A865 – 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
- Bill A865 when a patient is referred for a specific, limited issue that requires a focused assessment and clear recommendations, rather than a broad, in-depth workup.
- Use A865 for follow-up assessments on a previously diagnosed condition where the scope is defined and less extensive than a comprehensive consultation (A160).
- A865 is appropriate when the referring provider requests a specific opinion on a narrow clinical question, not requiring a full review of all past medical history.
Common Pitfalls
- Billing A865 when the service provided is more akin to a general assessment (e.g., A007) or a follow-up visit (e.g., A003) without meeting the consultation requirements.
- Failure to submit a written report to the referring physician, nurse practitioner, or dental surgeon will result in the fee being adjusted to a lesser assessment fee.
- Using A865 for an inpatient setting; C865 is the correct code for limited consultations in hospitals.
Billing Tips
- Ensure the written request from the referring provider clearly identifies the patient, consultant, referrer (with billing number), and the specific reason for consultation.
- When billing virtually, always append the 'A' suffix and confirm the service was conducted via video, as telephone-only consultations are not eligible for A865A.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
A. Consultations and Visits
Consultation
A written report (including findings, opinions, and recommendations) must be sent to the referring physician, nurse practitioner, or dental surgeon.
A copy of the signed written request must be kept in the consultant's medical record.
The request must identify the consultant, the referrer (with billing number), and the patient (with health number).
The consultant must perform a general, specific, or medical specific assessment, including a review of all relevant data.
If the requirements for a consultation are not met (e.g., no written request or report), the fee will be adjusted to a lesser assessment fee.
A865 is specifically listed under Nephrology (16) but follows the general preamble definitions for limited consultations.
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