L865 – Surgical Pathology, Level 5
OHIP Dermatology Code — DIAGNOSTIC AND THERAPEUTIC PROCEDURES · Schedule of Benefits
Surgical Pathology, Level 5, is an anatomical pathology service involving the gross and microscopic examination and interpretation of a complex surgical specimen, designated as level 5 within the pathology fee schedule structure. This service is one of several tiered levels for surgical pathology, reflecting a high degree of complexity.
When to Use
- Use L865 for complex specimens such as a radical prostatectomy or a total mastectomy with lymph node dissection that exceeds the complexity criteria for L864.
- Select L865 when the specimen requires extensive sectioning and microscopic evaluation of multiple tissue blocks to reach a definitive diagnosis, distinguishing it from the lower-complexity L864.
Common Pitfalls
- Billing L865 for specimens that fall under the L864 or L863 definitions will trigger audit flags for over-coding based on the standard pathology complexity tiers.
- Submitting L865 without a clear pathology report that justifies the Level 5 complexity criteria will result in a clawback during a Ministry audit.
Billing Tips
- Ensure the pathology report explicitly details the number of blocks and the complexity of the dissection to support the L865 fee if challenged by the Ministry.
Effective: April 1, 2026
J. Diagnostic and Therapeutic Procedures
DIAGNOSTIC AND THERAPEUTIC PROCEDURES
Laboratory
Diagnostic and Therapeutic Procedures
All insured services must be documented in appropriate records. The Act requires that the record establish that: 1. an insured service was provided; 2. the service for which the account is submitted is the service that was rendered; and 3. the service was medically necessary.
Ready to bill this code?
SnapBill makes OHIP billing simple — auto-filled codes, validation, and batch submission.