1What Is the C035 OHIP Code?
What is OHIP Billing Code C035?
The C035 code is utilized by general surgeons in Ontario for billing a consultation provided to a hospital in-patient. This code is applicable when a patient, often admitted with conditions such as suspected appendicitis, diverticulitis, bowel obstruction, or complications requiring surgical opinion, is evaluated.
An essential consideration with C035 is ensuring it is billed correctly in situations where frequent confusion arises — notably, this consultation cannot be claimed as an admission assessment unless it qualifies as the major pre-operative visit. For extended surgical evaluations, consider billing C935 instead. The out-patient equivalent to this service is A035.
2Related Codes
| Code | Name | Frequency | Description |
|---|---|---|---|
| A935 | Special surgical consultation | As specified | Higher complexity general surgery consult in out-patient settings. |
| C935 | Special surgical consultation | As specified | Higher complexity general surgery consultation in hospital settings. |
| A035 | Consultation | As specified | Equivalent outpatient consultation for general surgery. |
| A036 | Repeat consultation | As specified | For subsequent consultations regarding same issue within the permitted period. |
3Eligibility Requirements
Eligibility Requirements for C035
- Frequency Limitations: C035 can be billed for the same patient, by the same physician, with the same diagnosis, once every two consecutive 12-month periods. An exception allows for two services within this period if the second service is after 12 months but before 24 months, given it is rendered in a hospital inpatient or emergency department context.
- Unrelated Diagnoses: For clearly unrelated diagnoses, C035 may be billed once every 12 months.
- Virtual Delivery: C035 may be rendered virtually via video and billed as C035A. Telephone consultations do not qualify under this code.
- Certain Pre-operative Visits: When the consultation serves as the major pre-operative visit, it may be included within the surgical benefit. However, other hospital assessments may not be claimed unless they meet this criterion.
Note: Always verify specific patient scenarios against the Ontario Schedule of Benefits as policies may evolve.
4What Your Clinical Note Must Show
Ensure the following details are captured in the patient’s medical record:
- Patient identification and consent for consultation rendered
- Detailed reason for consultation including presenting symptoms
- Consultation findings and clinical decision-making process
- Plan of care or recommendations given post-consultation
- Record of discussion and any follow-up actions planned
5Weak vs. Strong Note Examples
The strong note succeeds by providing specific clinical findings, actions taken, and contextual details that support the consultation's necessity. The weak note lacks detail and documentation of clinical reasoning.
Patient referred with abdominal pain. Discussed options.
Patient with suspected appendicitis presented with severe right lower quadrant pain, nausea, and elevated white cell count.
Conducted a thorough physical examination, reviewed imaging results, and discussed potential surgical intervention, explaining possible outcomes and complications.
- Diagnosis of suspected appendicitis confirmed by lab results.
- Surgical consultation provided regarding procedure and risks.
