A265 – Paediatric consultation
OHIP General Listings Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation rendered by a Paediatrician following a written request from a referring physician, nurse practitioner, or dental surgeon, requiring a comprehensive assessment and a written report with findings and recommendations.
When to Use
- Bill A265 when a pediatrician performs a comprehensive assessment for a child referred by a GP for a new diagnosis of suspected juvenile idiopathic arthritis, including a detailed report.
- Use A265 for a pediatrician's assessment of a neonate referred by an obstetrician for a complex congenital anomaly, provided the assessment is not covered by other specific codes like A260.
- A265 is appropriate when a pediatrician is consulted by a dentist for a child with a severe dental abscess requiring systemic management, and a written report is provided.
Common Pitfalls
- Claims for A265 are frequently rejected if the written referral from the referring physician, NP, or dental surgeon is missing or incomplete, failing to include the required details.
- Billing A265 for a patient already managed by the pediatrician for the same condition can lead to rejection, as it implies ongoing management rather than a true consultation.
- Failure to submit a comprehensive written report to the referring provider will result in the claim being reduced to a lesser assessment fee, not the full A265 specialist fee.
Billing Tips
- Ensure the written request for A265 clearly specifies the patient's condition and the information required from the consultant pediatrician to avoid ambiguity.
- When billing A265, remember to apply the appropriate age premium add-on codes (e.g., AGE_PREMIUM_LT_30_DAYS, AGE_PREMIUM_1_YEAR_TO_LT_2_YEARS) based on the patient's age at the time of service.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultations and Visits
Consultation
Written request from a referring physician, nurse practitioner, or dental surgeon (for hospital-based dental procedures).
Written report (including findings, opinions, and recommendations) must be sent to the referring provider.
The consultant must perform a general, specific, or medical specific assessment, including a review of all relevant data.
A copy of the signed written request must be kept in the consultant's 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.
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