C055 – Consultation
OHIP Surgical Procedures Code — NON-EMERGENCY HOSPITAL IN-PATIENT SERVICES · Schedule of Benefits
A consultation rendered to a hospital in-patient by a specialist in Community Medicine (05) following a written request from a referring physician, nurse practitioner, or dental surgeon. The service includes the necessary assessment and a written report back to the referrer.
When to Use
- Use C055 when a Community Medicine specialist is formally requested to provide an opinion on a complex inpatient case that does not meet the 50-minute threshold required for C050.
- Use C055 for an initial inpatient assessment requested by a primary care physician or nurse practitioner to address a specific diagnostic or management question regarding a patient's community health status.
Common Pitfalls
- Billing C055 when the patient is under your ongoing care for the same condition, as this should be billed as a subsequent visit (e.g., C052) rather than a consultation.
- Failing to document the specific written request from the referring practitioner in the hospital chart, which leads to automatic rejection or clawbacks during audits.
- Billing C055 when the time spent exceeds 50 minutes, as this must be billed as C050 to avoid incorrect coding penalties.
Billing Tips
- Ensure the referral note explicitly states the reason for the consultation and the specific question to be addressed, as vague requests often trigger audit scrutiny.
- If the patient requires a follow-up after the initial C055, transition immediately to subsequent hospital visit codes (C052) to avoid billing conflicts.
Effective: June 1, 2025
A. Consultations and Visits
NON-EMERGENCY HOSPITAL IN-PATIENT SERVICES
Hospital In-Patient
Consultation
A written request from a referring physician, nurse practitioner, or dental surgeon (for hospital-based dental procedures) is mandatory.
The consultant must provide a written report (findings, opinions, and recommendations) to the referring practitioner.
The request must be kept in the medical record (common hospital records are acceptable).
The request must identify the consultant, the referrer (including billing number), and the patient (including health number).
The written request sets out the information relevant to the referral and specifies the service(s) required.
If the consultation is requested by a Medical Trainee, the fee is adjusted to a lesser assessment fee.
Preoperative consultations for low-risk elective procedures (e.g., cataracts, colonoscopy) are only eligible if medically necessary and documented as such.
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