C005 – Consultation
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation rendered by a family or general practitioner for a non-emergency hospital in-patient. A consultation is defined as an assessment rendered following a written request from a referring physician, nurse practitioner, or dental surgeon who requests the opinion of a consultant because of the complexity, seriousness, or obscurity of the case, or because another opinion is requested by the patient or their representative. This service includes all the specific elements of an assessment as defined in , such as a direct physical encounter, history taking, and physical examination. The consulting physician must prepare a written report of findings, opinions, and recommendations for the referring practitioner. The service must meet all the requirements outlined in of the Schedule of Benefits. This code is specifically for services rendered to non-emergency in-patients in an acute care hospital, as defined in to .
When to Use
- Use C005 when you are requested by another physician, nurse practitioner, or dental surgeon to provide a formal opinion on a complex, serious, or obscure clinical issue for a non-emergency hospital in-patient.
- Use C005 when a patient or their representative specifically requests a second opinion on their management, provided the request is documented and a formal report is sent to the primary attending practitioner.
Common Pitfalls
- Billing C005 without a formal, written request from the referring practitioner on file will result in a downgrade to a standard assessment fee during an audit.
- Claiming C005 for a patient you are already managing for the same diagnosis within the last 12 months will trigger a rejection or automatic adjustment to a subsequent visit code.
- Failing to include the referring practitioner's name and billing number in the written request or the subsequent consultation report is a frequent cause for claim rejection.
Billing Tips
- Ensure your written report explicitly states the findings, opinions, and recommendations, as this is the primary documentation required to justify the C005 fee over a standard hospital visit (C002).
- If you are called to the hospital for an urgent, non-scheduled assessment, ensure you bill the appropriate Special Visit Premium (e.g., C996) in addition to the C005 to maximize the claim value.
Effective: April 1, 2026
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultation
Consultations, Hospital and Institutional Consultations and Assessments
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 (unless in a common hospital record).
The written 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.
A written report including findings, opinions, and recommendations must be prepared for the referring practitioner.
A direct physical encounter with the patient is required, including taking a patient history and performing a physical examination.
See to for rules on Non-Emergency Hospital In-Patient Services.
For emergency calls and other special visits to in-patients, use General Listings ('A' prefix codes) and Premiums when applicable. See to .
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