C111 OHIP Complex Re-assessment Code

1What Is the C111 OHIP Code?

C111 is a billing code under the Ontario Health Insurance Plan (OHIP) specifically for complex medical specific re-assessments in a critical care setting. This code is used when a reassessment of a hospital in-patient is necessary due to the complexity, obscurity, or seriousness of their condition.

Typically, this code applies to situations where the patient, often recovering from a critical illness or deteriorating towards readmission to intensive care, requires a comprehensive reassessment covering multiple failing systems and the supports each system requires.

It is important to document these reassessments thoroughly, as missing documentation or misclassification can lead to denied claims or incorrect billing payments.

2Related Codes

Code	Name	Frequency	Description
A713	Medical specific assessment	Limited to four per 12 months	Assessment under Critical Care Medicine.
C713	Medical specific assessment	Limited to four per 12 months	Assessment under Critical Care Medicine.
A111	Complex medical specific re-assessment	Limited to four per 12 months	Applicable for out-patient equivalent assessments.
A114	Medical specific re-assessment	Limited to four per 12 months	A standard re-assessment under Critical Care Medicine.

3Eligibility Requirements

The C111 code is eligible for billing in non-emergency hospital in-patient settings, specifically under the Critical Care Medicine listing. Physicians must adhere to a few key eligibility requirements:

The reassessment must involve complex, serious, or obscure conditions requiring comprehensive care.
The code is limited to four re-assessments per patient per physician within a 12-month period. Additional claim submissions exceeding this limit will be adjusted to a lesser assessment fee.
The reassessment service must be time recorded in the patient's medical record, noting both the start and end times.
Virtual delivery is applicable only through video, billed as C111A. Telephone services are not eligible under this provision.

See General Preamble GP40 to GP48 for details on emergency calls and other special in-patient visit premiums.

4What Your Clinical Note Must Show

1Time Documentation

Document the start and end time of the service in the patient's medical record.

Record start time
Record end time

2Complexity Justification

Provide details on why the patient's condition is complex, serious, or obscure.

Describe the complexity
Include system assessments

3Re-assessment Contents

Document all elements included in the specific re-assessment.

System assessment
Patient progress
Treatment modifications

5Weak vs. Strong Note Examples

The strong note succeeds by providing detailed information about each failing system and the specific supports required, while the weak note lacks detail and fails to demonstrate the complexity of care.

❌ Weak Note

Re-assessed patient in ICU. Conditions reviewed. No issues noted.

✓ Strong Note

Re-assessed patient presenting with multi-system complications post critical illness.

Cardiovascular support adjustments
Respiratory system stability
Renal function monitoring
Neurological status evaluation

6Common Reasons This Code Is Missed

Insufficient Documentation

Failing to record start and end times for the reassessment can lead to claim rejections.

Misclassification of Patient Condition

Overlooking the complexity of the patient's condition can result in underbilling or claim denials.

Frequency Limit Exceeded

Billing more than four re-assessments per patient in a year under a single physician is a common error.

Virtual Care Missteps

Attempting to bill for services delivered by telephone rather than video can lead to denials.

Failure to Update Records

Not routinely updating the patient's chart with comprehensive system re-assessments can cause billing issues.

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8Frequently Asked Questions

What is the fee for billing C111 under OHIP?

The fee for C111 is CAD 83.40 as per the current OHIP fee schedule.

How often can C111 be billed annually?

C111 can be billed up to four times per year per patient by the same physician.

What type of patient scenarios make C111 applicable in critical care?

Patients with multiple system failures recovering from critical illness or deteriorating towards intensive care readmission are typical candidates.

Can C111 be billed for telephone consultations?

No, C111 can only be billed for video consultations, not telephone consultations.

What justifies using C111 instead of a regular assessment?

The need for complex evaluations due to a patient's serious, obscure, or multifactorial condition justifies upgrading to C111.

In what setting is C111 most often used?

C111 is most often used in non-emergency hospital in-patient settings for critical care assessments.

Which related codes should be considered when scheduling multiple assessments?

Related codes include A713, C713 for initial assessments and A111, A114 for re-assessments in different contexts.

Why is it critical to document the start and end times for C111?

Time documentation is necessary to meet OHIP service billing requirements and ensure claims are processed without issues.

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.

C111 OHIP Billing Code: Complex Medical Re-assessments in Critical Care

1What Is the C111 OHIP Code?

2Related Codes

3Eligibility Requirements

4What Your Clinical Note Must Show

5Weak vs. Strong Note Examples

6Common Reasons This Code Is Missed

8Frequently Asked Questions