A765 – Consultation, Patient 16 Years of Age and Under
OHIP General Listings Code — Cardiology (60), Clinical Immunology (62), Endocrinology & Metabolism (15), Gastroenterology (41), Haematology (61), Infectious Disease (46), Internal and Occupational Medicine (13), Medical Oncology (44), Nephrology (16), Radiation Oncology (34), Respiratory Disease (47), Rheumatology (48) · Schedule of Benefits
A consultation for a patient 16 years of age and under, billable by specialists in Cardiology (60), Clinical Immunology (62), Endocrinology & Metabolism (15), Gastroenterology (41), Haematology (61), Infectious Disease (46), Internal and Occupational Medicine (13), Medical Oncology (44), Nephrology (16), Radiation Oncology (34), Respiratory Disease (47), and Rheumatology (48). As defined in the Schedule of Benefits on page , 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. The request is made 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 the services necessary for the consultant to prepare a written report (including findings, opinions, and recommendations) to the referring practitioner. Except where otherwise specified, the consultant is required to perform a general, specific or medical specific assessment, including a review of all relevant data. Additional requirements as per : - A copy of the written request, signed by the referring practitioner, must be kept in the consulting physician's medical record. - The request must identify the consultant by name, the referring practitioner by name and billing number, and the patient by name and health number. - The written request must set out the information relevant to the referral and specify the service(s) required.
When to Use
- Bill A765 when a specialist receives a written referral for a patient 16 years or younger with a complex cardiac condition requiring expert assessment, such as suspected congenital heart disease.
- Use A765 for a referral to a pediatric rheumatologist for a child under 16 presenting with multi-joint pain and suspected juvenile idiopathic arthritis.
- A765 is appropriate when a pediatric endocrinologist is consulted for a patient aged 10 for newly diagnosed Type 1 diabetes, requiring a comprehensive assessment and management plan.
Common Pitfalls
- Billing A765 when the referral is not from a physician, nurse practitioner, or dental surgeon, or if the written request is missing or incomplete, leading to claim rejection.
- Submitting A765 for a patient over 16 years of age, as this code is strictly for patients 16 years and under.
- Claiming A765 if the physician initiates the referral request after providing the service, rather than receiving a pre-service request from the referring practitioner.
Billing Tips
- Ensure the written referral clearly states the reason for consultation and is signed by the referring practitioner, including their name and OHIP billing number.
- When billing A765, consider applicable age-based premiums (e.g., AGE_PREMIUM_UNDER_30D, AGE_PREMIUM_1Y_TO_2Y) to maximize reimbursement for younger patients.
Effective: October 1, 2009
Consultations and Visits
Cardiology (60), Clinical Immunology (62), Endocrinology & Metabolism (15), Gastroenterology (41), Haematology (61), Infectious Disease (46), Internal and Occupational Medicine (13), Medical Oncology (44), Nephrology (16), Radiation Oncology (34), Respiratory Disease (47), Rheumatology (48)
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, 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 written report (including findings, opinions, and recommendations) must be sent to the referring physician, nurse practitioner or dental surgeon.
Patient 16 years of age and under
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