1What Is the C016 OHIP Code?
The C016 billing code applies to repeat consultations in an anesthesiology context for non-emergency hospital in-patient services in Ontario. It is utilized when an anesthesiologist sees a patient again within the same hospital stay due to a change in the patient's condition, such as a reassessment of a pain management regimen or an airway management assessment in advance of a subsequent procedure. These consultations require a new written referral from a physician, nurse practitioner, or dental surgeon. This can often be overlooked if proper documentation is not maintained, leading to a downgrading of the amount payable.
2Related Codes
| Code | Name | Frequency | Description |
|---|---|---|---|
| A015 | Consultation | Based on Schedule | Standard consultation for anaesthesiology services. |
| A016 | Repeat Consultation | Based on Schedule | Out-patient equivalent to the in-patient C016 repeat consultation. |
| A210 | Special Anaesthetic Consultation | Based on Schedule | For more complex cases requiring specialized assessment. |
| A215 | Limited Consultation for Acute Pain Management | Based on Schedule | Consultation linked to a special visit for acute pain management in in-patients. |
3Eligibility Requirements
To be eligible for billing under C016, the consultation must be a repeat service for a patient already seen by another physician in the interval since the initial consultation. The following conditions must be met:
- A new written consultation request from a referring physician, nurse practitioner, or dental surgeon is required.
- The request must be kept in the patient’s medical record unless the service is provided in a setting where common medical records are maintained, such as a hospital.
- The service must be conducted for in-patient services, not suitable for emergency settings according to the Anaesthesia listing.
- C016 can be billed for virtual services if delivered via video.
4What Your Clinical Note Must Show
A written request for the repeat consultation must be documented.
- Signed by the referring physician, nurse practitioner, or dental surgeon.
- Stored in the patient's medical record unless in a common record-keeping setting.
Detailed record-keeping of the consultation is necessary.
- Detail the reason for repeat consultation.
- Notes on the patient's current condition and changes since the last consultation.
5Weak vs. Strong Note Examples
The strong note includes specific referral documentation and comprehensive clinical details, ensuring compliance with billing requirements. The weak note lacks specific information and documentation, risking a downgrade to an assessment fee.
Patient seen for follow-up. No detailed notes recorded. No new referral documented.
Patient presented for repeat consultation due to persistent pain post-surgery.
New referral received from Dr. Smith, indicating reassessment of current pain management regimen.
Thorough evaluation conducted; new analgesia plan documented.
- Contains new referral documentation.
- Includes detailed clinical findings and updated treatment plan.
