A415 – Consultation - Gastroenterology
OHIP General Listings Code — Gastroenterology (41) · Schedule of Benefits
A consultation is an assessment rendered following a written request from a referring physician, nurse practitioner or dental surgeon who requests the opinion of a gastroenterologist because of the complexity, seriousness, or obscurity of the case.
When to Use
- Bill A415 when a patient aged 17+ presents with complex or obscure symptoms of inflammatory bowel disease (e.g., diagnostic code 555) and requires a specialist's opinion beyond that of the referring physician.
- Use A415 for a patient referred by a dentist for evaluation of oral manifestations of gastrointestinal disease, provided a relevant diagnostic code (e.g., 263) is used and the referral criteria are met.
- A415 is appropriate when a patient with a history of unexplained GI bleeding (diagnostic code 571) requires a gastroenterologist's assessment and management plan, following a formal written request.
Common Pitfalls
- Claims for A415 are frequently rejected if the written request from the referring provider is missing or incomplete, failing to identify the patient, referring provider's billing number, or the specific service required.
- Billing A415 without one of the specified diagnostic codes (263, 555, 556, 571, 579) will result in the claim being reduced to a lesser assessment fee.
- Failure to submit a written report back to the referring provider detailing findings, opinions, and recommendations can lead to audits and potential clawbacks, even if the initial consultation requirements were met.
Billing Tips
- Ensure the written request for A415 clearly states the reason for consultation and the specific questions the gastroenterologist is expected to address to justify the consultation level of service.
- When a patient requires a consultation for a condition unrelated to a previous A415 claim, ensure the new referral and documentation clearly indicate the unrelated diagnosis to avoid usage limit issues.
Effective: June 1, 2025
Consultations and Visits
Gastroenterology (41)
Office/Outpatient
Consultation
Written request from a referring physician, nurse practitioner, or dental surgeon.
Written report back to the referring provider including findings, opinions, and recommendations.
Must include a general, specific, or medical specific assessment.
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.
For patients aged 17 years or older. For patients 16 years of age and under, see A765.
Virtual care (A415A) is restricted to Video Only (Appendix J).
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