1What Is the C565 OHIP Code?
The C565 billing code is categorized under limited consultations for pediatric patients admitted to hospital settings. It is used when a pediatric specialist provides a focused evaluation on a specific medical question – often determining if further investigation is required on a particular finding before a patient's discharge.
Commonly, C565 is used when the full scope of a consultation is not necessary, allowing for a more targeted look at the child's current condition. This makes it a practical choice when healthcare resources must be efficiently managed. However, it may be missed in instances where the documentation does not clearly differentiate it from a full consultation or where inexperience with the nuances of the service applicability leads to incorrect coding.
2Related Codes
| Code | Name | Frequency | Description |
|---|---|---|---|
| A260 | Special paediatric consultation | Varies per patient need and specialty | A comprehensive evaluation for complex pediatric cases with significant healthcare needs. |
| A265 | Consultation | Can be billed as needed per unique case, within limits | Standard pediatric consultation requiring significant time and expertise. |
| A266 | Repeat consultation | Varies, typically involves follow-up of existing cases | Follow-up consultations when patient conditions warrant additional assessments. |
| A565 | Limited consultation | One per two consecutive 12-month periods or annually for unrelated diagnosis | Equivalent service for outpatient settings. |
3Eligibility Requirements
Eligibility Criteria for C565
C565 is specifically designated for limited consultations provided to hospital in-patients and may also be performed virtually under certain conditions. Eligibility for virtual delivery requires use of video conferencing, as telephone consultations are excluded from eligible settings. Physicians can bill C565A for virtual services, but must ensure that it is a video-only interaction for it to qualify as an eligible Comprehensive Virtual Care Service.
Billing Frequency:
- One C565 service is allowed per two consecutive 12-month periods for the same patient, physician, and diagnosis.
- One service every 12 months for a distinctly different and unrelated diagnosis.
4What Your Clinical Note Must Show
Ensure detailed and precise medical documentation to support C565 billing.
- Clearly document the specific question or issue addressed.
- Indicate the decision-making process regarding further investigation or discharge.
- Include virtual care delivery notes if applicable, specifying video conferencing use.
- Specify differentiation from a full consultation, avoiding overlap.
5Weak vs. Strong Note Examples
The strong note succeeds because it clearly outlines the specific clinical question, the assessment pathway, and decision outcome, whereas the weak note fails to demonstrate the focused nature or outcome of the limited consultation.
Consulted for pediatric patient with fever. Saw the patient briefly, advised to await labs. No additional details discussed.
Consulted upon request regarding potential discharge suitability for pediatric patient admitted with abdominal pain. Provided assessment post-existent ultrasound; determined appendicitis not indicated, advised discharge with follow-up.
Virtual session conducted via video, per Comprehensive Virtual Care guidelines.
- Specified clinical question addressed.
- Documentation of decision-making process.
- Use of virtual care documented, if applicable.
