C255 – Limited consultation
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A limited consultation is a consultation which is less demanding and, in terms of time, normally requires substantially less of the physician's time than the full consultation. Otherwise, a limited consultation has the same requirements as a full consultation. As per , a consultation is an assessment rendered following a written request from a referring physician, <referralSourceType>nurse practitioner</referralSourceType>, or <referralSourceType>dental surgeon</referralSourceType>. It includes the services necessary to enable the consultant to prepare a written report (including findings, opinions, and recommendations) to the referring practitioner. The consultant is required to perform a general, specific or medical specific assessment, including a review of all relevant data.
When to Use
- Use C255 for a focused specialist assessment that requires significantly less time and complexity than a full consultation (e.g., a brief second opinion on a stable, well-documented condition).
- Use C255 when the clinical question is narrow in scope, allowing for a concise written report that still meets the formal requirements of a consultation under GP16.
Common Pitfalls
- Billing C255 when a written referral is missing or does not contain the referring provider's billing number, which will trigger a downgrade to a lower-paying assessment code.
- Attempting to bill C255 for a routine follow-up visit, which is ineligible for consultation codes and must be billed as a repeat assessment or visit code.
- Failing to document a formal written report back to the referring provider, as the absence of this report invalidates the consultation claim during an audit.
Billing Tips
- Ensure the referral request clearly specifies the service required, as vague requests can lead to claims being adjusted to a standard assessment fee.
- Verify that the referring provider's billing number is included in your electronic medical record for every C255 claim to avoid automated rejections.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultation
Hospital and Institutional Consultations and Assessments, Consultations
A copy of the written request for the consultation, signed by the referring physician, <referralSourceType>nurse practitioner</referralSourceType> or <referralSourceType>dental surgeon</referralSourceType> 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.
The request must identify the consultant by name, the referring physician, <referralSourceType>nurse practitioner</referralSourceType> or <referralSourceType>dental surgeon</referralSourceType> by name and billing number, and identify 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.
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