< Billing codes

Billing code

A263A — Medical Specific Assessment

Paediatric full assessment

A paediatrician bills A263 for a full history of the complaint and detailed exam of the affected systems, outside the patient's home.

Watch for: One per patient per physician per 12 months, extras pay less; patients 18 or older qualify only in listed cases.

Code

A263A

Description

Medical Specific Assessment

FHO+ basket

Not in the FHO+ base rate basket (Schedule 2 or 2B).

Effective date

Apr 1, 2026

Termination date

No end date

Explanation

Updated October 26, 2026

Paediatrics (26) medical specific assessment: full history of the complaint and detailed exam of the affected systems by a paediatrician.

What it covers

A263 is the medical specific assessment in the Paediatrics (26) listing. A medical specific assessment is a specialist service, rendered somewhere other than the patient's home, with a full history of the presenting complaint and a detailed examination of the affected parts, regions or systems needed to make a diagnosis, exclude disease or assess function (GP23, A170).

For patients 18 or older, paediatricians may bill only if they saw the patient in the 12 months before the 18th birthday, ongoing chronic care is needed and the patient is under 22, or with the Ministry's written approval (A168).

Billing rules

• One per patient per physician per 12 months. A second is allowed for a clearly different, unrelated diagnosis, or if at least 90 days have passed and the second is a hospital admission assessment. Extra ones are paid at a lesser assessment fee (GP23).
• Medical specific assessments and complex medical specific re-assessments (A661) combined are limited to four per patient per physician per 12 months (GP23).
• Not payable in the patient's home (GP23).
• Specialists bill consultations and visits from their own specialty's listing (GP9).
• A263 can be billed by video or telephone as comprehensive virtual care when an existing relationship exists, with K300A or K301A (A70, AJ1).

Often billed with

• E078 chronic disease assessment premium (+50%) in an office or hospital out-patient clinic (not the ED), for an established chronic disease on the GP26 diagnostic code list (A170, GP25, GP26).
• E080 first visit after an acute care discharge, when the paediatrician is the patient's primary care physician (GP28).

Common rejections

• EQ2: The specialty code on the claim wasn't registered and active for the physician on the service date. Correct it, or update the registration, then resubmit.
• EH2: The health card version code doesn't match the Ministry's record. Get the current version code and resubmit.
• AT3: Billed by video or phone (K300A/K301A), but OHIP found no existing relationship: no in-person service in 24 months and no enrolment to you or your group (A66). Otherwise bill A101/A102.
• V21: OHIP's description is 'diagnostic code required': the claim had no diagnostic code. Add the code for the main reason for the visit; E078 also needs one from the GP26 list.
• A4D: The code is in the Paediatrics (26) listing, and specialists bill from their own specialty's listing (GP9). The specialty on the claim can't bill it.

Related codes: A264, A661, A262, A265, E078

Source: Schedule of Benefits (July 1, 2026), Consultations and Visits, Paediatrics (26), pages A168 and A170; General Preamble GP23 (medical specific assessment)

APEX checks every paid claim against the Schedule of Benefits and flags codes billed below what the visit qualified for. See how APEX works · Pricing