C613 OHIP Billing Code: Medical Specific Assessment

1What Is the C613 OHIP Code?

C613 is used by hematologists to bill for medical specific assessments of hospital in-patients. This service involves a thorough evaluation of the patient, focusing on hematological concerns such as a declining platelet count or anticoagulation management.

The assessment must include a complete history of the presenting complaint and a detailed examination relevant to the hematologic condition. Often, it is employed when a focused evaluation is required to establish a diagnosis or to assess the patient's clinical status, particularly in complex or acute in-patient scenarios.

Due to its specific requirements, the C613 code can sometimes be overlooked when symptoms initially seem ambiguous or unrelated to hematological specialty, leading to missed opportunities for appropriate coding.

2Related Codes

Code	Name	Frequency	Description
A613	Medical specific assessment	Once per patient per 12 months (eligibility rules apply)	The out-patient equivalent of C613 for ambulatory settings.
A611	Complex medical specific re-assessment	As needed, subject to specific eligibility criteria.	A complex re-assessment for hematology patients in an out-patient setting.
A614	Medical specific re-assessment	As needed, subject to specific eligibility criteria.	A re-assessment for hematology cases requiring follow-up in an out-patient setting.
C611	Complex medical specific re-assessment	As needed, subject to specific eligibility criteria.	A complex re-assessment for in-patient hematology cases.

3Eligibility Requirements

The C613 code applies to hematology in-patient non-emergency settings. To be eligible:

The assessment must be rendered by a specialist.
It requires a full history and detailed examination of the presenting complaint.
Only one specific assessment per patient, per physician, per 12-month period is usually allowed. A second assessment in the same period is permissible if:
- The patient presents with an unrelated diagnosis.
- At least 90 days have passed, and it involves a hospital admission assessment.

Time documentation must include start and end times of the service in the patient’s medical record.

4What Your Clinical Note Must Show

1Time Recording

For a C613 service to be payable, accurate time documentation is essential:

Start and end times of the assessment must be recorded in the patient’s medical record.

5Weak vs. Strong Note Examples

The strong note succeeds because it details the specific clinical actions related to hematology, justifying the assessment and aligning with billing requirements.

❌ Weak Note

Patient seen for assessment. History taken and examination performed.

✓ Strong Note

Comprehensive assessment conducted due to falling platelet count. Relevant hematological history reviewed, and detailed examination performed focusing on spleen size and potential bleeding sources.

Completed a full history focused on hematological symptoms.
Conducted detailed examination targeting suspected hematological issues.

6Common Reasons This Code Is Missed

Overlooking Specific Diagnoses

C613 requires a focus on a specific hematological diagnosis, which can be missed if initial assessments are not detailed.

Inadequate Documentation

Failure to record start and end times or detailed findings may result in non-payment.

Frequency Limits Misunderstood

Misinterpretation of frequency limits and related eligibility criteria can lead to billing errors.

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8Frequently Asked Questions

How often can C613 be billed for the same patient within a year?

C613 can generally be billed once per patient per year. A second assessment may be billed if an unrelated diagnosis is present or 90 days have passed since a hospital admission assessment.

Can C613 be performed virtually?

Yes, C613 can be billed for virtual assessments, but only if conducted via video.

What conditions warrant a C613 assessment by a hematologist?

Cases involving falling platelet counts or complicated anticoagulation scenarios are typical hematological conditions needing C613 assessment.

When should a hematologist choose C613 over other assessment codes?

C613 is appropriate when a comprehensive hematology-specific assessment is required as it provides a higher level of detail and scrutiny into the patient's condition.

How does a referral scenario affect C613 billing?

Patients referred due to acute hematological issues like sudden falls in platelet counts often necessitate a C613 assessment to determine further care.

In what scenarios would a re-assessment code be more appropriate than C613?

If the patient has had a previous assessment and requires follow-up without significant new complaints, using re-assessment codes A611 or A614 might be suitable.

How should start and end times be documented for C613?

Record the exact start and end times of the assessment as part of the patient's permanent medical record for billing compliance.

Under what circumstances can a second assessment be billed within a year?

A second assessment may be billed if there is a clearly different diagnosis present or at least 90 days have elapsed since a hospital admission assessment was performed.

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.

C613 OHIP Billing Code: Hematology Specific Assessment Guide

1What Is the C613 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