W265 – Consultation - Non-Emergency Long-Term Care In-Patient Services
OHIP Neurology Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A consultation is an assessment rendered by a paediatrician following a written request from a referring physician or nurse practitioner. This service is for patients in a non-emergency long-term care institution, including Chronic Care Hospitals, Convalescent Hospitals, Nursing Homes, or Homes for the Aged. The service requires a review of relevant data and a written report with findings, opinions, and recommendations sent back to the referring practitioner. The request must be documented in the patient's medical record. As per the general requirements for all assessments, this service includes a direct physical encounter with the patient, history taking, physical examination, and arranging any necessary follow-up care. For full consultation requirements, see .
When to Use
- Use W265 for the initial comprehensive assessment of a paediatric patient residing in a long-term care facility, such as a chronic care hospital or nursing home, when requested by a referring physician or nurse practitioner.
- Select W265 instead of a standard hospital consultation (e.g., A265) when the patient's primary residence is a designated long-term care institution, ensuring the referral documentation explicitly mentions the institutional setting.
Common Pitfalls
- Billing W265 without a formal, written referral request in the patient's chart will lead to a reduction to a lower-value assessment code upon audit.
- Failing to include the referring practitioner's name and billing number in your clinical notes or billing submission is a frequent cause of rejection for consultation codes.
- Attempting to bill W265 for patients aged 18 or older will result in automatic rejection, as this code is strictly limited to paediatric patients.
Billing Tips
- Always apply the appropriate age premium (e.g., 5 to 16 years) to W265, as these are not automatically calculated by the system and must be added to your claim.
- Ensure your written report is sent to the referring practitioner promptly; the absence of this report in the event of a Ministry review will invalidate the consultation claim.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultation
Consultations, Hospital and Institutional Consultations and Assessments
The request identifies the consultant by name and/or the specialty being consulted, the referring physician, nurse practitioner or dental surgeon by name and billing number, and identifies the patient by name and health number.
Service is for paediatric patients (newborn, infant, child, or adolescent).
For emergency calls and other special visits to in-patients, use General Listings and Premiums when applicable - see General Preamble to .
In surgical cases requiring medical direction, standard in-hospital medical fees are to be claimed in addition to the surgical fee. This includes all operations on babies under one year of age, and all other older children who require medical supervision.
Ready to bill this code?
SnapBill makes OHIP billing simple — auto-filled codes, validation, and batch submission.