W223 – Extended special genetic consultation (Long-Term Care In-Patient)
OHIP Neurology Code — CONSULTATIONS AND VISITS · Schedule of Benefits
An extended special genetic consultation rendered to a patient in a non-emergency, long-term care in-patient setting. As per page , this includes Chronic Care Hospitals, Convalescent Hospitals, Nursing Homes, Homes for the Aged, and designated chronic or convalescent care beds in hospitals. This service is subject to the same conditions as A223. As per the requirements for a consultation on page , this service must be initiated by a written request from a referring physician, nurse practitioner, or dental surgeon and requires a full assessment and a written report to the referring practitioner. A consultation is payable at nil if a genetic assessment (K016) or genetic care (K222) has previously been claimed by the same physician.
When to Use
- Use W223 for an initial, comprehensive genetic consultation requested for a patient residing in a long-term care facility, nursing home, or chronic care hospital.
- Select W223 when the patient requires a formal genetic evaluation that meets the full consultation requirements defined in GP16, distinguishing it from a routine genetic assessment (K016) or ongoing genetic care (K222).
Common Pitfalls
- Billing W223 after having previously claimed K016 or K222 for the same patient will result in a payment of nil, as these codes are mutually exclusive for the same physician.
- Failure to maintain a written, signed referral from the attending physician or nurse practitioner in the patient's record will lead to a clawback or reduction to a lower assessment fee upon audit.
- Using W223 for patients in acute care settings is incorrect; ensure the facility meets the definition of a long-term care or chronic care institution as specified in GP49.
Billing Tips
- Ensure the written referral explicitly states the clinical question or reason for the genetic consultation, as a generic request may not satisfy the documentation requirements for a full consultation fee.
- Apply the appropriate age premium (e.g., for patients under 16) to the W223 base fee to ensure maximum allowable reimbursement for pediatric genetic consultations in long-term care.
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 physician, nurse practitioner or dental surgeon must be kept in the consulting physician's medical record.
The written 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.
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