W402 – Admission assessment - Type 1
OHIP Neurology Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A Type 1 admission assessment is a general assessment rendered to a patient on admission to a non-emergency long-term care setting (). Eligible Settings This service applies to patients in: - Chronic Care Hospitals - Convalescent Hospitals - Nursing Homes - Homes for the Aged - Designated chronic or convalescent care beds in hospitals - (Excludes patients in designated palliative care beds) As a general assessment, this service requires a full history (presenting complaint, family medical history, past medical history, social history, and functional inquiry of all body systems) and a comprehensive physical examination of all body systems, with exceptions for breast, genital, or rectal exams if not indicated or refused (). Payment Rules - If the physician has rendered a consultation, general assessment, or general re-assessment of the patient prior to admission, the amount payable for the service will be adjusted to a lesser fee (). - This admission assessment is considered a component of the Monthly Management of a Nursing Home or Home for the Aged Patient fee (W010) and is not separately payable if the Most Responsible Physician (MRP) claims W010 for that month (, ).
When to Use
- Use W402 when performing the initial comprehensive admission assessment for a patient newly admitted to a nursing home or chronic care facility.
- Use this code when you are the attending physician conducting the full history and physical required for facility admission, provided you are not the MRP claiming W010 for that month.
Common Pitfalls
- Claiming W402 in the same calendar month as W010 will result in a rejection or clawback, as the admission assessment is considered bundled into the monthly management fee.
- Billing W402 when the patient is in a designated palliative care bed, which is explicitly excluded from the eligibility criteria for this code.
- Failing to account for the mandatory fee reduction if you previously performed a consultation or general assessment on the same patient shortly before the admission.
Billing Tips
- If you are the MRP, do not bill W402; instead, ensure your comprehensive admission work is reflected in your initial W010 monthly management claim.
- Ensure your documentation explicitly mirrors the requirements of a general assessment (full history and multi-system physical) to withstand an audit, as W402 is a high-value assessment code.
Ready to bill this code?
SnapBill makes OHIP billing simple — auto-filled codes, validation, and batch submission.