1What Is the A035 OHIP Code?
This code is a compensation vehicle for general surgery consultations primarily in offices or outpatient clinics. The typical use involves evaluating patients referred by other healthcare providers for potential surgical issues, such as hernias, gallstones, or lumps in breasts or thyroids.
The consultation serves to determine the necessity and timing of surgery, differentiating it from assessments conducted in hospital settings. Typically, the consultation where a final decision to operate is made, known as the major pre-operative visit, is billable under this code.
Physicians often miss the intricate rules around the A035 billing, especially the distinction between a regular consultation and the major pre-operative visit, leading to potential underbilling if not claimed separately.
2Related Codes
| Code | Name | Frequency | Description |
|---|---|---|---|
| A935 | Special surgical consultation | As required | For complex surgical cases requiring specialized consultation. |
| C935 | Special surgical consultation | As required | Hospital inpatient equivalent for special surgical consultations. |
| A036 | Repeat consultation | As required | For follow-up consultations after an initial consultation has been billed. |
| C035 | Consultation | As required | The same service provided to a hospital inpatient. |
3Eligibility Requirements
The A035 code is used specifically for a general surgery consultation and is subject to specific billing frequency constraints. A physician can bill this code for the same patient, diagnosis, and physician once every two consecutive 12-month periods. An exception allows two services in these periods if the second occurs over 12 but less than 24 months from the first for hospital inpatients or emergency department patients.
This code can also be rendered virtually if conducted via video, billed as A035A. However, telephone consultations are not eligible under this code as virtual care services.
4What Your Clinical Note Must Show
To ensure proper billing for A035, documentation must reflect the consultation's comprehensive nature.
- Detailed history and physical examination relevant to surgical decision-making
- Clear documentation of the surgical decision process
- Consultation details including reasons and outcomes discussed
5Weak vs. Strong Note Examples
The strong note succeeds due to its comprehensive documentation of the evaluation and surgical decision-making process, whereas the weak note lacks specificity and documentation of clinical impressions.
Patient referred for gallstones. Surgical consultation conducted with decision deferred.
Patient referred for symptomatic gallstones. Comprehensive history and examination performed. Discussed surgical options, risks, and benefits, ultimately deciding to proceed with cholecystectomy.
- History of gallstone attacks documented
- Physical exam focused on abdominal findings
- Surgical decision-making process detailed
