C226 – Repeat consultation - genetics
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A repeat consultation is an additional consultation rendered by the same consultant for 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. As a 'C' prefix code, this service applies to non-emergency in-patient services in an acute care hospital. Service Requirements: - A new written request from a referring physician, nurse practitioner, or dental surgeon (for specific hospital procedures) is mandatory. The request must be kept in the consultant's medical record, identify all parties, and state the reason for the referral. (:33, :30) - The service must include all the specific elements of an assessment as outlined in the Schedule of Benefits, such as a direct physical encounter, history taking, physical examination appropriate for the problem, and discussion with the patient or their representative. (:29) - If the requirements for a repeat consultation are not met, the service will be paid as a lesser assessment fee. (:32)
When to Use
- Use C226 when you are re-evaluating a patient for a genetic condition after they have been managed by another physician (e.g., a specialist or GP) since your last consultation.
- Use C226 for a new inpatient genetic consultation request when the patient has previously been seen for the same condition but the clinical situation has evolved significantly under the care of the primary team.
Common Pitfalls
- Billing C226 when you have previously billed K222 for the same patient, which results in a zero-dollar payment per A110:238.
- Failing to secure a new written referral for the repeat consultation, which will cause the claim to be downgraded to a lesser assessment fee.
- Submitting C226 for a follow-up visit where no intervening care by another physician occurred, which does not meet the definition of a repeat consultation.
Billing Tips
- Ensure the referring physician's name and billing number are clearly documented in the chart to support the 'intervening care' requirement for C226.
- If the patient has been seen by you previously but the criteria for a repeat consultation are not met, bill a subsequent visit code (e.g., C022) instead of C226 to avoid rejection or adjustment.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultation
Hospital and Institutional Consultations and Assessments, Consultations
A new written request from the referring physician, nurse practitioner, or dental surgeon is required.
A copy of the written request, signed by the referring practitioner, must be kept in the consulting physician's medical record (or on the common medical record in a hospital).
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.
A consultation is payable at nil if genetic care (K222) has previously been claimed by the same physician.
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