A485 – Complex rheumatology assessment
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 who requests the opinion of a rheumatologist because of the complexity, seriousness, or obscurity of the case. It includes the services necessary to prepare a written report to the referring provider.
When to Use
- Bill A485 for the initial assessment of a patient with suspected systemic lupus erythematosus (SLE) requiring a specialist opinion on diagnosis and management plan.
- Use A485 when a patient is referred by their GP for a complex workup of undifferentiated inflammatory arthritis that has not responded to initial treatments.
- A485 is appropriate for the initial consultation of a patient with suspected vasculitis, where a detailed assessment and management strategy are required.
Common Pitfalls
- Billing A485 for routine follow-up of established rheumatologic conditions; this should be billed using A480 or other appropriate follow-up codes.
- Failure to obtain and retain a valid written referral from a physician, NP, or dental surgeon will result in the claim being adjusted to a lesser assessment fee.
- Submitting A485 for uncomplicated conditions like osteoarthritis or simple back pain, which are not considered complex rheumatologic assessments.
Billing Tips
- Ensure the written report to the referring provider includes detailed findings, opinions, and specific recommendations for ongoing management.
- A485 can be billed with applicable age premiums (GP64) for patients under 16 years of age, provided all other requirements are met.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
A. Consultations and Visits
Consultation
Written request from a referring physician, nurse practitioner or dental surgeon.
Written report (including findings, opinions, and recommendations) to the referring physician, nurse practitioner or dental surgeon.
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.
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.
Full history and assessment of the patient.
A485 is not intended for the evaluation of uncomplicated rheumatologic disorders (e.g., osteoarthritis, bursitis, neck/back pain) if billed as a complex assessment.
If the requirements for a consultation are not met (e.g., no written request), the fee will be adjusted to a lesser assessment fee.
Ready to bill this code?
SnapBill makes OHIP billing simple — auto-filled codes, validation, and batch submission.