C765 – Consultation, patient 16 years of age and under
OHIP Surgical Procedures Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation rendered in an acute care hospital for a non-emergency in-patient who is 16 years of age or under. This service is performed following a written request from a referring physician, nurse practitioner, or dental surgeon. It requires a full assessment of the patient's condition, including a review of all relevant data, to provide an expert opinion and recommendations, which must be documented in a written report to the referring practitioner. This code is used by several specialties including Cardiology, Clinical Immunology, Endocrinology, Haematology, and others. The requirements for a consultation as outlined in the Schedule of Benefits on page must be met.
When to Use
- Use C765 for the initial inpatient assessment of a pediatric patient (16 or under) when a formal written referral is received from another physician or nurse practitioner for a non-emergency opinion.
- Use C765 when providing a comprehensive specialist evaluation for a complex inpatient case that requires a formal written report back to the referring practitioner, distinguishing it from a standard subsequent hospital visit (e.g., C165).
- Use C765 for a planned inpatient consultation where the patient's condition necessitates a full review of clinical data and a documented expert recommendation, provided the referral criteria in GP16 are satisfied.
Common Pitfalls
- Failing to document a formal written request or a copy of the referral in the patient's chart will result in the claim being downgraded to a lesser assessment fee upon audit.
- Billing C765 for a patient who has already been seen by your specialty for the same condition within the last 12 months without meeting the requirements for a repeat consultation, which triggers an automatic payment adjustment.
- Submitting C765 without a corresponding written report sent to the referring practitioner, as the Ministry requires evidence of this communication to validate the 'consultation' status.
Billing Tips
- Ensure you apply the correct age-based premium (e.g., 30% for <30 days, 25% for <1 year) to the C765 base fee to maximize reimbursement for pediatric patients.
- If the patient meets trauma criteria (ISS > 12 for those < 16 years old), append the E420 trauma premium to the C765 claim to receive a 50% increase on the base fee.
Effective: October 1, 2009
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.
Patient 16 years of age and under
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