W164 – General Re-Assessment of Patient in Nursing Home (As per the Nursing Homes Act)*
OHIP Neurology Code — Nephrology (16) · Schedule of Benefits
A general re-assessment of a patient in a non-emergency long-term care setting, such as a nursing home, as per the requirements of the Nursing Homes Act. According to , 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. As a 'W' prefix code, this service applies to patients in chronic care hospitals, convalescent hospitals, nursing homes, homes for the aged, and designated chronic or convalescent care beds in hospitals (as per ). It is intended for routine assessments and not for emergency calls or special visits, for which 'A' prefix codes and special visit premiums should be used.
When to Use
- Use W164 for a comprehensive periodic re-assessment of a nursing home patient that exceeds the scope of a routine follow-up visit.
- Apply this code when performing the mandatory periodic review required by the Nursing Homes Act that does not qualify for the monthly management fee W010.
Common Pitfalls
- Billing W164 in the same month as W010 will result in an automatic rejection, as the re-assessment is considered inclusive of the monthly management fee.
- Submitting more than two W164 claims per patient within a 12-month period triggers an automatic payment adjustment to a lower assessment fee rate.
- Attempting to claim W164 for an acute, episodic, or emergency visit is incorrect; these scenarios require 'A' prefix codes and appropriate special visit premiums.
Billing Tips
- Ensure your documentation clearly reflects the 'general re-assessment' criteria, specifically noting the review of current status and updated care plan, to justify the fee over a standard follow-up code.
Ready to bill this code?
SnapBill makes OHIP billing simple — auto-filled codes, validation, and batch submission.