W185 – Consultation - Non-Emergency Long-Term Care In-Patient Services
OHIP Neurology Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation for a patient in a non-emergency long-term care setting, including Chronic Care Hospitals, Convalescent Hospitals, Nursing Homes, Homes for the Aged, and designated chronic or convalescent care beds. As per the General Preamble (), a consultation is an assessment rendered following a written request from a referring physician, nurse practitioner, or dental surgeon who requests the opinion of a specialist because of the complexity, seriousness, or obscurity of the case. The consultant must perform an assessment and provide a written report with findings, opinions, and recommendations back to the referring practitioner. For emergency calls and other special visits to these patients, A prefix codes and Special Visit Premiums should be used.
When to Use
- Use W185 when providing a formal specialist opinion for a patient residing in a nursing home or chronic care facility following a written request from the attending physician or nurse practitioner.
- Select W185 for a comprehensive assessment of a complex LTC patient that requires a formal written report back to the referring practitioner, distinguishing it from a routine follow-up assessment (W186).
Common Pitfalls
- Billing W185 without a documented, dated written referral request from the referring practitioner will lead to a clawback to a lower assessment fee during an audit.
- Failing to send a formal written report to the referring practitioner is a common compliance failure; the consultation is not considered complete for billing purposes until this report is generated.
- Attempting to bill W185 for emergency visits; these must be billed using A-prefix codes and applicable Special Visit Premiums instead.
Billing Tips
- Ensure the referral request explicitly states the reason for the consultation and the specific service required, as vague requests may be flagged for insufficient documentation.
- If the patient is under 16 years of age, remember to append the appropriate age-based premium to the W185 claim to maximize the fee.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultation
Consultations, Hospital and Institutional Consultations and Assessments
A copy of the written request for the consultation, signed by the referring practitioner, must be kept in the patient's medical record. In settings with a common medical record (e.g., hospital, LTC institution), the request may be on that 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.
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