A055 – Consultation
OHIP General Listings Code — Community Medicine (05) · Schedule of Benefits
A consultation rendered by a specialist in community medicine following a written request from a referring physician, nurse practitioner, or dental surgeon. The service includes the necessary assessment and the preparation of a written report (including findings, opinions, and recommendations) to the referring provider.
When to Use
- Bill A055 when a specialist in community medicine provides a comprehensive assessment and written report following a referral from a physician, NP, or dental surgeon for a condition not previously managed by the consultant.
- Use A055 for a community medicine specialist's initial assessment and report when the patient presents with a new, distinct diagnosis unrelated to a previous consultation, even if within the 12-month period for unrelated diagnoses.
- A055 is appropriate for a community medicine specialist's consultation where the assessment and report are completed within a single encounter, and the complexity does not warrant A050 or A400.
Common Pitfalls
- Billing A055 when the patient has already received a consultation for the same condition from another physician in the interval; A056 (Repeat consultation) should be used instead.
- Using A055 for a less demanding assessment that requires substantially less time; A405 (Limited consultation) is the correct code in such cases.
- Failure to obtain and retain a signed written request from the referring provider (physician, NP, or dental surgeon) can lead to claim rejection or audit issues, unless the consultation occurs in a setting with common medical records.
Billing Tips
- Ensure the written report to the referring provider clearly outlines findings, opinions, and recommendations, and is sent promptly to avoid payment delays.
- If the referral is from a nurse practitioner, remember to send the report to both the NP and the patient's primary care provider, if applicable.
Effective: June 1, 2025
Consultations and Visits
Community Medicine (05)
Consultations and Visits
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.
The request would ordinarily also include appropriate clinical information, such as the reason for the referral for consultation, present and past history, physical findings and relevant test results and reports.
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.
The consultant is required to perform a general, specific or medical specific assessment, including a review of all relevant data.
Preoperative consultations for low-risk elective procedures (e.g., cataracts, colonoscopy) are only eligible if medically necessary and documented as such.
If the consultant has been paid for a consultation and then receives a referral for ongoing management, subsequent services are not payable as consultations.
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