C166 – Nephrology repeat consultation
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A repeat consultation is an additional consultation rendered by the same consultant, in respect of the same presenting problem, following care rendered to the patient by another physician in the interval following the initial consultation but preceding the repeat consultation. A repeat consultation has the same requirements as a consultation including the requirement for a new written request by the referring physician, nurse practitioner or dental surgeon. This service is rendered for a non-emergency hospital in-patient under the care of a nephrologist. A consultation includes the services necessary to enable the consultant to prepare a written report (including findings, opinions, and recommendations) to the referring physician, nurse practitioner or dental surgeon. Except where otherwise specified, the consultant is required to perform a general, specific or medical specific assessment, including a review of all relevant data. As an assessment, this service includes the following specific elements in addition to common elements (as described on ): - A direct physical encounter with the patient including taking a patient history and performing a physical examination. - Other inquiry to arrive at an opinion as to the nature of the patient's condition. - Performing any procedure(s) during the same encounter unless separately payable. - Making arrangements for any related assessments, procedures or therapy, and/or interpreting results. - Making arrangements for follow-up care. - Discussion with, and providing advice and information to the patient or the patient's representative. - When medically indicated, monitoring the condition of the patient and intervening, until the next insured service is provided.
When to Use
- Use C166 when a nephrology patient is re-admitted to the hospital for the same chronic condition after being discharged from your care, provided a new written referral is obtained.
- Use C166 when a patient remains in the hospital for an extended period and a new clinical problem arises that requires a formal consultation request from the attending physician, distinct from your ongoing C163 follow-up visits.
Common Pitfalls
- Billing C166 without a new written request from the referring physician is a frequent audit failure; a verbal request or a note in the chart is insufficient.
- Attempting to bill C166 for a patient seen by a medical trainee without the consultant performing and documenting their own independent assessment will result in a claim adjustment to a lower assessment fee.
- Billing C166 in conjunction with a special visit premium is prohibited; use the appropriate 'A' prefix assessment code instead if the visit was an emergency.
Billing Tips
- Ensure your documentation explicitly references the new referral request and the specific clinical change that necessitated the repeat consultation to distinguish it from routine C163 follow-up care.
- Unlike initial consultations, C166 is not subject to the 12-month frequency limit, making it the correct code for recurring hospital-based nephrology consults throughout the year.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultation
Hospital and Institutional Consultations and Assessments, Consultations
A new written request by the referring physician, nurse practitioner or dental surgeon is required for the repeat consultation.
A copy of the written request, 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 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.
The limits applicable to all consultations (e.g., one service per two consecutive 12 month periods) do not apply to repeat consultations.
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