H104 OHIP Billing Code

1What Is the H104 OHIP Code?

The H104 billing code applies to re-assessments conducted by family medicine practitioners within emergency departments or Hospital Urgent Care Clinics. This code is relevant for reassessments that occur at least two hours after an initial assessment, indicating further care or investigation is necessary.

During an emergency department visit, family physicians frequently need to reassess patients after treatment or upon receiving new test results. The H104 code ensures that these crucial follow-ups are appropriately compensated. Missing or incorrect usage of this code can result in lost revenue for services that deserve reimbursement.

2Related Codes

Code	Name	Frequency	Description
A914	GP focused practice comprehensive consultation by Video	Governed by specialty listing	Used for comprehensive consultations conducted via video in a family practice setting.
A006	Repeat consultation	Governed by specialty listing	Billed for repeat consultations in a family practice setting.
A010	GP focused practice consultation by Video	Governed by specialty listing	For consultations done via video in a GP focused practice.
A011	GP focused practice repeat consultation by Video	Governed by specialty listing	For repeat consultations conducted via video.

3Eligibility Requirements

Eligibility for billing the H104 code is based on specific criteria as outlined in the OHIP Schedule of Benefits:

The service must occur at least two hours after the original assessment or a prior re-assessment and must be necessary due to an indicated need for further care.
It should not be billed for discharge assessments, upon the patient's admission by the emergency physician, or if the reassessment leads directly to a referral for consultation.
The re-assessment service under H104 is limited to three occurrences per patient per day and two per physician per patient per day. Services exceeding these limitations are ineligible for payment.

Additionally, proper time recording is essential, including the start and end times of the service on the patient's medical record. Failure to include these details will render the service unpayable.

4What Your Clinical Note Must Show

1Service Time Documentation

Ensure that the medical record contains the following:

Start time of the re-assessment service
End time of the re-assessment service

5Weak vs. Strong Note Examples

The strong note succeeds because it provides a detailed account of the clinical reasoning behind the reassessment, specific improvements or actions taken, and accurately records the time, maximizing eligibility for remuneration. The weak note falls short by lacking specific details and time documentation.

❌ Weak Note

Reviewed patient. Pt stable. Reassessed.

✓ Strong Note

Reassessed the patient two hours post-initial assessment owing to persistent symptoms. Necessary adjustments in care plan based on test results indicating elevated markers. Documented time of reassessment as follows:

Start: 15:00
End: 15:30

6Common Reasons This Code Is Missed

Failure to Document Time

The absence of documented start and end times in the medical record leads to non-payment.

Assuming Discharge Assessments are Covered

Misinterpreting re-assessment as including discharge assessments can result in claims being denied.

Exceeding Allowed Number of Re-assessments

Billing more than two per physician per patient per day or more than three per patient can result in denied claims.

Lack of Medical Necessity Documentation

Failing to document the medical necessity for the reassessment.

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8Frequently Asked Questions

What is the fee for billing H104?

The fee for billing the H104 code is CAD 22.75.

How many times can H104 be billed for the same patient in one day?

H104 can be billed up to three times per patient per day.

What types of conditions commonly require re-assessment in family medicine?

Conditions requiring further monitoring after initial treatment, like asthma exacerbations, often require reassessment.

How does a reassessment differ from a discharge assessment?

A reassessment is for ongoing care before discharge, whereas a discharge assessment occurs when discharging a patient.

When is it appropriate to request a reassessment?

A reassessment is appropriate if new symptoms or test results indicate the need for further examination or a change in treatment.

Does direct referral for consultation qualify for reassessment billing?

No, if the reassessment leads directly to a referral for consultation, it is not eligible for H104 billing.

Can the reassessment be conducted during after-hours?

No, H104 is specifically scheduled for weekday daytime hours between 08:00h to 17:00h.

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.

H104 OHIP Billing Code: Optimize Re-Assessments in Family Medicine

1What Is the H104 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