C395 – 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. A consultation is an assessment rendered following a written request from a referring physician, nurse practitioner, or dental surgeon in connection with an insured dental procedure in a hospital. The request is made because of the complexity, seriousness, or obscurity of the case, or because another opinion is requested. The service includes all work necessary to prepare a written report with findings, opinions, and recommendations to the referring practitioner.
When to Use
- Use C395 for an acute care hospital inpatient assessment that meets all consultation criteria but lacks the complexity or time requirement of a full C095 consultation.
- Select C395 when providing a focused second opinion on a specific clinical question for an inpatient, provided a formal written referral is present.
Common Pitfalls
- Billing C395 for a follow-up visit on the same patient for the same diagnosis is a common audit trigger; use subsequent visit codes instead.
- Failing to document the specific written request from the referring practitioner in the chart will lead to a clawback of the consultation fee to a lower assessment code.
- Submitting C395 when the service was actually an emergency department assessment; C-prefix codes are strictly for non-emergency hospital inpatients.
Billing Tips
- Ensure the referral request explicitly mentions the consultant by name or specialty to satisfy the Schedule of Benefits requirements for a valid consultation.
- Always verify that the referring physician's billing number is included in your documentation to avoid rejection during a post-payment audit.
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, 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.
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.
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