A255 – Limited consultation
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A limited consultation is a consultation which is less demanding and, in terms of time, normally requires substantially less of the physician’s time than the full consultation. Otherwise, a limited consultation has the same requirements as a full consultation, including a written request from a referring physician, nurse practitioner, or dental surgeon, and a written report to the referring provider.
When to Use
- When a referring provider requests a focused opinion on a specific endocrinological issue that does not require a full history and physical, such as a single abnormal lab result needing interpretation.
- When a patient requires a brief assessment of a new endocrinological complaint, and the complexity does not warrant a full consultation (A155) but still necessitates a formal referral and report.
- When a patient is referred for a second opinion on a previously diagnosed endocrinological condition, and the scope of the assessment is limited to a specific aspect of the condition or treatment.
Common Pitfalls
- Billing A255 when the service provided was a simple follow-up visit (e.g., K005) or a minor assessment (e.g., K013) without a formal referral and report.
- Forgetting to obtain and retain a written request from the referring provider, or failing to send a written report back to the referring provider, which are mandatory requirements for A255.
- Billing A255 for a patient who is an inpatient or in the emergency department, as C255 is the appropriate code for these settings.
Billing Tips
- Ensure the patient's chart clearly documents the written referral, the specific question asked by the referring provider, and the detailed written report provided to them, as these are critical for audit purposes.
- If a patient requires a more in-depth assessment or management plan for an endocrinological issue, consider billing the full consultation code (A155) instead of A255.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultation
Consultation
A written request identifying the consultant, referring provider, and patient must be kept in the medical record.
The consultant must provide a written report (findings, opinions, and recommendations) to the referring provider.
The service must meet the definition of a consultation but be less demanding/time-consuming than a full consultation (A155).
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