W105 – Consultation
OHIP Neurology Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation is an assessment rendered in a long-term care institution following a written request from a referring practitioner, which can be a physician, nurse practitioner, or a dental surgeon (in connection with an insured dental procedure in a hospital). The request is made because of the complexity, seriousness, or obscurity of the case, or because the patient or their representative requests a second opinion. The service includes all necessary work to provide a written report with findings, opinions, and recommendations to the referring practitioner. **Requirements as per :** - A copy of the written request for the consultation must be kept in the patient's record. For an institutional setting, this may be on the common medical 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. - Failure to meet these requirements may result in the service being paid as a lesser assessment fee.
When to Use
- Use W105 when a patient in a long-term care institution requires a specialist opinion for a complex, obscure, or serious condition following a formal written request.
- Use W105 when a patient or their representative specifically requests a second opinion regarding their care in a long-term care setting, provided the referral criteria are met.
Common Pitfalls
- Billing W105 without a documented written request from the referring practitioner, which will trigger a downgrade to a lesser assessment fee upon audit.
- Failing to include the referring practitioner's billing number on the referral request, as this is a mandatory requirement under GP16.
- Billing W105 for routine preoperative assessments for low-risk elective procedures, which are generally not considered medically necessary and are subject to rejection.
Billing Tips
- Ensure the written request is clearly identifiable in the common medical record of the long-term care facility to satisfy documentation requirements without needing a separate paper copy.
- If the patient is under 16 years of age, remember to append the appropriate age-based premium code to the W105 claim to maximize the specialist fee.
Effective: April 1, 2026
A. Consultations and Visits
CONSULTATIONS AND VISITS
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, 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.
Consultation limits are applicable to all consultations, including time-based and age-specific consultation services (e.g. special, extended and comprehensive consultations) but not repeat consultations.
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