C035 – Consultation
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation rendered to a hospital in-patient by a specialist in General Surgery following a written request from a referring physician, nurse practitioner, or dental surgeon. The service includes a review of all relevant data and the preparation of a written report containing findings, opinions, and recommendations.
When to Use
- Use C035 when you are requested by an attending physician to provide a formal surgical opinion on an inpatient who has not been previously assessed by you for the same condition within the last 12 months.
- Use C035 as the major pre-operative assessment when the decision to proceed with surgery is made during the inpatient encounter, provided the referral criteria are met.
Common Pitfalls
- Claiming C035 for a routine hospital admission assessment when you are the MRP, which is often ineligible unless it qualifies as a major pre-operative visit.
- Failing to document the specific written request from the referring provider, which leads to automatic downgrades to a lower-valued assessment code during audits.
- Billing C035 when the patient has been seen by you for the same diagnosis within the previous 12 months, triggering a rejection for exceeding usage limits.
Billing Tips
- If you spend 50 minutes or more in direct patient contact for the consultation, bill C935 instead of C035 to capture the higher complexity fee.
- Ensure your documentation explicitly references the referring physician's name and billing number to satisfy the mandatory referral requirement for a valid consultation claim.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Non-Emergency Hospital In-Patient Services
Consultation
If the requirements for a consultation are not met (e.g., no written request), the fee will be adjusted to a lesser assessment fee.
Pre-operative consultations for low-risk elective procedures (e.g., cataract, colonoscopy) are only eligible if the medical record demonstrates specific medical necessity.
C035 constitutes the admission assessment if the admitting physician has not assessed the patient for the same illness within the previous 90 days.
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