A235 – Ophthalmology 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 hospital-based insured dental procedures). The consultant physician, due to the complexity, seriousness, or obscurity of the case, provides an opinion and recommendations. The service includes the necessary assessment elements and a written report back to the referrer.
When to Use
- Bill A235 when a patient is referred by a GP for a second opinion on a complex retinal detachment that requires further investigation beyond a standard office visit.
- Use A235 for a referral from an optometrist regarding a suspected optic nerve anomaly in a patient with a history of glaucoma, requiring specialist assessment and a report.
- A235 is appropriate when a patient is referred by a specialist in another field (e.g., neurologist) for an ophthalmological opinion on visual disturbances potentially related to a neurological condition.
Common Pitfalls
- Billing A235 without a documented written referral from a physician, NP, or dental surgeon will result in the claim being adjusted to a lesser assessment fee (e.g., A233 or A234).
- Submitting A235 when the consultant physician initiates the request for follow-up management, rather than receiving a referral for an opinion, is incorrect; a visit fee should be claimed instead.
- Claiming A235 for a patient seen for ongoing management after the initial consultation, without a new referral, is not permissible and may lead to audits.
Billing Tips
- Ensure the written report back to the referring practitioner is comprehensive, including findings, opinions, and clear recommendations, as this is a mandatory component of A235.
- Retinal photography can be billed in addition to A235 when medically necessary, provided it is documented in the patient's chart.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
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 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) 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 cataract surgery are only eligible for payment where the medical record demonstrates the consultation is medically necessary (noted as very uncommon). (p.)
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