1What Is the C065 OHIP Code?
The C065 billing code represents a consultation service provided by an orthopaedic surgeon. It is typically used when assessing patients admitted to the hospital for issues such as fractures from falls, diabetic foot infections, or unrelated musculoskeletal problems identified post-operatively.
Orthopaedic consultations are crucial in determining optimal treatment pathways, especially when complex surgical input is needed. However, the use of this code might be missed if there is confusion over eligible scenarios, such as consultations that occur outside of the pre-operative context or for issues deemed unrelated to the primary admission reason.
2Related Codes
| Code | Name | Frequency | Description |
|---|---|---|---|
| A935 | Special surgical consultation | As per consultation needs | Higher fees for more complex consultation needs. |
| C935 | Special surgical consultation | As per consultation needs | In-patient special consultation service. |
| A065 | Consultation | Same as C065 but in out-patient settings | Applicable outside in-patient settings. |
| A066 | Repeat consultation | As needed after initial consultation | Follow-up after an initial consultation. |
3Eligibility Requirements
Eligibility for billing under C065 includes the following conditions:
-
Billing Frequency: This service can be billed once per two consecutive 12-month periods for the same patient and physician with the same diagnosis. An exception allows two services within two consecutive 12-month periods if the second consultation occurs in a hospital inpatient or Emergency Department setting and is more than 12 but less than 24 months after the first.
-
Diagnosis: Should a distinctly unrelated diagnosis be present, one consultation every 12 months is permissible.
-
Virtual Care: C065 may be rendered virtually, billed as C065A through video consultation only; telephone consultations do not qualify.
-
Pre-Operative Visit: It is important to note that C065 cannot be claimed for the major pre-operative visit unless it meets the criteria outlined in the Surgical Preamble.
4What Your Clinical Note Must Show
Ensure comprehensive notes accompany each consultation claim, demonstrating clinical necessity and meeting eligibility criteria.
- Document the patient's clinical presentation and relevance to referred issue.
- Provide details of the clinical assessment performed and recommendations made.
- Include rationale for virtual care delivery when applicable.
5Weak vs. Strong Note Examples
The strong note succeeds because it provides a comprehensive overview of the patient’s situation, potential interventions, and sufficient justification for the consultation, whereas the weak note lacks detail and clarity.
Patient examined, fracture confirmed. Plan for surgery discussed.
Patient presented with a suspected fracture after a fall. Comprehensive examination conducted.
Assessment included an evaluation of previous mobility status, pain scale, and potential surgical need.
Recommendation for immediate imaging and potential surgical intervention was provided.
- Documented detailed reasoning for hospitalization.
- Included patient history and future plan.
