W095 – Consultation
OHIP Neurology Code — Cardiac Surgery (09) · Schedule of Benefits
A consultation provided by a Cardiac Surgeon to a patient in a non-emergency long-term care setting. This service is rendered following a written request from a referring physician, nurse practitioner, or dental surgeon for an opinion on a complex, serious, or obscure case. The service includes all elements necessary to prepare a written report to the referring practitioner. This code is specifically for use in Chronic Care Hospitals, Convalescent Hospitals, Nursing Homes, Homes for the Aged, and designated chronic or convalescent care beds in hospitals, excluding designated palliative care beds. For emergency or special visits, an 'A' prefix code from the General Listings must be used instead.
When to Use
- Use W095 when providing a formal cardiac surgical consultation for a patient residing in a long-term care facility or chronic care bed upon a written request from a primary care provider.
- Use this code for elective, non-urgent cardiac surgical assessments where the patient's complex condition requires a written opinion and formal report to the referring practitioner.
Common Pitfalls
- Attempting to bill W095 in conjunction with Special Visit Premiums (Table IV) will result in automatic rejection, as this code is strictly for non-emergency, scheduled institutional visits.
- Failing to retain a formal written request from the referring practitioner in the patient's chart is a primary cause for audit recovery, as the Ministry requires proof of the referral source and intent.
- Billing W095 for patients in designated palliative care beds is prohibited; ensure the facility designation matches the code's specific institutional requirements.
Billing Tips
- If the patient is under 16 years of age, ensure you append the appropriate age-based fee premium to the W095 claim to maximize the specialist fee.
- Always verify that the referring practitioner's billing number is recorded in your documentation, as this is a mandatory requirement for a valid consultation claim.
Effective: June 1, 2025
Consultations and Visits
Cardiac Surgery (09)
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 facility with common medical records, the written request may be on the common record.
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.
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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