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OHIP Billing Guide🩺 ServicePublished 2026
A004

A004 OHIP Billing Code: Enhance Patient Care with General Re-assessments

The A004 OHIP code allows family physicians to conduct general re-assessments, vital for monitoring complex cases over time.

For Ontario Physicians & Billing StaffOHIP Schedule of Benefits Reference39.35 CAD~3 min read

1What Is the A004 OHIP Code?

What is the A004 Billing Code?

The A004 billing code is used for general re-assessments by family physicians. This code supports the follow-up evaluation of a patient's condition, after an initial assessment has been completed, focusing on cases that display complexity across multiple systems. General re-assessments are integral for ensuring continuity of care, particularly in cases where patient needs are expected to evolve.

These re-assessments allow physicians to provide a complete periodic review tailored to the complex nature of chronic or multi-system issues in patients. The code is essential for maintaining updated health profiles in conditions that require ongoing attention and adjustment of treatment plans.

2Related Codes

CodeNameFrequencyDescription
A003General assessmentAs clinically necessary per patient encounterComprehensive assessment covering multiple systems for new or complex cases.
C003General assessmentAs clinically necessary per hospital inpatientGeneral assessment for hospital in-patient care coordination.
C004General re-assessmentAs clinically necessary per hospital inpatientRe-assessment for in-patients, tracking progression from previous admissions.
W004General re-assessment of patient in nursing homeAs clinically necessary within nursing home settingsAssessment tailored to the setting of a nursing home, considering chronic conditions.

3Eligibility Requirements

Eligibility for A004 Billing

To bill the A004 code, the service must meet specific requirements:

  • Frequency Limit: General re-assessments are limited to two per 12-month period, per patient, per physician, except for hospital admissions. Exceeding this may result in billing at a lesser fee.
  • Inclusions: When collection of cervical cancer screening specimens is part of the procedure, it is included in the re-assessment rate unless using add-on codes E430 or E431 for services outside of hospitals or ICHSC.
  • Documentation: Time details must be recorded; the service's start and end times are compulsory in the patient's medical record.

These parameters ensure that the billing is appropriately justified and documented.

4What Your Clinical Note Must Show

1Essential Documentation for A004

Ensure the following are documented to support the billing:

  • Start and end times of the re-assessment service
  • Re-assessment details differing from initial assessment
  • Relevant clinical findings and changes in patient condition
  • Any procedures performed, including cervical cancer screenings

5Weak vs. Strong Note Examples

The strong note offers specific insights into the patient's condition, management plan, and clearly documents the time, justifying the service and its billing.

❌ Weak Note

Patient came in for re-assessment. Routine check performed. No new issues found.

✓ Strong Note

36-year-old male revisited for general re-assessment due to ongoing complex issues. Updated on the status of HTN management. Noted improvement in blood pressure control; 2 weeks follow-up scheduled.

Recorded time: 9:00 AM - 9:25 AM.

  • Patient condition complexities and progression
  • Therapeutic adjustments made
  • Follow-up plan established with precise timelines

6Common Reasons This Code Is Missed

1
Failure to document time properly
Start and end times are vital and missing them invalidates the billing.
2
Exceeding frequency limits
Billing more than twice in a 12-month period without proper justification or context results in reduced payment.
3
Including non-eligible procedures
Including procedures not directly associated or listed under the A004 code may cause billing issues.
4
Insufficient clinical detail
Re-assessment notes lacking new clinical findings or changes from previous visits are often disallowed.
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8Frequently Asked Questions

What is the fee for A004?
As per the OHIP Schedule, the flat fee for A004 is CAD 39.35.
How often can A004 be billed?
It can be billed twice per 12 months per patient, per physician, except for hospital admissions.
Which conditions often necessitate a re-assessment in family medicine?
Complex, multi-system conditions like diabetes management or hypertension benefit most from periodic reviews.
What makes a case suitable for a general re-assessment?
Cases showing progression or complications across multiple systems often require re-assessment.
How to determine if a patient is ready for a re-assessment?
Consider if the patient's condition has changed significantly since the last assessment or if it's been 6 months.
When should a family physician opt for a re-assessment over a general assessment?
Typically after significant new findings post the initial assessment that require nuanced management.
When would a cervical cancer screening be billed alongside A004?
When done outside a hospital and recorded as per OHIP guidelines using add-on codes.
Disclaimer: This article is intended as a general educational resource for physicians and billing staff. It does not constitute billing advice or a definitive interpretation of the OHIP Schedule of Benefits. Always verify current billing codes, eligibility criteria, and documentation requirements directly against the official Schedule of Benefits or consult with a qualified medical billing specialist.
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