1What Is the C255 OHIP Code?
A limited consultation (C255) under OHIP is a concise clinical service designed for endocrinologists to assist in non-emergency hospital in-patient settings. This service typically involves delivering a brief expert opinion on specific endocrine-related issues, such as decisions regarding insulin dosages or steroid replacement, which do not warrant a full work-up. Physicians should choose this billing code when the level of complexity or time devoted is considerably less than what is required for more comprehensive consultations.
Sometimes, physicians overlook C255 due to its specificity, confusing it with more general or comprehensive consultation codes. It is essential to accurately assess the service requirements to ensure proper billing under this code.
2Related Codes
| Code | Name | Frequency | Description |
|---|---|---|---|
| A150 | Comprehensive endocrinology consultation | variable | $342.25 for comprehensive evaluations. |
| A155 | Consultation | variable | $172.95 for standard endocrinology consultations. |
| A156 | Repeat consultation | as needed | $110.15 for follow-up consultations. |
| A255 | Limited consultation | similar criteria as C255 | $110.15 for limited consultations outside hospital settings. |
3Eligibility Requirements
Eligibility Requirements
- Setting: C255 can only be billed for services provided to non-emergency hospital in-patients.
- Virtual Delivery: The service is eligible for video consultations and should be billed as C255A. Telephone consultations are not covered.
- Consultation Criteria: A formal consultation following a written request from a referring physician, nurse practitioner, or dental surgeon is mandatory.
- Consultation Definition: Must be a limited service, meaning it requires substantially less time and is more specific than a full consultation.
- Frequency Limits: One limited consultation is permitted per 24 months per patient, per physician for the same diagnosis. A second consultation may be billed if the criteria are met for a hospital in-patient with the same diagnosis more than 12 but less than 24 months after the initial consultation.
- Out-Patient Code Equivalent: Utilize A255 for outpatient settings.
4What Your Clinical Note Must Show
Ensure that a written request is present from one of the approved referral sources.
- Physician
- Nurse practitioner
- Dental surgeon in connection with an insured dental procedure
Document a concise summary of the consultation, noting time constraints and specificity.
- Patient's condition and diagnosis
- Details of the advice or decision made
- Length and scope of consultation
For virtual services billed under C255A, record the mode of delivery (video only).
- Platform used for video consultation
- Patient consent for telehealth services
5Weak vs. Strong Note Examples
The strong note succeeds by specifying the referring source, clearly documenting the consultation detail, and including virtual consultation specifics, which are crucial for billing C255A. The weak note lacks detail and does not justify the limited consultation criteria.
Consulted on patient's insulin dosage. No further details.
Patient referred by Dr. Smith for opinion on insulin regimen adjusting.
Current regimen: 20 units of insulin glargine nightly.
Recommendation: Adjust to 25 units based on current blood glucose trends.
Discussion held via videoconference using Zoom platform.
Patient expressed understanding and consent to changes.
- Referring source and reason for referral.
- Details of current treatment and corresponding adjustment.
- Use of virtual platform and patient consent.
