W996 – First person seen - Long-Term Care Institution
OHIP Neurology Code — GENERAL PREAMBLE · Schedule of Benefits
W996 is a special visit premium payable for the first patient seen during a non-elective visit to a Long-Term Care Institution. A special visit is defined in the Schedule of Benefits on page as a visit initiated by a patient or their representative for a non-elective service. This premium applies when the visit commences during weekdays daytime (07:00-17:00) with sacrifice of office hours. This premium must be claimed in conjunction with an appropriate A-prefix assessment fee. As per page , the time of the special visit must be documented in the patient's medical record for the premium to be eligible for payment. It is not payable for routine rounds or elective services. The table on page indicates there is no maximum number of these services per time period.
When to Use
- Use W996 when you are called to a long-term care facility for an urgent, non-elective assessment of a patient that requires you to leave your office during daytime hours.
- Use W996 for the first patient seen when responding to an acute clinical deterioration or urgent request from nursing staff that cannot wait for your next scheduled routine visit.
Common Pitfalls
- Billing W996 for routine, pre-scheduled rounds or elective follow-ups is a frequent audit trigger, as it is strictly reserved for non-elective, patient-initiated urgent visits.
- Failing to document the exact time of the visit in the patient's chart will lead to automatic rejection or clawback, as this is a mandatory requirement under GP69.
- Claiming W996 when you are already at the facility for other routine work is invalid, as the premium requires the sacrifice of office hours to travel to the institution.
Billing Tips
- Always pair W996 with an appropriate A-prefix assessment code (e.g., A007) and ensure the visit time is clearly noted in the chart to satisfy the General Preamble requirements.
Effective: April 1, 2026
GP. General Preamble
GENERAL PREAMBLE
Premium
Special Visit Premiums (Table IV - Long-Term Care Institution)
The time at which the special visit takes place must be documented on the medical record.
When a special visit service occurs in a long-term care institution where common medical records are maintained, the time when the visit takes place may be documented anywhere in the common medical record.
A special visit is a visit initiated by a patient or an individual on behalf of the patient for the purpose of rendering a non-elective service.
This premium is eligible for payment for the first person seen at the destination.
Submit claims using the appropriate A-prefix assessment fee from the “General Listings" for an assessment rendered in conjunction with a special visit premium.
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