C265 – Paediatric Non-Emergency Hospital In-Patient Consultation
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation is an assessment rendered to a hospital in-patient following a written request from a referring physician, nurse practitioner, or dental surgeon. The paediatric consultant provides an opinion because of the complexity, seriousness, or obscurity of the case, or because another opinion is requested by the patient or patient's representative. A written report of findings, opinions, and recommendations must be provided to the referring practitioner. This service is for patients under the care of the Paediatrics specialty (26).
When to Use
- Use C265 for a non-emergency, scheduled inpatient consultation requested by a referring physician or nurse practitioner for a patient under 16 years of age.
- Use C265 when providing a formal opinion on a complex or obscure pediatric case that requires a comprehensive review of data and a written report to the referring provider.
Common Pitfalls
- Billing C265 when the request originates from a medical trainee (resident or fellow); these must be downgraded to a hospital visit code as they do not meet the formal referral requirement.
- Failing to document the specific written request in the chart, which leads to automatic downgrades to a lower-value assessment fee during audits.
- Billing C265 in conjunction with special visit premiums; if a special visit premium is applicable, you must use the 'A' prefix equivalent (A265) instead.
Billing Tips
- Always verify the patient's age at the time of service to ensure the correct age-based premium (e.g., under 30 days, under 1 year) is applied to the base C265 fee.
- Ensure the written consultation report is clearly dated and includes the referring practitioner's name and billing number to satisfy the mandatory documentation requirements.
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 physician, nurse practitioner or dental surgeon 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. In such cases, the written request may be contained on the common medical record.
The request identifies the consultant by name and/or the specialty being consulted, the referring physician, nurse practitioner or dental surgeon by name and billing number, and identifies the patient by name and health number.
The written request sets out the information relevant to the referral and specifies the service(s) required.
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. Where the referral is made by a nurse practitioner, the consultant shall provide the report to the nurse practitioner and the patient’s primary care provider, if applicable. Except where otherwise specified, the consultant is required to perform a general, specific or medical specific assessment, including a review of all relevant data.
Patient is less than 16 years of age.
The 'C' prefix indicates a non-emergency hospital in-patient service.
For emergency calls and other special visits to in-patients, use General Listings ('A' prefix codes) and Special Visit Premiums when applicable.
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