C085 – Consultation
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation rendered by a Plastic Surgeon following a written request from a referring physician, nurse practitioner, or dental surgeon, including a review of relevant data, assessment, and a written report.
When to Use
- Use C085 for the initial evaluation of a new patient referred by a primary care provider for a specific plastic surgery concern, provided no consultation for the same diagnosis has occurred in the previous 24 months.
- Use C085 when a patient is referred for a second opinion on a complex surgical case, provided the referral meets all documentation requirements and the 12-month rule for unrelated diagnoses is satisfied.
Common Pitfalls
- Billing C085 when the patient has been seen by you for the same diagnosis within the previous 24 months, which instead requires the use of C086 or a follow-up assessment code.
- Failing to retain a copy of the written referral in the patient's chart, which is a mandatory audit requirement unless the service occurs in a hospital or multi-specialty clinic with a shared medical record.
- Submitting C085 without a formal written report sent to the referring provider, which triggers a downgrade to a lower assessment fee during an audit.
Billing Tips
- Ensure the referral note explicitly names you as the consultant or specifies the specialty of Plastic Surgery to avoid rejection for missing referral details.
- If the patient presents with a new, unrelated issue within 12 months of a previous C085, clearly document the distinct diagnosis to justify the use of a second consultation rather than a repeat consultation code.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Professional Fee
Consultation
Written request from a referring physician, NP, or dental surgeon
Written report sent to the referring provider
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.
Where the referral is made by a nurse practitioner, the consultant shall provide the report to the nurse practitioner and the patient’s primary care provider, if applicable.
If consultation requirements (e.g., written report) are not met, the fee is reduced to a lesser assessment fee.
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