W035 – Consultation - Non-Emergency Long-Term Care In-Patient Services
OHIP Neurology Code — CONSULTATIONS AND VISITS · Schedule of Benefits
This service represents a consultation provided by a General Surgeon for a non-emergency in-patient in a long-term care facility. As per the definition on page , a consultation is an assessment rendered following a written request from a referring physician, nurse practitioner, or dental surgeon. It requires a comprehensive evaluation of the patient's condition, a review of relevant data, and the preparation of a written report with findings and recommendations for the referring practitioner. The service must be rendered in a long-term care setting such as a chronic care hospital, convalescent hospital, nursing home, or home for the aged, as specified on page .
When to Use
- Use W035 when a General Surgeon performs a comprehensive, non-emergency assessment in a nursing home or chronic care facility following a formal written request from a primary care provider.
- Select W035 for a scheduled surgical opinion on a long-term care patient where the clinical complexity requires a full consultation report rather than a standard assessment code.
Common Pitfalls
- Billing W035 for emergency situations; emergency assessments in LTC facilities must be billed using 'A' prefix codes with applicable Special Visit Premiums instead.
- Failing to document the written referral request from the referring practitioner, which leads to automatic payment reduction to a lower-value assessment fee upon audit.
- Exceeding frequency limits of one consultation per two years for the same condition or one per year for a new condition, which triggers an automatic adjustment to a lower assessment fee.
Billing Tips
- Ensure the written report is sent to the referring practitioner immediately to satisfy the core requirement for a consultation, as failure to do so will result in a payment reduction.
- Always verify that the referral request explicitly names both the consulting surgeon and the referring practitioner to avoid rejection for incomplete documentation.
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 practitioner, must be kept in the consulting physician's medical record (or on the common medical record in a hospital/LTC setting).
The request must identify the consultant by name, the referring practitioner by name and billing number, and the patient by name and health number.
The written request must set out the information relevant to the referral and specify the service(s) required.
A written report (including findings, opinions, and recommendations) must be prepared and sent to the referring practitioner.
For emergency calls and other special visits to in-patients, use General Listings and Premiums when applicable - see General Preamble to .
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