C415 – Gastroenterology Consultation
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation is an assessment rendered by a specialist in Gastroenterology for a hospital in-patient following a written request from a referring physician, nurse practitioner, or a dental surgeon (for an in-hospital dental procedure). The request is made due to the complexity, seriousness, or obscurity of the case, or at the request of the patient or their representative. The service includes all necessary steps for the consultant to provide a written report with findings, opinions, and recommendations to the referring practitioner. A full assessment, including a review of all relevant data, is required. The 'C' prefix indicates the service is for a non-emergency in-patient in an acute care hospital as per .
When to Use
- Use C415 when a hospital inpatient requires a formal gastroenterological opinion for a complex diagnostic dilemma or management plan, provided there is a documented written request from the attending physician or nurse practitioner.
- Use C415 for a new inpatient consultation request that meets the 'complexity or obscurity' criteria, distinguishing it from a routine daily follow-up visit which should be billed as a subsequent visit (C413).
Common Pitfalls
- Billing C415 when the request is from a medical trainee, which is ineligible for consultation fees and will be downgraded to a standard assessment fee.
- Failing to document the specific written request in the chart, which is a primary trigger for audit recovery even if the clinical work was performed.
- Billing C415 for a preoperative assessment for a routine colonoscopy without clear documentation of medical necessity, as these are often flagged as ineligible.
Billing Tips
- Ensure the written request explicitly names you as the consultant and includes the referring practitioner's billing number to satisfy the mandatory documentation requirements.
- If you see the patient for a follow-up on a different, unrelated condition later in the same admission, ensure your documentation clearly differentiates the two to avoid rejection when billing subsequent visit codes.
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 practitioner, must be kept in the consulting physician's medical record. In hospitals where common medical records are maintained, the written request may be on the common record.
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.
Consultation limits apply to all consultations, including time-based and age-specific consultation services, but not repeat consultations.
In the preoperative preparation of a patient undergoing specific low risk elective surgical procedures (e.g., cataract surgery, colonoscopy), a preoperative consultation is only eligible for payment where the medical record demonstrates it is medically necessary.
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