C405 – Limited consultation
OHIP Surgical Procedures Code — COMMUNITY MEDICINE (05) · Schedule of Benefits
A limited consultation rendered by a specialist in Community Medicine for a non-emergency hospital in-patient. A limited consultation is defined as 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 defined in the General Preamble (). The 'C' prefix indicates the service is for a non-emergency acute care hospital in-patient.
When to Use
- Use C405 for a focused, time-limited consultation in a non-emergency hospital setting when the clinical question is narrow and does not require the comprehensive history and physical examination mandated for C400.
- Use C405 when a specialist in Community Medicine is requested to provide a specific opinion on a patient already admitted to an acute care hospital, provided the request meets all GP16 documentation standards.
Common Pitfalls
- Billing C405 when the documentation does not explicitly demonstrate a formal referral request from a physician, nurse practitioner, or dental surgeon, which leads to automatic downgrades to a subsequent visit fee.
- Claiming C405 for routine follow-up or ongoing management of a patient; consultations must address a new clinical problem or a specific request for an opinion on an existing condition.
- Failing to document the specific 'limited' nature of the service, which creates audit risk if the clinical notes resemble a comprehensive consultation (C400) or a daily hospital visit (C052).
Billing Tips
- Ensure the referring practitioner's name and billing number are clearly recorded in the patient's chart to satisfy the mandatory GP16 documentation requirements for a valid consultation claim.
- If the patient is in an ICU or CCU, remember to append the C101 premium to the C405 claim to capture the additional institutional complexity, provided no other excluded team-based fees are claimed.
Effective: June 1, 2025
A. Consultations and Visits
COMMUNITY MEDICINE (05)
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.
In a hospital, long-term care institution or multi-specialty clinic with common medical records, the written request may be on the common medical record.
The written 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 information relevant to the referral and specify the service(s) required.
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