W065 – Consultation - Non-Emergency Long-Term Care In-Patient Services
OHIP Neurology Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation is an assessment rendered following a written request from a referring physician, nurse practitioner, or dental surgeon who requests the opinion of a consultant physician because of the complexity, seriousness, or obscurity of the case. This service, specifically for Orthopaedic Surgery, applies to non-emergency in-patients in long-term care institutions as defined in the Schedule. The service includes a general, specific, or medical specific assessment, a review of all relevant data, and the preparation of a written report to the referring practitioner. As per , all assessments include a direct physical encounter, history taking, necessary procedures not otherwise billed, arranging follow-up, and discussion with the patient or representative.
When to Use
- Use W065 when providing an initial orthopaedic assessment for a non-emergency patient in a long-term care facility following a formal written request from a primary care provider.
- Select W065 for elective orthopaedic consultations in chronic care or convalescent beds where the patient is not in an acute crisis requiring emergency intervention.
- Use this code for planned orthopaedic consultations in nursing homes or homes for the aged where the complexity of the musculoskeletal condition necessitates a specialist opinion.
Common Pitfalls
- Billing W065 for emergency orthopaedic assessments will result in rejection or audit recovery; use 'A' prefix codes with appropriate special visit premiums for emergency scenarios.
- Failure to document a specific written request from the referring physician, nurse practitioner, or dental surgeon in the chart is a primary cause for audit clawbacks.
- Attempting to claim special visit premiums (Table IV) alongside W065 is prohibited and will cause claim rejection.
Billing Tips
- Ensure the referring practitioner's name and billing number are clearly documented in the consultation report to satisfy the mandatory referral requirements.
- If the patient is under 16 years of age, remember to append the appropriate age-based fee premium to the W065 base code to maximize the claim value.
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, 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 and/or the specialty being consulted, 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.
Non-Emergency Long-Term Care In-Patient Services includes Chronic Care Hospitals, Convalescent Hospitals, Nursing Homes, Homes for the Aged, designated chronic or convalescent care beds in hospitals and nursing homes or homes for the aged, other than patients in designated palliative care beds. 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.