W435 – Limited consultation
OHIP Neurology Code — INTERNAL AND OCCUPATIONAL MEDICINE (13) · Schedule of Benefits
A limited consultation is an assessment rendered by a specialist in a long-term care institution following a written request from a referring practitioner. This service is less demanding and normally requires substantially less time than a full consultation (e.g., W235), but must meet all other requirements of a consultation as defined in the Schedule of Benefits. The service is provided to a patient in a non-emergency capacity within a long-term care facility, such as a chronic care hospital, convalescent hospital, nursing home, or home for the aged. It includes a written report back to the referring practitioner.
When to Use
- Use W435 when a specialist provides a focused assessment in a long-term care facility for a specific clinical question that does not require the comprehensive depth of a full consultation like W235.
- Use this code for routine specialist reviews in nursing homes or chronic care hospitals where the referral request specifies a limited scope of service.
Common Pitfalls
- Billing W435 when the service provided actually meets the complexity criteria for a full consultation (W235), resulting in under-billing.
- Attempting to add special visit premiums to W435, which is strictly prohibited as W-prefix codes are institutional and ineligible for these premiums.
- Failing to ensure the written referral request explicitly identifies the consultant and the referring practitioner by name and billing number, which leads to automatic rejection during audits.
Billing Tips
- Ensure the written request is clearly documented in the common medical record of the long-term care facility to satisfy the consultation requirement without needing a separate paper referral.
- If the patient is under 16 years of age, always apply the appropriate age-based premium to the W435 fee to maximize the claim value.
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, except in the case of a consultation which occurs in a hospital, long-term care institution or multi-specialty clinic where common medical records are maintained. In such cases, the written request may be contained on the common medical 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.
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