C165 – Nephrology consultation
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation rendered by a nephrologist for a non-emergency hospital in-patient, aged 17 years or older. This service is claimed with a 'C' prefix, indicating it is for non-emergency in-patient services in an acute care hospital. Definition As per , a consultation is an assessment rendered following a written request from a referring physician, nurse practitioner, or dental surgeon (for in-hospital dental procedures). It is requested due to the complexity, seriousness, or obscurity of the case, or at the request of the patient or their representative. Required Elements - A written request from the referring practitioner must be kept in the consultant's medical record. - The request must identify the consultant, the referring practitioner (with billing number), and the patient (with health number). - The request must detail relevant information and specify the service(s) required. - The consultant must prepare a written report with findings, opinions, and recommendations for the referring practitioner. Failure to meet these requirements may result in the service being paid as a lesser assessment fee. For patients 16 years of age and under, see billing code C765.
When to Use
- Use C165 for the initial inpatient assessment of a patient 17 years or older when a formal written request is received from a referring physician or nurse practitioner for a nephrology opinion.
- Use C165 when managing complex electrolyte disturbances or acute kidney injury in an inpatient setting where the complexity of the case warrants a formal consultation rather than a subsequent visit (C166).
Common Pitfalls
- Billing C165 without a documented written request in the chart will result in a downgrade to a lesser assessment fee during an audit.
- Claiming C165 for a patient who is 16 years old or younger; these must be billed under C765 to avoid automatic rejection or adjustment.
- Attempting to bill C165 on the same day as a psychotherapy or psychiatric care service by the same physician without distinct, unrelated diagnoses will lead to payment rejection.
Billing Tips
- Ensure the referring practitioner's billing number is clearly recorded in your consultation note to satisfy the mandatory documentation requirements for C165.
- If the patient is in an ICU or CCU, remember to append the C101 premium to the C165 claim to capture the additional complexity of the care environment.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultation
Consultations, Hospital and Institutional Consultations and Assessments
A copy of the written request for the consultation, signed by the referring practitioner, must be kept in the consulting physician's medical record. In a hospital where common medical records are maintained, the written request may be on the common medical record.
The request must identify the consultant by name, the referring practitioner by name and billing number, and the patient by name and health number.
The written request must set out the information relevant to the referral and specify the service(s) required.
The consultant must prepare a written report including findings, opinions, and recommendations to the referring practitioner.
For patients 17 years of age and older. Use C765 for patients 16 years of age and under.
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