A005 – Consultation
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation is an assessment rendered following a written request from a referring: 1. physician 2. nurse practitioner or 3. dental surgeon in connection with an insured dental procedure rendered in a hospital, who, in light of his/her professional knowledge of the patient, requests the opinion of a physician (the “consultant physician”) competent to give advice in this field because of the complexity, seriousness, or obscurity of the case, or because another opinion is requested by the patient or patient’s representative. A consultation includes the services necessary to enable the consultant to prepare a written report (including findings, opinions, and recommendations) to the referring physician, nurse practitioner or dental surgeon. Where the referral is made by a nurse practitioner, the consultant shall provide the report to the nurse practitioner and the patient’s primary care provider, if applicable. Except where otherwise specified, the consultant is required to perform a general, specific or medical specific assessment, including a review of all relevant data.
When to Use
- When a specialist provides an opinion on a complex cardiac arrhythmia after a referral from a cardiologist, including a written report.
- When a neurologist is consulted by a primary care physician for a patient with a newly diagnosed, complex seizure disorder, requiring a detailed assessment and report.
- When a surgical consultant is requested by a dentist for a patient requiring complex maxillofacial reconstruction following trauma, with a written opinion provided.
Common Pitfalls
- Billing A005 when the referral is from another specialist for a routine follow-up, instead of a new problem requiring a consultant's opinion.
- Failing to send a written report to the referring physician, nurse practitioner, or dental surgeon, which can lead to payment adjustment to an assessment fee.
- Billing A005 for a patient seen for a condition that has already been the subject of a consultation by the same physician within the last 12 months, without meeting repeat consultation criteria.
Billing Tips
- Ensure the referral documentation clearly states the specific question or reason for consultation, not just a general request for assessment.
- If the consultation is for a hospital inpatient, confirm that the written request is part of the common medical record if applicable, to meet documentation requirements.
Effective: April 1, 2026
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultation
Consultation
A copy of the written request for the consultation, signed by the referring physician, nurse practitioner or dental surgeon must be kept in the consulting physician’s medical record, except in the case of a consultation which occurs in a hospital, long-term care institution or multi-specialty clinic where common medical records are maintained. In such cases, the written request may be contained on the common medical record.
The request identifies the consultant by name and/or the specialty being consulted, the referring physician, nurse practitioner or dental surgeon by name and billing number, and identifies the patient by name and health number.
The written request sets out the information relevant to the referral and specifies the service(s) required.
Except where otherwise specified, the consultant is required to perform a general, specific or medical specific assessment, including a review of all relevant data.
A written report (including findings, opinions, and recommendations) must be sent to the referring physician, nurse practitioner or dental surgeon. Where the referral is made by a nurse practitioner, the consultant shall provide the report to the nurse practitioner and the patient’s primary care provider, if applicable.
Preoperative consultations for low-risk elective procedures (cataract surgery, colonoscopy, cystoscopy, carpal tunnel surgery, or arthroscopic surgery) are only eligible if the medical record demonstrates the consultation is medically necessary.
If the consultation is requested by a Medical Trainee, the fee is adjusted to an assessment fee.
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