W865 – Limited consultation
OHIP Neurology Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A limited consultation is a consultation which is less demanding and, in terms of time, normally requires substantially less of the physician's time than the full consultation. Otherwise, a limited consultation has the same requirements as a full consultation. A full consultation is an assessment rendered following a written request from a referring physician, nurse practitioner, or dental surgeon in connection with an insured dental procedure in a hospital. The consultant provides an expert opinion due to the complexity, seriousness, or obscurity of the case, or because a second opinion is requested. It includes all services necessary to prepare a written report for the referring practitioner. This service is for patients in a non-emergency long-term care setting, such as a chronic care hospital, convalescent hospital, nursing home, or home for the aged.
When to Use
- Use W865 for a focused, time-limited specialist assessment of a patient in a long-term care facility where the complexity does not warrant the full scope of a W165 consultation.
- Select W865 when providing a second opinion or expert advice on a specific, non-complex clinical question for a patient residing in a nursing home or chronic care hospital.
Common Pitfalls
- Billing W865 for patients in acute care hospital beds; this code is strictly reserved for non-emergency long-term care settings like nursing homes or chronic care hospitals.
- Attempting to claim a special visit premium with W865; 'W' prefix codes are ineligible for premiums, and you must use 'A' prefix assessment codes if a special visit premium is required.
- Failing to secure a written referral request prior to the service; if the referral is obtained after the visit, the claim will be rejected as a consultation and must be billed as a standard visit.
Billing Tips
- Ensure the written referral request explicitly states the clinical question or service required, as a generic 'please see' note may be insufficient to support the consultation fee upon audit.
- If you provide psychotherapy on the same day as W865, ensure your documentation clearly distinguishes the two services with separate, unrelated diagnoses to avoid automatic rejection.
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, 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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