W004 – General re-assessment of patient in nursing home
OHIP Neurology Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A general re-assessment rendered to a patient in a long-term care institution (chronic care hospitals, convalescent hospitals, nursing homes, homes for the aged, etc.), identified by the 'W' prefix as per . Definition/Required elements of service: As defined in , a general re-assessment includes all the services listed for a general assessment, with the exception of the patient's history, which need not include all the details already obtained in the original assessment. A general assessment requires a full history (presenting complaint, family, past, social history, and a functional inquiry into all body parts and systems) and an examination of all body parts and systems, except where not medically indicated or refused (). This service also includes the specific elements of assessments outlined in , such as a direct physical encounter, making arrangements for related care, and providing advice to the patient. This service is a component of the monthly management fee W010 and is not separately payable in a month where W010 is billed ().
When to Use
- Use W004 for a comprehensive periodic review of a nursing home patient when you are not billing the monthly management fee W010 for that specific month.
- Use W004 when performing a significant, scheduled re-evaluation of a patient's chronic conditions that exceeds the scope of a routine follow-up visit (W109).
Common Pitfalls
- Billing W004 in the same calendar month as W010 will result in an automatic rejection, as the Ministry considers W004 a component of the monthly management fee.
- Exceeding the limit of two W004 claims per 12-month period per patient will trigger a payment adjustment to a lower assessment fee unless the service is linked to a hospital admission.
- Failing to document a physical examination of all relevant body systems, which is a mandatory requirement for a 'general' assessment/re-assessment code.
Billing Tips
- Always append the age premium (K081/K082 equivalent logic) if the patient is 65 or older to receive the mandatory 15% increase on the W004 fee.
- If you are managing a patient's chronic care monthly, ensure you are billing W010 instead of W004 to avoid administrative rejections and ensure proper compensation for the management service.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Hospital and Institutional Consultations and Assessments, Assessments
A direct physical encounter with the patient including taking a patient history and performing a physical examination ().
A general re-assessment includes all the services listed for a general assessment, with the exception of the patient’s history, which need not include all the details already obtained in the original assessment ().
Included as a component service of W010 - Monthly Management of a Nursing Home or Home for the Aged Patient.
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