C160 – Comprehensive nephrology consultation
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A comprehensive nephrology consultation is a service rendered by a specialist in nephrology for a hospital in-patient. It requires the physician to provide all appropriate elements of a consultation and spend a minimum of seventy-five (75) minutes of direct contact with the patient, exclusive of time spent rendering any other separately billable intervention or non-patient-facing time (e.g., chart review).
When to Use
- Use C160 for complex hospital in-patients requiring extensive evaluation, such as new-onset multi-organ failure or complex acid-base disturbances, where direct patient contact exceeds 75 minutes.
- Choose C160 over C165 when the clinical complexity necessitates a deep dive into the patient's history and physical examination that cannot be completed within the standard consultation timeframe.
Common Pitfalls
- Including chart review, imaging analysis, or report writing in the 75-minute calculation will lead to audit recovery, as only direct face-to-face patient contact is eligible.
- Failing to record specific start and stop times in the patient's chart is the most common reason for OHIP to downgrade C160 claims to the lower-paying C165.
- Billing C160 on the same day as E060 is prohibited; ensure your billing software prevents this conflict to avoid automatic rejection.
Billing Tips
- If your direct contact time falls short of the 75-minute threshold, bill C165 instead to avoid a formal audit adjustment and ensure prompt payment.
- Always document the specific clinical activities performed during the direct contact time to justify the duration if requested during a post-payment review.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultation
Consultation
Must follow a written request from a referring physician, nurse practitioner, or dental surgeon (for hospital-based dental procedures).
Requires a written report (findings, opinions, and recommendations) to the referring provider.
Minimum of 75 minutes of direct contact with the patient is required.
Start and stop times must be recorded in the patient's permanent medical record.
Calculation of time excludes time devoted to any other service or procedure for which an amount is payable in addition to the consultation.
Calculation of time excludes non-patient-facing time such as reviewing charts, imaging, or documentation.
Patient age 17 years and older
Subject to the same conditions as A160 (the outpatient comprehensive nephrology consultation).
Eligible for age-based fee premiums () for patients under 16 years of age.
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