W106 – Repeat consultation
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 in connection with an insured dental procedure rendered in a hospital. It requires the opinion of a physician competent to give advice in this field because of the complexity, seriousness, or obscurity of the case, or because another opinion is requested by the patient or patient’s representative. A consultation includes the services necessary to enable the consultant to prepare a written report (including findings, opinions, and recommendations) to the referring physician, nurse practitioner or dental surgeon. The service includes all specific elements of assessments () and common elements (-).
When to Use
- Use W106 for a repeat consultation in a long-term care institution when a patient presents with a new, distinct, and unrelated diagnosis within 12 months of the initial consultation.
- Use this code when the patient has already had one consultation (W102) in the preceding 12 months and requires a second formal opinion for a different clinical issue.
Common Pitfalls
- Billing W106 when the patient has not met the criteria for a second unrelated diagnosis, which will result in a claim rejection or adjustment to a lower assessment fee.
- Failing to ensure the referring physician's name and billing number are clearly documented, as W106 strictly requires a formal written referral.
- Attempting to bill W106 in the same month as W010, which is prohibited as the monthly management fee is considered inclusive of such assessments.
Billing Tips
- Ensure the clinical note explicitly justifies the 'unrelated' nature of the second diagnosis to support the second W106 claim within the 12-month window.
- Verify that the service is provided in a long-term care institution, as the 'W' prefix is strictly reserved for these settings, unlike 'A' prefix codes used for hospital-based emergency consultations.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Hospital and Institutional Consultations and Assessments, Assessments
All insured services must be documented in appropriate records. The Act requires that the record establish that: 1. an insured service was provided; 2. the service for which the account is submitted is the service that was rendered; and 3. the service was medically necessary.
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.
The 'W' prefix codes are for non-emergency in-patient services rendered in a long-term care institution.
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