C465 – Infectious Disease Consultation - Non-Emergency Hospital In-Patient
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation service rendered by a specialist in Infectious Disease (46) for a non-emergency hospital in-patient. A consultation requires a written request from a referring practitioner and is performed due to the complexity, seriousness, or obscurity of the case. The service includes a full assessment of the patient and a written report of findings and recommendations back to the referring practitioner. This service must adhere to all requirements for consultations as outlined in the General Preamble, starting on page .
When to Use
- Use C465 when you are formally requested by another physician to provide an expert opinion on a complex infectious disease case for an inpatient aged 17 or older.
- Use C465 for a new, distinct infectious disease diagnosis in a patient who has already received a consultation for a different, unrelated condition within the same 12-month period.
Common Pitfalls
- Billing C465 when the service is actually a subsequent visit (C466) or a simple follow-up, which will trigger a rejection or audit adjustment to a lower-value assessment code.
- Failing to document a formal written request from the referring practitioner, which is a mandatory requirement for all consultation codes under the General Preamble.
- Attempting to bill a Special Visit Premium (e.g., K962) alongside C465, as these are explicitly restricted for this code class.
Billing Tips
- Ensure the referring physician's name and billing number are clearly documented in your consultation report to satisfy the audit requirements for a valid referral.
- If the patient is under 17, use C765 instead of C465 to avoid immediate rejection based on age-based eligibility.
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.
For patients 17 years of age and older. For patients 16 years of age and under, see billing code C765.
See General Preamble to for rules on Non-Emergency Hospital In-patient Services.
For emergency calls and other special visits to in-patients, use General Listings and Premiums when applicable - see General Preamble to .
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