A635 – Consultation
OHIP General Listings Code — Nuclear Medicine (63) · Schedule of Benefits
A consultation is an assessment rendered following a written request from a referring physician, nurse practitioner, or dental surgeon in connection with an insured dental procedure rendered in a hospital, who requests the opinion of a 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 representative. It includes the services necessary to enable the consultant to prepare a written report (including findings, opinions, and recommendations) to the referring provider. Where the referral is made by a nurse practitioner, the consultant shall provide the report to the nurse practitioner and the patient’s primary care provider, if applicable. Except where otherwise specified, the consultant is required to perform a general, specific or medical specific assessment, including a review of all relevant data.
When to Use
- Bill A635 when a specialist provides a written opinion and recommendations to a referring physician for a complex case, after receiving a formal written request.
- Use A635 when a patient or their representative requests a second opinion from a specialist, provided there is a written referral from the primary physician.
- A635 is appropriate when a dental surgeon requests a physician's opinion regarding a patient undergoing an insured dental procedure in a hospital setting.
Common Pitfalls
- Billing A635 for a patient already under your care in hospital; this should be billed as a subsequent visit.
- Failure to obtain and retain a signed written request from the referring provider, which is a mandatory requirement for A635.
- Submitting A635 without a corresponding written report sent to the referring provider; this can lead to claim rejection or require billing as a lesser assessment code.
Billing Tips
- Ensure the written request for A635 clearly specifies the patient, referring provider's billing number, and the service required.
- When a nurse practitioner refers, remember to send the written report for A635 to both the NP and the patient's primary care provider, if applicable.
Effective: June 1, 2025
Consultations and Visits
Nuclear Medicine (63)
Consultations and Visits
Consultation
A written request from a referring physician, nurse practitioner, or dental surgeon is required.
The request must identify the consultant by name and/or the specialty being consulted, the referring physician, nurse practitioner or dental surgeon by name and billing number, and the patient by name and health number, and set out the information relevant to the referral and specify the service(s) required.
A written report (including findings, opinions, and recommendations) must be sent to the referring physician, nurse practitioner or dental surgeon. Where the referral is made by a nurse practitioner, the consultant shall provide the report to the nurse practitioner and the patient’s primary care provider, if applicable.
The consultant is required to perform a general, specific or medical specific assessment, including a review of all relevant data.
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.
If a physician is already in the hospital and assesses one of their own patients, it constitutes a subsequent visit, not a consultation.
Consultations requested by a Medical Trainee are adjusted to the amount payable for a general or specific assessment.
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