What assessment types does the OHIP General Preamble define?

The General Preamble – Assessments section (GP21–GP39) lays out the definitions and rules that apply across multiple specialties. Key assessment types include:

• General assessment

• Periodic health visit

• General re-assessment

• Pre-dental / pre-operative assessments (definition cross-referenced to A4)

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• Specific assessment, medical specific assessment

• Specific re-assessment, medical specific re-assessment

• Complex medical specific re-assessment

• Partial assessment

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• Chronic Disease Assessment Premium (add-on to certain assessment types)

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• Level 1 & Level 2 paediatric assessments

• Intermediate assessment, including pronouncement of death

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• Minor assessment

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• Periodic oculo-visual assessment

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• Detention (K001) and detention-related services (K101, K111, K112, K102)

• Newborn care, low birth weight baby care, well baby care, enhanced 18-month well baby visit

• Psychiatric assessment under the Mental Health Act (K620, K623, K624, K629)

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• E-assessments (initial, repeat, follow-up and minor e-assessments)

The later specialty sections (Family Practice, Paediatrics, Psychiatry, etc.) then reference these definitions for their A-/C-/K- codes.

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How do general assessments, periodic health visits and general re-assessments work?

General assessment

• Performed at a place other than the patient’s home.

• Requires a full history (presenting complaint, family, past, social, functional inquiry) and exam of all body parts and systems, except breast/genital/rectal when not indicated or refused.

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• Limit:

  • 1 per patient per physician per 12-month period.

  • Up to 2 per 12 months if:

    • the second visit is for a clearly different, unrelated diagnosis, or

    • ≥90 days have elapsed and the second is a hospital admission assessment.

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• Claims beyond the limit are down-coded to a lesser assessment fee.

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Periodic health visit (PHV)

• Patient has no acute physical or mental illness at the visit.

• Must include an intermediate assessment, level 2 paediatric assessment, or partial assessment focused on age and gender-appropriate history, exam, screening and counselling.

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• Limit: 1 PHV per patient per physician per 12-month period.

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• PHVs beyond this limit are not insured.

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• Billed using K-codes such as K017 child, K130 adolescent, K131 adult 18–64, K132 adult 65+, K133 adult with IDD, or paediatric PHV codes K267/K269, depending on age and specialty.

General re-assessment

• Includes all services of a general assessment, but the history need not repeat all prior details.

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• Limit:

  • 2 general re-assessments per patient per physician per 12 months, except when done for hospital admissions.

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• Excess services are adjusted to a lesser assessment fee.

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How do specific, medical specific and complex medical specific assessments work?

Specific assessment & medical specific assessment

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• Specialist services (not in patient’s home).

• Require a full history of the presenting complaint and a detailed exam of affected part(s)/region(s)/system(s) to diagnose, exclude disease or assess function.

Frequency rules

• 1 per patient per physician per 12 months, increased to 2 if:

  • the second visit is for a clearly different diagnosis, or

  • for medical specific, ≥90 days have elapsed and the second is a hospital admission assessment.

• Any combination of medical specific assessments + complex medical specific re-assessments is limited to 4 per patient per physician per 12 months; excess is down-coded.

Specific re-assessment & medical specific re-assessment

• Specialist services requiring a full relevant history and physical exam of one or more systems.

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• Limit: up to 2 per patient per physician per 12 months, except when used as hospital admission assessments (which are treated specially).

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Complex medical specific re-assessment

• Re-assessment due to complexity, obscurity, or seriousness of the condition.

• Must include all the requirements of a medical specific re-assessment and a written report to the patient’s primary care physician; otherwise it is down-coded.

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• Limit: 4 per patient per physician per 12 months.

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What is a partial assessment and when does the Chronic Disease Assessment Premium apply?

Partial assessment

• A limited service that includes:

  • history of the presenting complaint,

  • necessary physical exam,

  • advice to the patient, and

  • appropriate record.

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Chronic Disease Assessment Premium

• Payable in addition to the eligible assessment fee when all criteria are met:

  1. Assessment type is one of:

     • medical specific assessment,

     • medical specific re-assessment,

     • complex medical specific re-assessment,

     • partial assessment, or

     • level 2 paediatric assessment.

  2. Physician specialty is one of:

     • 07 (Geriatrics), 15 (Endocrinology & Metabolism), 18 (Neurology), 26 (Paediatrics),

     • 28 (Pathology), 31 (Physical Medicine), 34 (Therapeutic Radiology), 44 (Medical Oncology),

     • 46 (Infectious Disease), 47 (Respiratory Disease), 48 (Rheumatology), 61 (Haematology), 62 (Clinical Immunology).

  3. Service is rendered in an office or out-patient hospital clinic (not ED).

  4. Patient has an established chronic disease diagnosis documented in the chart.

• The SoB lists diagnostic codes that must accompany the claim (e.g., 250 Diabetes mellitus, 428 Congestive Heart Failure, 343 Cerebral Palsy, etc.).

• Not payable to:

  • in-patients,

  • patients in long-term care,

  • patients in an emergency department, and

  • cases where the diagnosis has not yet been established.

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How do paediatric, intermediate and minor assessments work?

Level 1 paediatric assessment

• Includes one or both of:

  • brief history and exam of the affected part/region or related mental/emotional disorder, or

  • brief advice/information on health maintenance, diagnosis, treatment and/or prognosis.

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Level 2 paediatric assessment

• More extensive than Level 1, with history, inquiry and exam of affected parts/systems/mental or emotional disorder to diagnose, exclude disease or assess function.

• Includes well baby care (periodic assessment of a well infant in first two years, with full exam + weight/measurements + caregiver instructions).

Intermediate assessment

• Primary-care general practice service, more extensive than a minor assessment.

• Requires history of presenting complaint, inquiry and exam of affected parts/systems/mental or emotional disorder to diagnose, exclude disease or assess function.

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Intermediate assessment – pronouncement of death

• Pronouncing a patient dead in a location other than the patient’s home, including counselling of relatives and completion of the death certificate.

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Minor assessment

• Limited service that includes either:

  • brief history and exam of the affected part/region or mental/emotional disorder, or

  • brief advice/information on health maintenance, diagnosis, treatment and/or prognosis.

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What is a periodic oculo-visual assessment and how often is it insured?

Periodic oculo-visual assessment

• Eye and vision exam rendered primarily to determine if the patient has a simple refractive error (myopia, hypermetropia, presbyopia, anisometropia, astigmatism) in patients ≤19 or ≥65.

• Includes history, visual acuity, ocular motility, slit lamp exam, ophthalmoscopy, tonometry, advice and written prescription if needed.

• Limit: 1 per patient per 12 months, regardless of whether billed by an optometrist or physician.

• Not insured for patients aged 20–64, or when frequency limit exceeded.

• For non-ophthalmologists, no other insured service is payable same day to the same patient.

• Re-assessment after a periodic oculo-visual assessment should be billed with a lesser assessment fee and diagnostic code 367.

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How does detention (K001) work with assessments?

Detention (K001) is a time-based add-on when a physician must provide considerable extra time in active treatment and/or monitoring of a patient, to the exclusion of all other work, after another insured service.

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• Billed as K001 per full 15-minute unit.

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• A table lists minimum times required for the “base” service before detention is payable (e.g., 30 minutes for minor/partial/multiple systems/paediatric level 1 and 2/intermediate or subsequent hospital visit; 40 minutes for general or specific re-assessment; 60–180 minutes for various consultations and complex assessments).

• Not payable:

  • with diagnostic procedures, obstetrics, or therapeutic procedures where the fee already includes an assessment (e.g., non-IOP surgery),

  • for waiting time,

  • when billed same patient same day as certain comprehensive psychiatry codes (A190, A191, A192, A195, A197, A198, A695, A795, A895).

• Claims require a written explanation (IC review).

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What are detention-in-ambulance and organ-transport detention services?

Detention-in-Ambulance

• Constant attendance with a patient in an ambulance, providing all aspects of care.

• Time is only for the period the physician is in constant attendance in the ambulance.

• Includes initial exam, ongoing monitoring and all interventions (unless another fee is separately billable).

• Codes:

  • K101 – ground ambulance transfer with patient, per quarter hour or part thereof.

  • K111 – air ambulance transfer with patient, per quarter hour or part thereof.

  • K112 – return trip without patient after air/ground transfer, per half hour or major part thereof.

• Claims are IC-assessed and require explanation.

• K101 is not for attendance in vehicles other than an ambulance; in those cases, K001 may apply.

Detention for the Transport of Donor Organs (K102)

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• Payable for travel time to and from a donor centre (excluding time in the centre) to collect and transport donor organ(s), including fresh bone.

• Billed per quarter hour or part thereof, not eligible with K001.

• Claims are IC-assessed and judged on the most time-efficient means of travel.

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How do newborn care, low birth weight baby care and well baby care work?

Newborn care

• Routine care of a well newborn for up to the first 10 days of life, in hospital or home.

• Includes an initial general assessment, any needed subsequent assessments, and instructions to caregiver(s).

• Limit: 1 per patient; can be billed at both hospitals if a well baby is transferred (e.g., due to mother’s health).

• A special visit premium may be billed in addition if the physician makes an extra hospital visit outside normal rounds to facilitate same-day newborn discharge.

Low birth weight baby care

• Any assessment of a well newborn/infant weighing <2.5 kg at birth.

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Well baby care

• Periodic assessment during the first two years of life, including a complete exam with weight and measurements and instructions to parent/representative about health care.

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Enhanced 18-month well baby visit (subset of well baby care)

• For children 17–24 months.

• Must include:

  • all services of well baby care,

  • an 18-month age-appropriate developmental screen, and

  • review of a brief standardized tool completed by the caregiver to identify risk of developmental disorders.

• Medical record must document the screen and concerns from the standardized tool.

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What is a psychiatric assessment under the Mental Health Act?

Psychiatric assessment under the Mental Health Act covers services billed under K620, K623, K624, K629.

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• Includes appropriate psychiatric history, inquiry and exam to enable completion of the relevant Mental Health Act forms, and notification of patient, family, representative and authorities when appropriate.

• Separate codes in the Psychiatry section define:

  • K620 – consultation for involuntary psychiatric treatment (time-based units),

  • K623 – application for psychiatric assessment (Form 1),

  • K624 – certification of involuntary admission (Form 3),

  • K629 – re-certification(s) of involuntary admission.

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How do e-assessments, repeat, follow-up and minor e-assessments work?

E-assessment (specialist)

• Performed by a specialist at the request of a primary care physician or nurse practitioner using a secure electronic method (e.g., secure messaging, EMR).

• Specialist reviews all relevant data (history, labs, diagnostics, images).

• Must provide an opinion/recommendations to the requester within 30 days.

• Includes specific elements of assessments (except common elements A & B).

• Not payable when:

  • used solely to arrange transfer of care,

  • used to arrange a consultation/other assessment/visit/K-time service or diagnostic procedure,

  • the specialist bills a K-prefix time-based service within 30 days, or

  • the physician is otherwise compensated (salary, APP/AFP, etc.).

• If the specialist later sees the patient face-to-face for the same diagnosis within 60 days, only a specific or partial assessment is payable (not a full consultation).

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Initial e-assessment frequency

• Limited to 1 per patient per specialist per 12 months,

• can increase to 2 if a second request is for a clearly different diagnosis unrelated to the first.

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Repeat e-assessment

• First e-assessment after an initial e-assessment or consultation by the same specialist, for the same diagnosis.

• Requires review of new/relevant data and an opinion with management advice.

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• Limited to 1 per patient per physician per 12 months, or 2 if the second relates to a clearly different diagnosis.

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Follow-up e-assessment

• Limited e-assessment for follow-up by a specialist who has previously rendered any insured service for the same diagnosis.

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• Time and intensity ~ partial assessment.

• Limits:

  • 1 per patient per day per physician,

  • 4 per patient per physician per 12 months,

  • 1000 per physician per 12 months total.

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Minor e-assessment

• Brief e-assessment where the specialist reviews relevant information and answers a specific clinical question from the primary care physician or NP.

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Primary care data-collection premium (K738)

• Payable to the primary care physician when they must collect additional data (e.g., images) not already in their records to support the e-assessment.

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When is the first-visit-after-hospital-discharge premium (E080) payable?

E080 – First visit after hospital discharge premium

• Add-on to certain visit/assessment codes for a visit with the patient’s primary care physician in office or patient’s home within two weeks of discharge from an acute care in-patient admission.

• Not payable if hospital stay was for obstetrical delivery (unless ICU admission), newborn care (unless NICU admission), or day surgery.

• Only payable when rendered with specific A/K/P codes (e.g., A001, A003, A004, A007, A008, A261–A264, A888, A900, K004–K008, K013, K014, K022, K023, K028–K030, K032, K033, K037, K623, P003, P004, P008).