A245 – 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 (in connection with an insured dental procedure in a hospital) who requests the opinion of a physician competent to give advice in the field because of the complexity, seriousness, or obscurity of the case, or because another opinion is requested by the patient or representative.
When to Use
- Bill A245 when a specialist provides a comprehensive assessment and written report following a formal referral for a complex or unclear medical issue, distinct from a routine follow-up.
- Use A245 for a specialist's opinion on a case where the patient or their primary physician requests a second opinion on a serious or obscure condition.
- A245 is appropriate when a specialist evaluates a patient based on a referral for a condition that is outside the scope of the referring physician's expertise.
Common Pitfalls
- Claiming A245 when the referral documentation is missing or incomplete, especially the written request and report to the referring physician.
- Billing A245 for a service that is essentially a follow-up visit or a specific assessment (A243) rather than a comprehensive consultation.
- Submitting A245 for a patient already seen by the same physician on the same day for a related issue, as it is not payable with other assessments on the same day.
Billing Tips
- Ensure the written report to the referring practitioner includes clear findings, opinions, and recommendations to support the A245 claim.
- Verify that the referral is from an eligible source (physician, NP, or dental surgeon) and clearly states the reason for consultation and the service required.
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.
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 provided 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 written request sets out the information relevant to the referral and specifies the service(s) required.
If the requirements for a consultation are not met, the amount payable will be reduced to a lesser assessment fee.
Preoperative consultations for low-risk elective surgical procedures (e.g., cataract surgery, colonoscopy, cystoscopy, carpal tunnel surgery, or arthroscopic surgery) are only eligible for payment where the medical record demonstrates the consultation is medically necessary.
If the consultant requests a referral after the service has been provided, a consultation is not payable; the appropriate visit fee should be claimed instead.
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