W536 – Repeat consultation - Non-Emergency Long-Term Care In-Patient Services - Ophthalmology
OHIP Neurology Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A repeat consultation rendered by an ophthalmologist (specialty 23) in a non-emergency long-term care setting. A repeat consultation is an additional consultation rendered by the same consultant for the same presenting problem, following care rendered to the patient by another physician in the interval following the initial consultation. Key Requirements: - As per , a repeat consultation has the same requirements as a regular consultation, which includes a new written request from a referring physician, nurse practitioner, or dental surgeon. - The written request must be kept in the patient's medical record. If in a facility with a common medical record, the request may be on that record. - The request must identify the consultant, the referring practitioner (with billing number), and the patient (with health number), and describe the reason for the referral. (See ). Applicable Locations: This service is for patients in: - Chronic Care Hospitals - Convalescent Hospitals - Nursing Homes - Homes for the Aged - Designated chronic or convalescent care beds in hospitals This service is not for patients in designated palliative care beds. () Billing Note: For emergency calls or visits qualifying for special visit premiums, use the appropriate 'A' prefix General Listing code, not W536. (, )
When to Use
- Use W536 when you are re-evaluating a patient for the same ophthalmological condition in a nursing home or chronic care facility after another physician has provided care in the interim.
- Use this code for a follow-up consultation requested by the primary care provider to address a new clinical development or complication related to a previously consulted condition in an LTC setting.
Common Pitfalls
- Billing W536 without a new, distinct written request from the referring practitioner will lead to a rejection or audit recovery; a standing order is insufficient.
- Using W536 for patients in palliative care beds is prohibited; ensure the patient's bed designation is confirmed as chronic or convalescent care to avoid invalid claims.
- Confusing W536 with a standard repeat visit code; remember that W536 requires the specific 'consultation' criteria, including a formal referral, unlike a routine assessment.
Billing Tips
- Ensure the referring physician's billing number is clearly documented on the referral request to satisfy the mandatory identification requirements for W536.
- If the patient is in a facility with common medical records, explicitly note the location of the written referral in your chart to streamline potential audit verification.
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 long-term care institution where common medical records are maintained, the written request may be contained on the common medical record.
The request must identify the consultant by name, the referring practitioner by name and billing number, and the patient by name and health number.
The written request must set out the information relevant to the referral and specify the service(s) required.
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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