a patient's condition when a full history and physical examination of one or more systems is required during an inpatient stay.
Common Pitfalls
- Billing C474 more than twice in a 12-month period will trigger an automatic payment adjustment to a lower assessment fee, as per the Schedule of Benefits.
- Attempting to bill a special visit premium (e.g., K963) with C474 will result in rejection; you must use an 'A' prefix code if you intend to claim a special visit premium.
- Confusing C474 with C473; C474 is specifically for a medical re-assessment, whereas C473 is the code for a general inpatient assessment.
Billing Tips
- If the patient is in the ICU or CCU, you can add C101 to your C474 claim to receive the additional premium for the intensive care setting.
- Ensure your documentation clearly reflects a full, relevant history and physical examination, as this is the mandatory threshold for the C474 fee.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Hospital and Institutional Consultations and Assessments
See to . For emergency calls and other special visits to in-patients, use General Listings and Premiums when applicable - see General Preamble to .
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