Overview
SOMB code 03.03A is the baseline limited assessment code for in-office family medicine encounters. It applies when the physician takes a history related to the presenting problem(s), performs a directed (problem-focused) physical examination, and provides advice and a plan. It is the correct code for most routine follow-up visits. A more comprehensive encounter should be billed as 03.04A instead — do not bill 03.04A simply to increase the fee.
Billing Requirements
- In-office, face-to-face encounter with the patient
- History taken related to the presenting problem(s)
- Directed (problem-focused) physical examination performed
- Advice and plan documented
Common Audit Traps
⚠️ Alberta Health auditors specifically look for these mistakes when reviewing 03.03A claims:
- Billing 03.03A for purely administrative or form-completion encounters
- Upgrading to 03.04A without a complete history and complete physical exam actually being performed
- Billing 03.03A for a phone or video visit (use 03.03CV instead)
Clinical Example
45-year-old presents with a 3-day sore throat. Focused history, throat and lymph node exam, advice and symptomatic plan. Bill 03.03A.
Documentation Tips (Audit-Proof)
- Chart the presenting complaint clearly
- Document the directed exam findings (normal and abnormal)
- Record the assessment and the plan communicated to the patient
Stop Looking Up Codes Manually.
RevNote AI automatically detects 03.03A and every other applicable modifier from your clinical notes — in under 10 seconds. 99% billing accuracy. Zero PHI stored.
No credit card required · HIA/PHIPA compliant
Related SOMB Codes
Comprehensive Assessment — In Office
Comprehensive in-office assessment requiring a complete history and a complete physical examination. Use only when documentation actually supports a full workup.
Read GuideAssessment via Telephone or Secure Videoconference
Assessment of a patient's condition conducted via telephone or secure videoconference. Substantive clinical work only — not for admin or results-only calls.
Read GuideMinor Consultation — In Office
Minor in-office consultation performed at the request of another physician. Lower complexity than 03.08A.
Read Guide