1What Is the C265 OHIP Code?
C265 represents a billing code for pediatric consultations provided to hospital in-patients in Ontario. This service is essential for managing acute issues such as jaundice in newborns or asthma exacerbations in children requiring a comprehensive management plan.
Pediatric consultations under C265 are frequently requested by hospital departments like surgery, which require expert opinions on pediatric cases. One common oversight is the incorrect usage of A265 for out-patient settings, which often leads to billing errors.
2Related Codes
| Code | Name | Frequency | Description |
|---|---|---|---|
| A260 | Special Paediatric Consultation | Dependent on specific case complexity | Used for complex or atypical pediatric consultations requiring specialized expertise. |
| A265 | Consultation | Same one-per-12-month limit applies | Applicable for consultations in out-patient settings. |
| A266 | Repeat Consultation | As needed after prior consultation | Used for follow-up consultations after the initial one. |
| A565 | Limited Consultation | As needed for limited cases | Utilized for limited scope consultations when full assessments are not necessary. |
3Eligibility Requirements
For C265, a pediatric consultation can only be billed once per two consecutive 12-month periods for the same patient and diagnosis, unless an exception applies. Two consultations are permitted within these periods if the second service is more than 12 months after the first and delivered to an in-patient or emergency department patient. For virtual consultations, C265 can be billed as C265A through video calls only, not through telephone.
For unrelated diagnoses, a new consultation can be billed once every 12 months. It is crucial to note the correct setting: C265 applies to in-patient services, while A265 would be billed for out-patient settings.
4What Your Clinical Note Must Show
Ensure that the documented details meet the OHIP requirements for C265 billing:
- Document the clinical question being addressed and the consulting service requested.
- Record the patient’s hospital in-patient status and the need for consultation.
- Include notes on diagnosis or management plans discussed during the consultation.
- Ensure clarity on whether the service was provided via video if billed as C265A.
5Weak vs. Strong Note Examples
The strong note succeeds because it records detailed clinical interactions and decision-making processes, while the weak note lacks sufficient detail needed for meaningful billing justification.
Consulted for jaundice.
Advised on feeding.
Consultation requested by neonatal unit for newborn with jaundice.
Discussed differential diagnosis, conducted examination, and advised on phototherapy initiation and feeding techniques.
Parents counseled on follow-up care and jaundice indicators for further evaluation.
- Details on the specific clinical concern addressed during the consultation.
- Comprehensive documentation of the consultation process and advice provided.
