A095 – 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, competent in the field due to the complexity, seriousness, or obscurity of the case, provides an opinion and recommendations. The service includes the necessary assessment (general, specific, or medical specific), a review of all relevant data, and the preparation of a written report back to the referrer.
When to Use
- When a specialist provides a written opinion and recommendations to a referring physician for a complex or obscure case, documented by a formal referral letter.
- When a nurse practitioner requests a consultation for a patient requiring specialized medical expertise beyond their scope, with a report provided to both the NP and the patient's primary care provider if applicable.
- When a dental surgeon requests a consultation for an insured dental procedure performed in a hospital setting, requiring specialist medical input.
Common Pitfalls
- Billing A095 when the service was an in-patient consultation; C095 is the correct code for hospital in-patient consultations.
- Billing A095 if the surgeon spends 50 minutes or more with the patient, as A935 (Special surgical consultation) is the appropriate code in such cases.
- Failing to obtain and retain a written referral from the requesting practitioner, which is a mandatory requirement unless the consultation occurs in a shared electronic record system.
Billing Tips
- Ensure the written report to the referrer is comprehensive, including findings, opinions, and recommendations, as this is a core component of the A095 service.
- For virtual consultations, always append the 'A' suffix and confirm the service was conducted via video to ensure proper reimbursement.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Outpatient/Office
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.
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.
For emergency calls and special visits to in-patients, refer to Special Visit Premiums ( to ).
Preoperative consultations for low-risk elective procedures (e.g., cataract, colonoscopy) are only eligible if medically necessary and documented as such.
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