W235 – Consultation - Non-Emergency Long-Term Care In-Patient Services
OHIP Neurology Code — INTERNAL AND OCCUPATIONAL MEDICINE (13) · Schedule of Benefits
A consultation service rendered by an Internal Medicine (13) or Occupational Medicine (13) specialist for a patient in a long-term care institution (e.g., chronic care hospital, convalescent hospital, nursing home, home for the aged). This service requires a written request from a referring physician, nurse practitioner, or dental surgeon. It includes a comprehensive assessment, review of relevant data, and a written report of findings and recommendations to the referring practitioner. This code is for non-emergency services. For emergency calls or other special visits, use 'A' prefix codes and special visit premiums as per to .
When to Use
- Use W235 when an Internal Medicine specialist performs a comprehensive, non-urgent consultation for a patient residing in a long-term care facility following a formal written request.
- Use this code for a first-time assessment of a complex chronic condition in a nursing home patient where the referring physician explicitly requests your expert opinion and management plan.
Common Pitfalls
- Billing W235 on the same day or within the same month as the W010 monthly management fee is a common audit trigger and will result in a rejection or clawback.
- Failing to document the specific name and billing number of the referring physician or nurse practitioner in the patient's chart will lead to a rejection during a post-payment audit.
- Attempting to add a special visit premium to W235 is prohibited; if the situation is urgent enough to warrant a premium, you must use an 'A' prefix code instead.
Billing Tips
- Ensure your written report is sent directly to the referring practitioner, as the absence of this documentation is the primary reason for downgrading the claim to a lower-paying assessment fee.
- If you are performing a follow-up visit after the initial consultation, switch to the appropriate follow-up code (e.g., W236) rather than repeating W235, as frequency limits apply.
Effective: June 1, 2025
A. Consultations and Visits
INTERNAL AND OCCUPATIONAL MEDICINE (13)
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 with common medical records, the written request may be on the common record.
The request identifies the consultant by name, 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 consultant must prepare a written report including findings, opinions, and recommendations to the referring physician, nurse practitioner or dental surgeon.
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