C865 – Limited consultation - Nephrology
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. This service (C865) is specifically for non-emergency in-patients in an acute care hospital.
When to Use
- Use C865 when a nephrology consultation is requested for an in-patient with a straightforward clinical question that does not require the comprehensive history and physical examination mandated by C165.
- Use C865 for focused, non-emergency inpatient assessments where the clinical scope is limited to a specific nephrological issue, such as a medication adjustment or a specific electrolyte management plan.
Common Pitfalls
- Billing C865 when the clinical complexity actually warrants a full consultation (C165); if the documentation does not support the 'limited' nature, auditors may downgrade the claim.
- Attempting to attach Special Visit Premiums to C865; as a C-prefix code, it is ineligible for these premiums, unlike A-prefix codes used for emergency or urgent in-patient assessments.
- Failing to ensure the written referral is present in the chart prior to the service; a retrospective request for a referral will result in a rejection or a forced downgrade to a subsequent visit code.
Billing Tips
- Ensure the referring physician's name and billing number are clearly documented in the consultation note to satisfy the mandatory referral requirements for C-prefix codes.
- If the patient is under 16 years of age, remember to append the appropriate age-based premium code to C865 to capture the percentage increase, as these are permitted for limited consultations.
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 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.
See General Preamble to . For emergency calls and other special visits to in-patients, use General Listings and Premiums when applicable - see General Preamble to .
Ready to bill this code?
SnapBill makes OHIP billing simple — auto-filled codes, validation, and batch submission.