Overview
SOMB code 03.04A is paid for a comprehensive in-office assessment that includes a complete history (past medical, surgical, family, social) and a complete multi-system physical examination. It is not a default upgrade from 03.03A — Alberta Health auditors compare the chart against the comprehensive-assessment definition in the SOMB. Bill 03.04A only when the encounter genuinely met both the complete-history and complete-exam requirements.
Billing Requirements
- Complete history: presenting problem(s), past medical, surgical, family, and social history
- Complete multi-system physical examination
- In-office, face-to-face encounter
- Assessment and management plan documented
Common Audit Traps
⚠️ Alberta Health auditors specifically look for these mistakes when reviewing 03.04A claims:
- Billing 03.04A for focused follow-ups that do not include a complete history and full physical
- Upgrading 03.03A encounters to 03.04A without supporting documentation
- Billing 03.04A more than once for the same issue when no change in clinical status justifies it
Clinical Example
New patient intake with multiple concerns. Complete history taken; HEENT, CV, respiratory, abdominal, MSK, and neurological exams performed and charted. Bill 03.04A.
Documentation Tips (Audit-Proof)
- Explicitly document each component of the complete history
- Chart all systems examined during the physical exam, not only abnormal findings
- State the clinical reason a comprehensive assessment was required
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Related SOMB Codes
Limited Assessment — In Office
Limited assessment of a patient's condition requiring a history related to the presenting problems, a directed examination, and advice. The default GP office visit code.
Read GuideInitial Prenatal Visit — Complete History & Physical
Initial prenatal visit requiring a complete history and complete physical examination. Prenatal-only — not interchangeable with 03.04A.
Read GuideComprehensive Consultation — In Office
Comprehensive in-office consultation performed at the request of another physician. Requires a complete history, complete physical examination, and a written consult report.
Read Guide