1What Is the A085 OHIP Code?
The A085 billing code is designated for consultations within the realm of plastic surgery in Ontario. It is primarily used in scenarios such as evaluating suspicious skin lesions, dealing with complex hand injuries involving tendons, planning for post-mastectomy reconstructions, and addressing scar contractures that limit function. This code is frequently applicable when a surgical decision is the outcome of the consultation, making it the major pre-operative visit as defined in the OHIP Schedule of Benefits.
This code is often underutilized due to misunderstandings about its eligibility criteria, particularly in distinguishing between consultations and assessment visits that might otherwise seem routine. Proper documentation of the decision to proceed with surgery is crucial for this billing code.
2Related Codes
| Code | Name | Frequency | Description |
|---|---|---|---|
| A935 | Special surgical consultation | As per surgical preamble | Used for complex consultations requiring advanced surgical planning. |
| C935 | Inpatient special surgical consultation | As per surgical preamble | Special consultations for inpatients involving intricate surgical decisions. |
| A086 | Repeat consultation | As needed for follow-up within guidelines | For follow-up consultations as determined necessary within a treatment period. |
| C085 | Inpatient consultation | Equivalent to A085 but for inpatients | Consultation services for hospital inpatients matching A085 criteria. |
3Eligibility Requirements
The A085 consultation can be billed for:
- Same patient, same physician, same diagnosis: one service per two consecutive 12-month periods.
- Exception: two services per two consecutive 12-month periods where the second service occurs over 12 but less than 24 months after the first and is for a hospital inpatient or emergency department patient.
- Clearly defined unrelated diagnosis: one service every 12 months.
If services exceed these limits, they are subject to payment at the general or specific assessment rate. Importantly, it can be rendered via video, billed as A085A, but cannot be billed by telephone delivery.
4What Your Clinical Note Must Show
Ensure that the following documentation is maintained:
- A clear referral from a licensed healthcare provider specifying the reason for consultation.
- Comprehensive notes on the evaluation of the patient, including diagnosis and any decision to proceed with surgery.
- Documentation of communication with the referring source if applicable.
- Confirmation that the consultation constitutes the major pre-operative visit where appropriate.
5Weak vs. Strong Note Examples
The strong note succeeds because it comprehensively documents the clinical assessment, decision-making process, and communication elements, whereas the weak note lacks specific detail and clarity regarding the surgical decision.
Consulted with patient about the hand injury.
Evaluated patient referred by Dr. Smith for a complex hand injury with tendon involvement. Discussed surgical options. Decision to proceed with tendon repair surgery, scheduled for January 20th, 2024. Referral communication documented.
- Detailed patient evaluation
- Clear decision regarding surgery
- Referral acknowledgment
