A565 – 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.
When to Use
- Billing A565 for a straightforward referral requiring a focused assessment and report, such as a second opinion on a common pediatric condition like otitis media, where a full consultation (A265) is not warranted.
- Utilizing A565 for a patient aged 18-21 referred for continuity of care on a specific, less complex issue, provided the referral criteria are met.
- Coding A565 when a referring physician requests a limited assessment for a condition like uncomplicated eczema in a pediatric patient, where the time and complexity are less than a full consultation.
Common Pitfalls
- Failing to obtain and retain a written request from the referring provider, which is mandatory for A565 and can lead to fee reduction to a lesser assessment code.
- Not submitting a written report to the referring provider detailing findings and recommendations, a key requirement for A565 that can result in claim rejection or clawback.
- Billing A565 for a condition that has already been consulted on by the same physician within the last two years, as A565 has a usage limit of one service per two-year period for the same diagnosis.
Billing Tips
- Ensure the written request for A565 clearly specifies the patient's condition and the service required, and that the report sent back to the referrer addresses these points.
- When billing virtually, remember to append 'A' to the code (A565A) to designate it as a 'Video Only' service.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultations and Visits
Consultation
Requires a written request from a referring physician, nurse practitioner, or dental surgeon (for hospital-based dental procedures).
The consultant must prepare a written report (findings, opinions, recommendations) 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 medical record (or common medical record in hospitals/clinics).
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.
If consultation requirements (written request/report) are not met, the fee will be reduced to a lesser assessment fee.
Neurodevelopmental consultations for less complex conditions (e.g., ADHD) are payable at a lesser fee (A565).
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