W511 – Complex physiatry assessment
OHIP Neurology Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A complex physiatry assessment for a non-emergency in-patient in a Long-Term Care Institution, which includes Chronic Care Hospitals, Convalescent Hospitals, Nursing Homes, and Homes for the Aged (). This service is subject to the same conditions as billing code A511. As per the General Preamble, all assessments must include a direct physical encounter with the patient, taking a patient history, performing a physical examination, and arranging any necessary follow-up care or procedures (). This 'W' prefix code is designated for non-emergency services; for emergency calls or other special visits to these patients, the 'A' prefix General Listings and appropriate Special Visit Premiums should be used (, ).
When to Use
- Use W511 for a comprehensive physiatry assessment of a patient with a stroke, spinal cord injury, or traumatic brain injury residing in a long-term care facility.
- Select W511 instead of W510 when the clinical complexity necessitates a detailed assessment equivalent to the A511 standard rather than a routine visit.
Common Pitfalls
- Billing W511 alongside E078 is prohibited; the system will reject the claim as these services are mutually exclusive.
- Failing to document the specific elements of a medical specific re-assessment often leads to OHIP downgrading the claim to a lower-value assessment code during audit.
Billing Tips
- Ensure the patient's diagnosis is clearly linked to the required conditions (TBI, stroke, or SCI) to avoid rejection, as this code is specifically designated for these complex neurological populations.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Hospital and Institutional Consultations and Assessments, Assessments
Must include the elements of a medical specific re-assessment, or the amount payable will be adjusted to a lesser assessment fee.
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