W972 – Palliative care in nursing home or home for the aged
OHIP Neurology Code — CONSULTATIONS AND VISITS · Schedule of Benefits
A subsequent visit is any routine assessment following the patient's admission to a long-term care institution. This service is for palliative care, defined as care provided to a terminally ill patient in the final year of life where the decision has been made that there will be no aggressive treatment of the underlying disease and care is directed to maintaining the comfort of the patient until death occurs. This service includes all common and specific elements of an assessment as defined in the Schedule of Benefits on pages -.
When to Use
- Use W972 for routine palliative assessments in a long-term care setting when the patient is in the final year of life and the care plan focuses on comfort rather than curative treatment.
- Use this code for subsequent palliative visits when you are the Most Responsible Physician (MRP) and have not already billed the monthly management fee (W010) for that patient in the same month.
Common Pitfalls
- Billing W972 in the same month as the monthly management fee (W010) by the same physician will result in a rejection, as these are mutually exclusive for the MRP.
- Attempting to use W972 for acute intercurrent illnesses is incorrect; these should be billed under W121 or appropriate 'A' prefix codes if a special visit is required.
- Confusing W972 with general subsequent visit codes; W972 is strictly restricted to patients meeting the specific palliative criteria defined in the Schedule of Benefits.
Billing Tips
- If you are a specialist who is not the MRP, you may bill W972 in addition to the MRP's monthly management fee (W010).
- Ensure your documentation explicitly supports the palliative status and the shift to comfort-directed care to satisfy audit requirements for this specific code.
Effective: June 1, 2025
A. Consultations and Visits
CONSULTATIONS AND VISITS
Assessment
Hospital and Institutional Consultations and Assessments
All insured services must be documented in appropriate records that establish the service was provided, the service claimed is the service that was rendered, and the service was medically necessary, as per .
Applies to patients in chronic care hospitals, convalescent hospitals, nursing homes, homes for the aged and designated chronic or convalescent care beds in hospitals other than patients in designated palliative care beds.
When acute intercurrent illness requires a special visit, submit claims using the appropriate fees under General Listings ('A' prefix) and premiums.
Submit claims for acute intercurrent illnesses requiring visits other than special visits using W121.
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