W765 – Consultation, patient 16 years of age and under
OHIP Neurology Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A Geriatric Medicine consultation provided to a patient in a long-term care institution such as a chronic care hospital, convalescent hospital, nursing home, home for the aged, or designated chronic or convalescent care bed. This service must be initiated by a written request from a referring practitioner for an expert opinion due to the complexity, seriousness, or obscurity of the case, or at the request of the patient or their representative. The service includes all the <term>specific elements</term> of an assessment, including a review of all relevant data, and requires a written report of findings, opinions, and recommendations to be sent to the referring practitioner.
When to Use
- Use W765 for an initial Geriatric Medicine consultation in a long-term care facility when a written referral is provided by a physician, nurse practitioner, or dental surgeon.
- Use this code when the patient is 16 years of age or under and requires a specialized geriatric assessment due to complex, chronic, or obscure medical conditions within an institutional setting.
Common Pitfalls
- Billing W765 without a formal, written referral request on file will result in an automatic adjustment to a lower-valued assessment fee.
- Attempting to bill a special visit premium alongside W765 will trigger a rejection; use an A-prefix assessment code if a premium is required.
- Submitting a consultation request after the service has already been rendered is invalid; the claim will be downgraded to a standard visit fee.
Billing Tips
- Ensure the written request in the common medical record explicitly identifies the consultant, the referring provider's billing number, and the specific clinical question to satisfy audit requirements.
- Always verify the patient's age at the time of service to ensure the correct age-based premium (e.g., 10% to 30% increase) is applied to the base W765 fee.
Effective: October 1, 2009
A. Consultations and Visits
CONSULTATIONS AND VISITS
Consultation
Hospital and Institutional Consultations and Assessments, Consultations
A copy of the written request for the consultation, signed by the referring physician, <term>nurse practitioner</term> or <term>dental surgeon</term> 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 identifies the consultant by name, the referring physician, <term>nurse practitioner</term> or <term>dental surgeon</term> by name and billing number, and identifies the patient by name and health number.
The written request sets out the information relevant to the <term>referral</term> and specifies the service(s) required.
A written report, including findings, opinions, and recommendations, must be prepared and sent to the referring practitioner.
The limits on consultation services are applicable to all consultations, including time-based and age-specific consultation services (e.g. special, extended and comprehensive consultations) but not repeat consultations.
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