A085 – Consultation
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation is an assessment rendered following a written request from a referring physician, nurse practitioner, or dental surgeon (for insured dental procedures in hospital). The consultant physician, due to the complexity, seriousness, or obscurity of the case, provides an opinion and advice. The service includes a general, specific, or medical specific assessment, a review of all relevant data, and the preparation of a written report to the referring provider.
When to Use
- Bill A085 when a specialist provides an opinion on a complex case referred by a primary care physician, including a detailed written report.
- Use A085 for a new patient assessment requested by a nurse practitioner for a condition outside the NP's usual scope of practice.
- A085 is appropriate when a dental surgeon requests a physician's opinion on a medically complex aspect of a dental procedure performed in hospital.
Common Pitfalls
- Claiming A085 when the referral was not initiated by a physician, NP, or dental surgeon; ensure the request is documented.
- Billing A085 without sending a written report to the referring provider; this is a mandatory component and failure to do so can result in adjustment to a lesser code like A083.
- Submitting A085 for ongoing management of a condition for which a previous consultation (A085) has already been billed within the last 24 months, unless it meets the criteria for A086.
Billing Tips
- When a nurse practitioner makes the referral, ensure the written report is sent to both the referring NP and the patient's primary care provider, if applicable.
- If the consultation is for a patient under 16 years old, remember to apply the appropriate age-based premium percentage to the specialist fee.
Effective: June 1, 2025
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.
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.
Includes a general, specific or medical specific assessment, including a review of all relevant data.
Age-based premiums apply: 30% (<30 days), 25% (30 days to <1 year), 20% (1 to <2 years), 15% (2 to <5 years), and 10% (5 to <16 years).
Special Visit Premiums (Travel and Person Seen) may be applicable for non-elective visits (see -).
Preoperative consultations for low-risk elective procedures (e.g., cataract, colonoscopy) are only payable if medically necessary and documented.
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