W096 – Repeat Consultation
OHIP Neurology Code — Cardiac Surgery (09) · Schedule of Benefits
This is a repeat consultation provided by a specialist in Cardiac Surgery (09) for a patient in a non-emergency, long-term care setting. As per , a repeat consultation is an additional consultation for the same presenting problem, rendered after another physician has provided care in the interim since the initial consultation. It requires a new written request from a referring practitioner (as per ). The service is rendered in a setting such as a Chronic Care Hospital, Convalescent Hospital, Nursing Home, or Home for the Aged (, ). The service includes all the constituent elements of a consultation, such as a direct physical encounter, review of data, and a written report to the referring practitioner.
When to Use
- Use W096 when a patient in a long-term care setting requires a new assessment for a previously consulted cardiac issue, provided another physician has actively managed the patient in the interim.
- Use this code when the 12-month limit for a standard consultation has been exceeded, as repeat consultations are exempt from the standard frequency restrictions.
Common Pitfalls
- Billing W096 without a new, distinct written referral request from the referring practitioner, which is a mandatory requirement under GP19.
- Using W096 for follow-up visits where no other physician has provided care for the condition since the initial consultation; these should be billed as subsequent visits (e.g., W092) instead.
- Attempting to claim Special Visit Premiums with W096; this code is strictly for non-emergency settings and will be rejected if combined with premium codes.
Billing Tips
- Ensure the written referral specifically mentions the need for a repeat consultation to justify the service beyond the standard consultation frequency.
- If the Ministry determines the criteria for a repeat consultation are not met, the claim will be downgraded to a lesser assessment fee, so ensure your documentation clearly highlights the 'interim care' provided by another physician.
Effective: June 1, 2025
Consultations and Visits
Cardiac Surgery (09)
Consultation
Hospital and Institutional Consultations and Assessments, Consultations
A copy of the new written request for the repeat consultation must be kept in the consultant's medical record, or on the common medical record if in a facility where common records are maintained.
The written 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 information relevant to the referral and specify the service(s) required.
The consultant must prepare a written report of their findings, opinions, and recommendations for 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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