OHIP Assessments and Consultation Guidelines

Ashley Lane
September 22, 2021

When should you bill a full consultation vs an assessment? Knowing exactly when to bill for what can be confusing or simply hard to remember. No matter what specialty you’re in, a majority of your visits with patients will be some form of consultation.

To help you narrow down the differences between the two, below you’ll find a useful overview of assessments and consultations recommended directly from MOH and OMA.

You can find details like when limits apply, some common billing errors, and a few case examples. The guide will help you decide if a consultation is eligible for payment and if so choose the right fee code for different scenarios. 

Overview 

  • Common billing errors related to assessment and consultation 
  • Family practice in general versus specialist assessments and consultation codes 
  • Key features of specific types of assessments 
  • Additional features of consultation 
  • Limits for consultations 
  • Case examples 

Common billing errors related to assessments and consultations 

In order for a claim to be approved the code must match the service provided. A common error is claiming an assessment or consultation code that doesn’t match the service described in your patient’s medical record. 

When you provide your patient with results or other information related to the service it’s not eligible to claim an assessment. This is a common error that will result in a rejected or refused claim.

Not all services can be claimed in combination with an assessment. Make sure the service you claim is eligible for payment if combined with an assessment otherwise it will be rejected or refused. Here are a few more reminders: 

  • Remember to include a referral when claiming a consultation.
  • Routine transfer of care is not eligible and will result in a rejected or refused claim. 

Family practice and practice in general versus specialist assessment and consultation code

Family physicians have their own set of visit codes listed in the Family Practice and Practice in General section of the Schedule (Pages A1-A163). All physicians can claim services like counseling and interviews as long as they follow the Schedule provisions and payment rules found in this section of the schedule. If you’re a specialist, you should first browse this section of the Schedule for visit fee codes associated with your specialty. If the service you’re providing doesn’t fall within the scope of your specialty then use the fee codes from the Family Practice and Practice in General section. If you’d like to search the schedule of benefits, quickly look up the consultation code using our searchable database.

OHIP Billing Codes: Ontario Schedule of Benefits 2021

Assessments 

An assessment must be personally provided and include a history and physical exam to be insured under OHIP. Depending on the type of patient visit, additional elements of assessments may be involved.

Additional elements of assessments Comments
Your patient’s condition requires further examination to form an opinion Before, during, or after the physical examination visit
Any procedure performed during the physical examination visit (obtaining specimens, diagnostic/therapeutic or surgical services) The procedure can be claimed if separately listed as payable with an assessment in the Schedule
Coordinating related assessments, procedures or therapy n/a
Interpreting results n/a
Coordinating follow-up care n/a
Providing advice or information to your patient or their representative Including reporting the results of related procedures or assessments before you provide the next insured service (by phone or in-person)
Monitoring your patient’s condition and intervening when necessary Until you provide the next service
Providing premises, equipment, supplies and personnel Except for any aspect performed in a hospital or nursing home

*To determine whether claims for some repeat Consults or Assessments are eligible for payment, remember that the General Preamble defines a 12 month period as any period of 12 consecutive months.

Consultations 

A consultation is an assessment requested in writing by a referring physician or nurse practitioner who has professional knowledge of the patient. As the consulting physician, you are competent to give advice because of the complexity of the case or because your patient or their representative requested another opinion.

Additional elements of consultations Comments
General, specific, or medical specific assessment Unless otherwise specified
Review of all relevant data n/a
Written report to the referring provider Including findings, opinions, and recommendations
A copy of the consultation request signed by the referring physician or nurse practitioner (not by a medical trainee) The copy must be kept in your medical record.

The consultation request must include the consultation name, referring provider, billing number, patient name, health number, and any relevant information.

Without a written request, the consultation will be paid as an assessment.

 

Examples of patient visits that do not meet payment criteria as consultation: 

Some patient visits do not meet consultation payment criteria. 

For example, if a patient requests additional consultation from a different physician with the same specialty for the same condition, the referring health care provider has to decide if the requests are medically necessary. 

Also, when a patient contacts a specialist or consultant office without a referral, the visit is not eligible to be paid as a consultation. 

If a hospital in-patient is transferred to one physician from another, only one consultation, general or specific assessment or reassessment is eligible for payment per patient. Services in excess of this limit will be paid as a lesser assessment fee.

Key Features General Assessment General Re-Assessment Minor Assessment Intermediate Assessment**
Location and Type of Physician Assessment provided anywhere other than the patient’s home when the GP/FPs and specialist are not providing a specialist service Re-assessment provided anywhere other than the patient’s home when the GP/FPs and specialist are not providing a specialist service GP/FPs and specialist are not providing a specialist service GP/FPs and specialist are not providing a specialist service
History and Physical examination, other elements Full history*AND Examination of all body parts and systems except for breast, genital, or rectal examination when not medically indicated or refused Including all the services for a general assessment except the patient’s history which is already included in the original assessment Brief history and examination of the affected part or region or related to a mental or emotional disorder AND/OR Brief advice or information regarding health maintenance, diagnosis, treatment AND/OR prognosis History of the complaint, inquiry Concerning, AND Examination of the affected part, region, system, or mental or emotional disorder if needed to make a diagnosis, exclude disease, and/or assess function
Limits One per patient per physician per 12 month period unless the second assessment is different and unrelated to the diagnosis made at the first general assessment OR

90 days have passed since the last general assessment and the second assessment is a hospital admission assessment

Two per patient per physician per 12 month period unless admitted to a hospital n/a n/a

*A full history must include:

  • history of the presenting complaint
  • family medical history
  • past medical history
  • social history
  • functional inquiry into all body parts and systems

**An intermediate assessment requires a more extensive examination than a minor assessment

Key Features Complex Medical Specific Re-Assessment Level 1 Paedeatric Assessment Level 2 Paedeatric Assessment** Partial Assessment Specific Assessment and Medical Specific Assessment Specific Re-Assessment and Medical Specific Re-Assessment
Type of Physician Specialist physicians Paedeatricians Paedeatricians Specialist physicians Specialist physicians Specialist physicians
History and Physical examination, other elements Includes all the services listed for a medical specific reassessment. You must provide a written report to the patient’s primary care physician A brief history and examination of the affected part or region or related to a mental or emotional disorder, OR Brief advice or information regarding health maintenance, diagnosis, treatment and/or prognosis History of the presenting complaint, inquiry concerning, AND Examination of the affected part, region, system, and mental or emotional disorder if needed to make a diagnosis, exclude disease, and/or assess function History of the presenting complaint 

Physical exam necessary to evaluate the presenting complaint 

Full history of the presenting complaint 

Detailed examination of the affected part, region, or system needed to make a diagnosis, and/or exclude disease, and/or assess function 

Relevant history and physical of one or more systems
Limits Any combination of medical specific assessments and complex medical specific reassessments are limited to 4 per patient per physician per 12 month period n/a n/a n/a One per patient per physician per 12 months period unless the second assessment is different and unrelated to the diagnosis made at the first general assessment OR 90 days have passed since the date of the last general assessment and the second assessment is a hospital admission assessment Two per patient per physician per 12 month period unless admitted to a hospital 

**A Level 2 paediatric assessment also includes well baby care. Well baby care is a periodic assessment of a well newborn/infant during the first two years of life. The assessment includes a complete examination with weight and measurements, and instruction to the parent or the patient’s representative regarding health care

Additional features of consultation 

Additional features Repeat consultation Limited consultation Emergency room physician consultation Special surgical consultation
Location and type of physician Specialist physicians All non-specialist physicians and some specialist physicians Emergency medicine specialists and non-specialist physicians working in the Emergency Room. The service must be provided in the Emergency Room Surgical specialists
Definition Additional consultation provided by the same consultant for the same presenting problem following care provided to the patient by another physician in between the initial consultation and the repeat consultation Specialist physicians: A shorter and less demanding consultation than a full consultation

Same requirements as a full consultation 

Any physician who is not a specialist: 

Same services as a specific assessment

Must include all elements of a consultation. The ER report is adequate documentation of the written report as long as all elements of a consultation are clearly documented and a copy of the ER report is sent to the referring physician or nurse practitioner Must include all elements of a regular consultation and take at least 50 minutes for the consultation, excluding any other services or procedures eligible for payment in addition to the consultation
Referral requirements New written request by the referring physician or nurse practitioner  Written request by the referring physician or nurse practitioner Written request by the referring physician or nurse practitioner who cannot be another ER physician in the same hospital Written request by the referring physician or nurse practitioner

Limits for consultations

When you provide more than one consultation (including time-based and age-specific consultation services but not repeat consultations) within a 24 month period, specific payment rules apply. Consultations in excess of the limit will be paid as a lesser assessment.

1st consultation – all locations 2nd consultation Location of 2nd consultation May claim 2nd service as Comment
Diagnosis “A” Diagnosis “A” All locations except hospital inpatient or Emergency Department  Repeat consultation Must meet the requirements of a repeat consultation
Diagnosis “A” Diagnosis “A” Hospital inpatient or Emergency Department  Repeat consultation Second service must meet the requirements of a repeat consultation and is provided within 12 months of the first consultation
Diagnosis “A” Diagnosis “A” Hospital inpatient or Emergency Department Consultation Second service must meet the requirements of a consultation and is provided between 12 and 24 months following the first consultation
Diagnosis “A” Diagnosis “B” All locations Consultation Second service must meet the requirements of a consultation, is provided within 24 months of first service, and represents an unrelated diagnosis to the first diagnosis (“A”)

Case examples

Scenario 1

Mr. Gerald sees Dr. Quentana, a GP concerned about a painful left red eye. Dr. Quentana refers Mr. Gerald to Dr. Isabella (an ophthalmologist) and provides a signed letter describing the reason for the consultation as well as the patient’s name, health number and contact information. Dr. Isabella reviews the referral letter and then assesses Mr. Gerald, conducting a specific assessment. She diagnoses glaucoma and recommends appropriate treatment and follow-up to the patient. Dr. Isabella proves a written report to Dr. Quentana outlining her findings, conclusions and recommendations. What fee code is eligible for payment to Dr. Isabella?

  • As Dr. Isabella has fulfilled the payment requirements for a consultation, A235 is eligible for payment.

Scenario 2: 

Mrs. Gerald (also a patient of Dr. Quentana) accompanies her husband to a follow-up visit with Dr. Isabella. She mentions to the ophthalmologist in passing that she is concerned about drooping of her upper eyelids which are making it difficult to read. As Dr. Isabella has had a cancellation in her clinic schedule, she offers to assess her problem and performs an appropriate history and physical examination and determines that she would benefit from formal visual field testing and consideration of blepharoplasty. Is it appropriate for Dr. Isabella to claim a consultation for this assessment? 

  • No. As there has been no written request from a referring family physician or nurse practitioner, a consultation is not eligible for payment. Dr. Isabella may claim the assessment that best describes the clinical encounter, which is a specific assessment.

Scenario 3: 

Mr. Gerald slips on ice and fractures his left ankle. He is assessed in the Emergency Room and referred to Dr. Appleyard who provides a consultation and personally applies a below knee cast for treatment of the undisplaced fracture. In total, Dr. Appleyard spends 50 minutes with Mr. Gerald providing these services including 10 minutes applying the cast. He documents the start and stop times of his visit in the patient medical record. Does the described clinical encounter meet payment criteria as a special surgical consult (A935)? 

  • No. While Dr. Appleyard has provided all the elements of a consultation, a special surgical consultation (A935) requires that the physician spend a minimum of 50 minutes with the patient, exclusive of time required for any other billable service. Dr. Appleyard should claim A065 for the consultation (40 minutes) and F074 for the fracture treatment (which took 10 minutes).

Scenario 4:

Dr. Appleyard continues to see Mr. Gerald periodically over the next 3 months as the fracture heals and Mr. Gerald progresses through rehabilitation. Six months later, Dr. Quentana sends a written referral request to Dr. Appleyard asking him to assess Mr. Gerald’s shoulder which has been stiff and painful since the original fall. Dr. Appleyard assesses Mr. Gerald in clinic, diagnoses a rotator cuff tear and recommends surgical treatment. He provides a report to Dr. Quetnana. What fee code is eligible for payment to Dr. Appleyard? 

  • As the patient’s concern relates to a different diagnosis from the first consultation, and Dr. Quentana has fulfilled the payment requirements for a consultation, A065 is eligible for payment.

Scenario 5: 

Dr. Grube, a family physician whose background includes several years experience working in rural emergency medicine performing minor surgical procedures, is working at an urgent care centre. She receives a call from a colleague working at a neighbouring family practice who asks her to see a patient with a complex laceration that requires suturing. The referring physician does not have the equipment in his clinic or expertise to perform the laceration repair and sends a consult note. Dr. Grube assesses the patient, focusing on the injury and sutures the laceration and dictates a report back to the referring physician. In addition to the procedure code for the laceration, what is the most appropriate assessment for Dr. Grube to claim? 

  • Dr. Marron should claim A905 for a limited consultation. 

Conclusion 

With this guide as your reference, you’ll better know when to bill for assessments vs. consultations. This means more efficiency in your administrative tasks since you’ll be less likely to commit common errors and know which fee codes apply to your specific scenarios. Finally, you can focus your attention on what matters most which will make your life easier overall!