C611 – Complex medical specific re-assessment
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A complex medical specific re-assessment is a re-assessment of a patient by a specialist because of the complexity, obscurity, or seriousness of the patient's condition. It includes all the requirements of a medical specific re-assessment, which requires a full, relevant history and physical examination of one or more systems. The service is rendered to a hospital in-patient on a non-emergency basis. As an assessment, it includes the specific elements described in the General Preamble (), which include: a direct physical encounter, history-taking, physical examination, performing non-listed procedures, arranging related assessments or therapy, discussing findings and advice with the patient, and monitoring the patient's condition. The physician must report his/her findings, opinions, or recommendations in writing to the patient's primary care physician; otherwise, the amount payable for the service will be adjusted to a lesser assessment fee.
When to Use
- Use C611 for an inpatient re-assessment when the patient's condition has significantly deteriorated or become obscure, requiring a comprehensive review beyond a standard C614 subsequent visit.
- Select C611 when managing a patient with multi-system failure where the complexity of the clinical picture necessitates a full history and physical examination that exceeds the scope of a routine daily visit.
Common Pitfalls
- Failure to send a written report to the primary care physician will result in an automatic downgrade to a lower-paying assessment code.
- Exceeding the limit of four C611 or C614 services per patient per physician per 12-month period triggers an automatic payment adjustment to a lesser fee.
- Billing C611 for routine daily inpatient follow-ups that do not meet the documented criteria of 'complexity, obscurity, or seriousness' is a common audit trigger.
Billing Tips
- Ensure the medical record explicitly documents the specific clinical factors that make the re-assessment 'complex' or 'obscure' to justify the higher fee over a standard C614.
- Always link the C611 to a Special Visit Premium if the patient was seen outside of scheduled hospital rounds, provided the criteria for the premium are met.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Assessments, Hospital and Institutional Consultations and 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.
The medical record must document the complexity, obscurity, or seriousness of the patient's condition justifying the service.
As an assessment, this service includes the specific elements outlined in , including a direct physical encounter, history, examination, and development of an opinion.
For Services not listed, refer to Internal Medicine Section.
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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