1What Is the C486 OHIP Code?
C486 is a billing code used in Ontario for repeat rheumatology consultations provided to non-emergency hospital in-patients. This code is utilized when a rheumatologist is re-consulted for the same patient issue following a period of care managed by another physician. Typically, these consultations arise for complex cases like vasculitis or lupus where the patient's condition has altered after admission.
Unlike initial consultations, C486 can be billed repeatedly under certain circumstances, provided each consultation is prompted by a new request from the referring physician, nurse practitioner, or dental surgeon. However, proper documentation is crucial, as billing errors often stem from failing to maintain the necessary written referral or misunderstanding eligibility criteria.
2Related Codes
| Code | Name | Frequency | Description |
|---|---|---|---|
| A485 | Consultation | once every 24 months | Initial consultation billed under Rheumatology. |
| A486 | Repeat consultation | as needed with new referrals | Outpatient equivalent of C486. |
| A590 | Comprehensive rheumatology consultation | as applicable | Comprehensive cases require this code. |
| A595 | Limited consultation | as applicable | Simpler or follow-up cases may use this code. |
3Eligibility Requirements
To be eligible for the C486 billing code:
- The consultation must be for a non-emergency hospital in-patient service.
- It must address the same medical issue previously reviewed and be requested anew by a referring healthcare provider.
- A copy of the written request from the referring physician, nurse practitioner, or dental surgeon must be retained in the patient records, unless a common medical record is in use within the institution.
- This consultation cannot be rendered via telephone; virtual delivery is permissible only if conducted via video.
- Failing to meet these requirements may result in the service being compensated at a lower assessment fee.
4What Your Clinical Note Must Show
Maintain a signed written request for the consultation from the referring healthcare provider.
- Referring physician
- Nurse practitioner
- Dental surgeon
Ensure accurate medical record documentation.
- Keep copies of all referrals
- Document consultation details
Adhere to virtual service guidelines for video consultations.
- Indicate video method used
5Weak vs. Strong Note Examples
The strong note clearly specifies the new referral, clinical background, and adherence to documentation standards, aligning with billing requirements. The weak note lacks detail about the referral and specific conditions addressed, risking improper billing compliance.
The patient required a consultation again due to worsening symptoms.
Received a new written request from Dr. Smith after patient's lupus exacerbated in the ward. Consultation today addressed same conditions as initial visit, with focus on updated symptoms.
Complied with in-patient documentation protocol.
- Retain referral copy from Dr. Smith
- Document findings accurately
