C485 – Rheumatology Consultation
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation is an assessment rendered following a written request from a referring physician, nurse practitioner or dental surgeon in connection with an insured dental procedure rendered in a hospital, who, in light of his/her professional knowledge of the patient, requests the opinion of a physician (the “consultant physician”) competent to give advice in this field because of the complexity, seriousness, or obscurity of the case, or because another opinion is requested by the patient or patient’s representative. A consultation includes the services necessary to enable the consultant to prepare a written report (including findings, opinions, and recommendations) to the referring physician, nurse practitioner or dental surgeon. Where the referral is made by a nurse practitioner, the consultant shall provide the report to the nurse practitioner and the patient’s primary care provider, if applicable. Except where otherwise specified, the consultant is required to perform a general, specific or medical specific assessment, including a review of all relevant data.
When to Use
- Use C485 for the initial rheumatological assessment of a patient 17 years or older when a formal written referral is received from a physician, nurse practitioner, or dental surgeon.
- Use C485 when providing a second opinion for a complex, obscure, or serious rheumatological condition at the specific request of the patient or their representative, provided a formal referral is documented.
- Use C485 for a new consultation regarding a patient who has been previously seen for an unrelated diagnosis, provided the frequency limit of one consultation every 12 months for an unrelated diagnosis is respected.
Common Pitfalls
- Billing C485 without a documented written referral in the chart, which will lead to a reduction to a lower-valued assessment fee upon audit.
- Exceeding the frequency limit of one consultation per two consecutive 12-month periods for the same diagnosis, which triggers an automatic adjustment to a general or specific assessment fee.
- Attempting to bill C485 for a patient 16 years of age or younger, which is a hard rejection; C765 must be used for that age group.
Billing Tips
- Ensure the referring physician's name and billing number are clearly linked to the consultation record to satisfy the mandatory documentation requirements.
- Always confirm that the written report has been sent to the referring provider, as the definition of a consultation explicitly includes the preparation and delivery of this report.
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, except in the case of a consultation which occurs in a hospital, long-term care institution or multi-specialty clinic where common medical records are maintained. In such cases, the written request may be contained on the common medical record.
The request identifies the consultant by name, the referring physician, nurse practitioner or dental surgeon by name and billing number, and identifies the patient by name and health number.
The written request sets out the information relevant to the referral and specifies the service(s) required.
A written report (including findings, opinions, and recommendations) must be prepared and sent to the referring physician, nurse practitioner or dental surgeon.
Applicable to patients aged 17 years and older. For patients 16 and under, use C765.
Consultation limits apply to all consultation types, including time-based and age-specific services, but not repeat consultations.
A preoperative consultation for low-risk elective surgeries (e.g., cataract surgery, colonoscopy) is only payable if the medical record demonstrates it is medically necessary, which is considered very uncommon.
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