W535 – Ophthalmology Consultation - Non-Emergency Long-Term Care In-Patient Services
OHIP Neurology Code — CONSULTATIONS AND VISITS · Schedule of Benefits
Represents an ophthalmology consultation rendered in a non-emergency long-term care facility. As per the general definition in , a consultation is an assessment provided following a written request from a referring practitioner (physician, nurse practitioner, or dental surgeon) due to the complexity, seriousness, or obscurity of the case. The consultant physician must provide a written report back to the referring practitioner. The 'W' prefix specifies the location of service as a long-term care institution.
When to Use
- Use W535 for a scheduled, non-urgent ophthalmological assessment of a long-term care resident following a formal written request from their primary care provider.
- Use this code for routine follow-up consultations in a nursing home or chronic care facility that meet the GP16 definition of a consultation, provided the patient is not in a designated palliative care bed.
Common Pitfalls
- Billing W535 for emergency ophthalmological assessments in a long-term care facility; these must be billed using A-prefix consultation codes combined with the appropriate Special Visit Premium.
- Failing to ensure the referring practitioner's name and billing number are present in the clinical record, which is a mandatory requirement for the consultation fee to be upheld during an audit.
- Billing W535 for a patient in a designated palliative care bed, as these are specifically excluded from the W-prefix long-term care definitions.
Billing Tips
- Ensure the written referral is clearly documented in the facility's common medical record to satisfy the GP16 documentation requirements without needing a separate paper referral form.
- Always verify if the patient qualifies for an age-based premium (e.g., if the patient is under 16 years of age) to maximize the claim value, as these are eligible add-ons for W535.
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, 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 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.
The written request sets out the information relevant to the referral and specifies the service(s) required.
Non-Emergency Long-Term Care In-Patient Services includes Chronic Care Hospitals, Convalescent Hospitals, Nursing Homes, Homes for the Aged, designated chronic or convalescent care beds in hospitals and nursing homes or homes for the aged, other than patients in designated palliative care beds.
For emergency calls and other special visits to in-patients, use General Listings and Premiums when applicable - see General Preamble to .
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