C525 – Limited consultation
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A limited consultation is a consultation which is less demanding and, in terms of time, normally requires substantially less of the physician's time than the full consultation. Otherwise, a limited consultation has the same requirements as a full consultation. 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 requests the opinion of a consultant physician because of the complexity, seriousness, or obscurity of the case, or because another opinion is requested by the patient. The consultant must prepare a written report for the referring practitioner. The 'C' prefix indicates this service is for non-emergency hospital in-patients. For services not listed, refer to the Internal Medicine Section.
When to Use
- Use C525 for a focused inpatient assessment when the referring physician requests an opinion on a specific, non-complex clinical question that does not require the comprehensive history and physical examination mandated by a full consultation (C625).
- Use C525 for a second opinion on a stable inpatient where the clinical complexity does not warrant the time-intensive workup required for a full consultation code.
Common Pitfalls
- Billing C525 when the documentation lacks a formal written request from the referring practitioner, which will lead to a clawback to a lower-valued assessment code upon audit.
- Failing to provide a formal written report back to the referring practitioner, as the absence of this report invalidates the consultation claim regardless of the clinical work performed.
- Billing C525 for a routine follow-up or a subsequent visit on the same patient; consultations are strictly for the initial assessment following a specific request.
Billing Tips
- Ensure the referral request explicitly states the reason for the consultation, as vague requests may be downgraded to a standard inpatient visit code (e.g., C002) during a Ministry review.
- If the patient's condition is complex and requires a full system review and comprehensive documentation, bill C625 instead of C525 to avoid under-billing for the time and cognitive effort expended.
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 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 request identifies the consultant by name, the referring practitioner by name and billing number, and the patient by name and health number.
The written request sets out the information relevant to the referral and specifies the service(s) required.
The consultant must prepare a written report (including findings, opinions, and recommendations) to the referring practitioner.
For emergency calls and other special visits to in-patients, use General Listings and Premiums when applicable - see to .
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