1What Is the A138 OHIP Code?
A partial assessment under OHIP billing code A138 is a limited service in internal medicine used when a physician conducts a brief review focusing on one or two systems. This is typical for monitoring changes in therapy for chronic conditions like heart failure or hypertension. Unlike a full specific assessment, a partial assessment involves a concise history, necessary physical examination, and patient advice with appropriate documentation.
Internal medicine specialists frequently use A138 during follow-up visits to monitor responses to established treatment plans. The emphasis is on evaluating a specific, defined problem rather than conducting a comprehensive assessment. Despite its frequency of use, the A138 code can sometimes be overlooked in favor of more complex codes if the scope of the visit creeps beyond a limited assessment.
To accurately use this billing code, consider the nature and scope of the patient's needs and ensure that the assessment remains focused, documenting it effectively to reflect the service provided.
2Related Codes
| Code | Name | Frequency | Description |
|---|---|---|---|
| A133 | Medical specific assessment | Variable, per specialty and General Preamble | Detailed assessments in the Internal Medicine category, at $95.95. |
| C133 | Medical specific assessment (hospital in-patient) | Variable, per specialty and General Preamble | Hospital in-patient equivalent of A133, at $95.95. |
| A131 | Complex medical specific re-assessment | Variable, per specialty and General Preamble | Complex reassessments in Internal Medicine, at $83.40. |
| A134 | Medical specific re-assessment | Variable, per specialty and General Preamble | Specific reassessments after initial assessment, at $72.00. |
3Eligibility Requirements
To be eligible to bill under code A138, a partial assessment must involve a history of the presenting complaint, a necessary physical examination, advice to the patient, and appropriate medical record entries. Physicians must document the start and end times of the service in the patient's permanent medical record.
The A138 service can be rendered in-person or virtually (billed as A138A), applicable for VIDEO OR TELEPHONE consultations. Importantly, this code is used when an assessment does not require the full depth of a medical specific assessment (A133) or more complex evaluation.
Physicians must ensure that the regulatory guidelines for this billing code are met, including adhering to any limits on billing frequency derived from the General Preamble assessment rules and specialty-specific preamble.
4What Your Clinical Note Must Show
For billing a partial assessment under A138, physicians must have the following documentation.
- The history of the presenting complaint.
- A record of the necessary physical examination.
- Documentation of advice provided to the patient.
- The exact time the service started and ended, recorded in the patient's medical record.
5Weak vs. Strong Note Examples
The strong note provides detailed information about the condition assessed, advice given, and includes specific time records, all of which are lacking in the weak note.
Checked the patient's blood pressure, advised to continue current medication. Visit lasted 10 minutes.
Reviewed the patient's response to antihypertensive therapy. Blood pressure stable at 125/80 mmHg. Assessed cardiovascular system and discussed the continuation of current medication regimen. Advised on lifestyle modifications. Noted potential need for dosage adjustment upon next assessment. Service duration: 15 mins.
- Specific patient condition assessment.
- Documented advice and follow-up plan.
- Explicit service start and end times.
