W516 – Repeat consultation - Non-Emergency Long-Term Care In-Patient Services
OHIP Neurology Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A repeat consultation rendered by a Physical Medicine & Rehabilitation (<specialtyCodes>31</specialtyCodes>) specialist for a patient in a non-emergency long-term care institution. As defined on page of the Schedule, a repeat consultation is an additional consultation for the same presenting problem, rendered by the same consultant, but only after care has been provided by another physician since the initial consultation. It requires a new written request from a referring practitioner. All standard consultation requirements, including the need for a written referral and specific documentation as outlined on page , apply. Eligible locations are detailed on page and include chronic care hospitals, convalescent hospitals, nursing homes, and homes for the aged.
When to Use
- Use W516 when a PM&R specialist provides a repeat consultation for a patient in a long-term care facility after another physician has provided care for the same presenting problem since the initial consultation.
- Use this code when the patient's condition has evolved or a new clinical question has arisen regarding the original diagnosis, necessitating a formal re-evaluation that meets the GP19 definition of a repeat consultation.
Common Pitfalls
- Billing W516 without a new, distinct written request from the referring practitioner, which is a mandatory requirement for every repeat consultation.
- Attempting to claim a Special Visit Premium (e.g., A900 series) alongside W516; W-prefix codes are strictly prohibited from being billed with any Special Visit Premiums.
- Confusing W516 with a subsequent visit code (e.g., W511); W516 requires a specific referral and is intended for a consultation-level assessment, not routine follow-up care.
Billing Tips
- Ensure the written request for W516 explicitly states the clinical reason for the repeat consultation to satisfy the documentation requirements on page GP16.
- Verify that the patient is located in an eligible facility (e.g., nursing home, chronic care hospital) as defined in A165, as W-prefix codes are location-specific.
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. 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 must identify 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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