W165 – Consultation
OHIP Neurology Code — Nephrology (16) · Schedule of Benefits
A consultation provided by a Nephrology (16) specialist to a patient in a non-emergency, long-term care setting. These settings include 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). As per the General Preamble (), a consultation requires a written request from a referring physician, nurse practitioner, or dental surgeon, and involves a comprehensive assessment to provide an opinion and recommendations, which are reported back to the referring practitioner.
When to Use
- Use W165 when performing a comprehensive nephrology assessment for a patient residing in a nursing home or chronic care facility following a formal written request from the primary care provider.
- Select W165 instead of W160 when the service involves a formal consultative opinion and written report back to the referring practitioner, rather than a routine follow-up visit.
Common Pitfalls
- Billing W165 for patients in acute care beds or designated palliative care beds will result in rejection or audit recovery, as these settings are specifically excluded from the W-prefix definition.
- Failure to maintain the original written referral request in the patient record is a primary cause of clawbacks during Ministry audits, even if the consultation report itself is present.
- Attempting to bill special visit premiums (e.g., K965) alongside W165 is prohibited; these premiums are only applicable to A-prefix codes for emergency or urgent in-patient services.
Billing Tips
- Ensure your written report explicitly addresses the specific clinical question posed in the referral to satisfy the 'opinion and recommendations' requirement of GP16.
- If you see the same patient for a follow-up in the same facility, switch to W160 to avoid frequency limit rejections associated with the consultation code W165.
Effective: June 1, 2025
Consultations and Visits
Nephrology (16)
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 hospital, long-term care institution or multi-specialty clinic 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 specify the service(s) required.
The consultant must prepare a written report (including findings, opinions, and recommendations) to the referring practitioner.
Patient is 17 years of age or older
Non-Emergency Long-Term Care In-Patient Services includes Chronic Care Hospitals, Convalescent Hospitals, Nursing Homes, Homes for the Aged, designated chronic or convalescent care beds in hospitals and nursing homes or homes for the aged, other than patients in designated palliative care beds.
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