C475 – Consultation
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation is an assessment rendered to a non-emergency hospital in-patient following a written request from a referring physician, nurse practitioner, or dental surgeon. This service is for cases where the referring practitioner seeks an expert opinion from a Respiratory Disease specialist due to the complexity, seriousness, or obscurity of the case, or at the patient's request. It requires a full assessment of the patient's condition, including a review of all relevant data, and concludes with a written report of findings, opinions, and recommendations sent back to the referring practitioner. Per (PDF page ), 'C' prefix codes are designated for acute care hospital non-emergency in-patient services.
When to Use
- Use C475 when a Respiratory Disease specialist is formally requested by an attending physician to provide an expert opinion on a complex, obscure, or serious pulmonary case for an admitted hospital patient.
- Use C475 for the initial assessment of a patient transferred to your service from another department where a formal written referral request is documented in the chart.
Common Pitfalls
- Claiming C475 when you have already seen the patient in the ER or OPD for the same illness prior to admission; this service is considered an admission assessment and C475 is not payable.
- Failing to ensure the written referral request is dated prior to the service; if the request is generated after the assessment, the claim will be downgraded to a lower-value assessment code.
- Attempting to bill C475 alongside Special Visit Premiums; C475 is strictly for non-emergency hospital in-patient services and is ineligible for these premiums.
Billing Tips
- Ensure the referring practitioner's name and billing number are clearly documented in the patient's chart alongside the written request to satisfy audit requirements.
- If you are the admitting physician, ensure you do not bill a separate admission assessment if you have already performed a consultation (C475) for the same condition during the same admission.
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 or the common medical 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 specifies the service(s) required.
A written report including findings, opinions, and recommendations must be sent to the referring physician, nurse practitioner or dental surgeon.
Patient 17 years of age or older. For patients 16 years and under, see C765.
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