C016 – Repeat consultation
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A repeat consultation is an additional consultation rendered by the same consultant, in respect of the same presenting problem, following care rendered to the patient by another physician in the interval following the initial consultation but preceding the repeat consultation.
When to Use
- Use C016 when you are re-evaluating a patient for the same presenting problem after they have been managed by another physician (e.g., the primary team or a different specialist) since your initial consultation.
- Use C016 for a follow-up assessment when the patient's clinical status has changed significantly enough to warrant a new formal consultation request from the referring provider, rather than a standard subsequent visit (C002).
- Use C016 when the patient has been discharged and subsequently re-admitted to the hospital for the same condition, provided a new written referral is obtained.
Common Pitfalls
- Billing C016 without a new, distinct written referral request for the repeat consultation, which will result in a clawback during audit.
- Billing C016 when the patient has not been seen or managed by another physician in the interim; in this case, the service is a subsequent hospital visit (C002) and not a repeat consultation.
- Failing to document the specific 'intervening care' provided by another physician, which is a mandatory requirement to justify the 'repeat' status of the consultation.
Billing Tips
- Ensure the referring physician explicitly requests a 'consultation' or 're-evaluation' in their note to satisfy the requirement for a new written request for each C016 claim.
- If the patient is seen in a hospital setting, ensure the referral request is clearly documented in the common medical record to satisfy the documentation requirement without needing a separate paper referral.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
In-patient
Consultation
A written request from a referring physician, nurse practitioner, or dental surgeon (for hospital-based insured dental procedures) is mandatory.
The consultant must provide a written report (findings, opinions, and recommendations) to the referring provider.
The service must be for the same presenting problem as the initial consultation.
Another physician must have rendered care to the patient in the interval between the initial consultation and the repeat consultation.
A new written request is required for each repeat consultation.
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 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 the requirements for a consultation are not met (e.g., no written request), the fee will be adjusted to a lesser assessment fee.
The pre-anaesthetic evaluation is considered part of the general anaesthesia service and is not separately billable as a consultation.
The routine pre-anaesthetic evaluation required by the Public Hospitals Act does not constitute a consultation.
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