C613 – Medical Specific Assessment
OHIP Surgical Procedures Code — Haematology (61) · Schedule of Benefits
A medical specific assessment rendered by a specialist for a non-emergency hospital in-patient. The 'C' prefix indicates the service is for an acute care hospital non-emergency in-patient, as defined in . As per , this service requires a full history of the presenting complaint and a detailed examination of the affected part(s), region(s), or system(s) needed to make a diagnosis, and/or exclude disease, and/or assess function. In addition to the common elements of all insured services (, ), all assessments include the following specific elements as per : - A direct physical encounter with the patient including history taking and physical examination. - Other inquiries to arrive at a medical opinion. - Performing any procedures not separately billable. - Making arrangements for related assessments, procedures, or therapy, and interpreting results. - Making arrangements for follow-up care. - Discussion and provision of advice to the patient or their representative. - Monitoring the patient's condition until the next insured service.
When to Use
- Use C613 for the initial hospital admission assessment of an inpatient when you have not seen the patient for the same illness within the previous 90 days.
- Use C613 for a subsequent hospital assessment when the patient presents with a new, clearly different diagnosis unrelated to the previous assessment within the same 12-month period.
- Use C613 for an inpatient assessment when you are the specialist of record and the service meets the criteria for a full history and detailed examination, provided no special visit premiums are claimed.
Common Pitfalls
- Billing C613 when the patient was seen for the same illness within the last 90 days; this must be billed as a C614 re-assessment.
- Attempting to claim C613 in conjunction with a special visit premium; if a premium is required, you must use the A-prefix equivalent (A613) instead.
- Exceeding the annual limit of 4 combined services for C613 and C611, which will trigger an automatic adjustment to a lower fee.
Billing Tips
- Ensure your documentation explicitly justifies the 'new diagnosis' if you are billing a second C613 within 12 months to avoid rejection based on the frequency limit.
- If you are the admitting physician, verify the patient's history for the last 90 days; if a prior assessment exists for the same condition, use C614 to prevent an automatic adjustment to a lower-paying code.
Effective: June 1, 2025
Consultations and Visits
Haematology (61)
Assessment
Hospital and Institutional Consultations and Assessments, Assessments
A full history of the presenting complaint and detailed examination of the affected part(s), region(s), or system(s) needed to make a diagnosis, and/or exclude disease, and/or assess function must be documented in the medical record.
For Services not listed, refer to Internal Medicine Section.
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