A405 – Limited Consultation
OHIP General Listings Code — Community Medicine (05) · Schedule of Benefits
A limited consultation rendered by a specialist in Community Medicine (05). Definition 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. Consultation Requirements A consultation is an assessment rendered following a written request from a referring practitioner (physician, nurse practitioner, or dental surgeon for an insured hospital dental procedure) who, in light of his/her professional knowledge of the patient, requests the opinion of a physician (the 'consultant physician') competent to give advice in this field because of the complexity, seriousness, or obscurity of the case, or because another opinion is requested by the patient or patient's representative. The service includes all work necessary for the consultant to prepare a written report with findings, opinions, and recommendations for the referring practitioner. The following are additional requirements: - 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. - The request must identify the consultant by name, the referring physician, nurse practitioner or dental surgeon by name and billing number, and the patient by name and health number. - The written request sets out the information relevant to the referral and specifies the service(s) required.
When to Use
- Bill A405 when a specialist in Community Medicine (05) provides a focused opinion on a specific aspect of a patient's case, requiring less time than a full consultation (e.g., reviewing a specific public health outbreak investigation).
- Use A405 for a Community Medicine specialist's assessment of a patient's suitability for a specific public health program, based on a referral from a primary care provider.
- A405 is appropriate when a Community Medicine specialist provides a brief, targeted opinion on a patient's infectious disease risk following a referral.
Common Pitfalls
- Claiming A405 when the referring physician's request is not documented in the specialist's chart, leading to rejection.
- Billing A405 for ongoing management of a patient rather than a distinct consultation, especially if the same physician previously provided a consultation for the same diagnosis.
- Submitting A405 without a written request that clearly identifies the referring provider's name and OHIP billing number, the consultant, and the patient's health number.
Billing Tips
- Ensure the written referral for A405 specifies the exact service required from the Community Medicine specialist to avoid ambiguity.
- A405 can be billed with age-based premiums (e.g., AGE_PREMIUM_LT30D) if the patient meets the age criteria and the service is rendered by a specialist.
Effective: June 1, 2025
Consultations and Visits
Community Medicine (05)
Consultation
Consultations
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.
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