W155 – Consultation
OHIP Neurology Code — Endocrinology & Metabolism (15) · Schedule of Benefits
A consultation provided by a specialist in Endocrinology & Metabolism (15) for a patient in a non-emergency long-term care (LTC) setting. This includes patients in Chronic Care Hospitals, Convalescent Hospitals, Nursing Homes, Homes for the Aged, and designated chronic or convalescent care beds in hospitals, but excludes patients in designated palliative care beds, as specified on page . As defined on page , a consultation is an assessment initiated by a written request from a referring physician, nurse practitioner, or dental surgeon. The request is made because the patient's case is complex, serious, or obscure, or a second opinion is required. The service requires the consultant to prepare a written report with findings, opinions, and recommendations for the referring practitioner. For emergency calls or other special visits to these patients, General Listings (A prefix codes) and applicable special visit premiums must be used instead.
When to Use
- Use W155 for the initial endocrine assessment of a patient residing in a nursing home or home for the aged, provided there is a formal written referral.
- Use W155 when evaluating a patient in a chronic care hospital bed for a complex metabolic issue that requires a specialist's opinion and a formal report to the referring practitioner.
Common Pitfalls
- Billing W155 for patients in designated palliative care beds, which is explicitly excluded; these should be billed under the appropriate A-prefix codes.
- Failing to maintain a written referral request in the patient's chart, which causes the claim to be downgraded to a lesser assessment fee during an audit.
- Billing W155 for a follow-up visit; once the initial consultation is complete, subsequent visits must be billed using the appropriate repeat assessment code (W156).
Billing Tips
- Ensure the written referral specifically identifies the consultant by name and includes the referring practitioner's billing number to meet the strict documentation requirements of GP16.
- If the patient is under 16 years of age, remember to append the appropriate age-based fee premium to the W155 base fee to maximize the claim value.
Effective: June 1, 2025
Consultations and Visits
Endocrinology & Metabolism (15)
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. In a long-term care institution where common medical records are maintained, the written request may be contained 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 specifies the service(s) required.
A written report, including findings, opinions, and recommendations, must be prepared and sent to the referring practitioner.
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