C425 – Comprehensive physical medicine and rehabilitation consultation
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A comprehensive physical medicine and rehabilitation consultation provided to a non-emergency hospital in-patient. The 'C' prefix designates this service for acute care hospital in-patient settings, distinct from general 'A' prefix services. This service is explicitly subject to the same conditions as A425. As a consultation, it must meet the requirements outlined in the General Preamble (), including a written request from a referring practitioner and a subsequent written report. See to for rules on non-emergency hospital in-patient services.
When to Use
- Use C425 for the initial comprehensive assessment of a non-emergency hospital in-patient when a formal written request is received from a referring physician, nurse practitioner, or dental surgeon.
- Use C425 when providing a full consultation for a patient already admitted to the hospital, provided the service meets the GP16 requirements for a formal consultation report.
Common Pitfalls
- Failure to document the exact start and stop time in the medical record will result in an automatic reduction of the fee to a lower assessment code.
- Billing C425 when the service was actually initiated via a special visit (e.g., emergency department or after-hours call) is incorrect; those scenarios require an 'A' prefix code per GP12 and GP69.
- Missing a formal written request or failing to send a written report to the referring practitioner will trigger a rejection or an adjustment to a lesser assessment fee.
Billing Tips
- Ensure the written request from the referring practitioner is clearly identifiable in the hospital chart, as this is the primary audit trigger for C425.
- Always verify if the patient qualifies for an age-based premium (e.g., under 16 years) or the E420 trauma premium, as these must be submitted on the same claim as C425 to be processed.
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. In a hospital where common medical records are maintained, the written request may be contained 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 consultant must prepare a written report including findings, opinions, and recommendations to the referring practitioner.
The start and stop time must be recorded in the patient’s permanent medical record or the payment for the service will be reduced to a lesser fee.
Subject to the same conditions as A425.
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