1What Is the C085 OHIP Code?
C085 refers to a consultation service billed for by plastic surgeons seeing hospital in-patients. Typically, this involves situations like complex facial lacerations, wound dehiscence, or burn injuries requiring expert assessment for potential treatment, such as grafting. The consultations are an integral step in patient management, often urgent in nature, as these conditions need immediate attention.
Plastic surgery consultations are subject to specific OHIP billing rules. Under C085, practitioners can bill for these services once every two consecutive 12-month periods, unless a different diagnosis is present, where it can be billed for once every 12 months. Proper documentation and clear notation of the diagnosis and its relation to any previous consultations are crucial to ensure compliance with billing requirements.
2Related Codes
| Code | Name | Frequency | Description |
|---|---|---|---|
| A935 | Special surgical consultation | Varies | Billed for more complex surgical consultation cases at $194.65. |
| C935 | Special surgical consultation | Varies | Billed for hospital in-patient cases requiring special surgical consultation at $194.65. |
| A085 | Consultation | Varies, typical for outpatient | Outpatient equivalent of C085 at $106.25. |
| A086 | Repeat consultation | Varies | Applies to consultations at $62.80 where a second opinion or follow-up is rendered after the initial consultation. |
3Eligibility Requirements
Eligibility for billing code C085 under OHIP requires adherence to specific stipulations:
- It can be billed once per two consecutive 12-month periods per patient per physician per diagnosis.
- The exception allows a second consultation within this period if subsequent to an inpatient hospital admission or an Emergency Department visit following the first consultation and is more than 12 months but less than 24 months later.
- Consultations can be billed virtually by video (C085A), but telephone consultations do not qualify.
- C085 is for inpatient contexts; use A085 for outpatient services.
- Consultations cannot be billed in conjunction with a hospital or daycare admission assessment unless it is the major pre-operative visit.
4What Your Clinical Note Must Show
Ensure all necessary items are included in patient records for claims efficiency:
- Date and time of consultation.
- Detailed notes on the clinical findings and diagnosis.
- Clearly written management plan or recommendations.
- Documentation of urgency or complexity justifying in-patient consultation.
- Reference to the type of setting (e.g., hospital in-patient) and video consultation confirmation if applicable.
5Weak vs. Strong Note Examples
The strong note provides a comprehensive account of the patient's condition, the rationale for the surgery, and OHIP compliance, unlike the weak note, which lacks detail and justification.
The patient presented with a wound dehiscence. Consultation done.
Patient X, admitted with post-operative wound dehiscence requiring urgent plastic surgery intervention due to severe tissue exposure and risk of infection. Exam confirmed wound complexity needing potential grafting. Recommendations for surgical plan documented and communicated with the care team.
Video consultation executed per OHIP guidelines.
- Clear documentation of patient condition.
- Detailed assessment and planned intervention.
- Compliance with video consultation requirements.
