1What Is the C585 OHIP Code?
What is the C585 OHIP Billing Code?
C585 is used to bill the Ontario Health Insurance Plan (OHIP) for diagnostic laboratory medicine consultations specifically related to pathology. This code applies when tissue samples, slides, specimens, or laboratory results from one licensed laboratory are referred to a laboratory medicine physician at a different licensed laboratory for a written diagnostic opinion. The main focus is to provide a thorough assessment of the referred materials, ensuring that patients receive accurate diagnoses and appropriate treatment planning.
Pathology consultations under C585 are critical when the referring lab requires expertise beyond its capacity or an unbiased second opinion on complex or obscure cases. The typical scenario revolves around material from hospital inpatients requiring timely consultation to avoid delays in patient management. Despite its importance, this billing code is often missed due to administrative oversights or misunderstanding of eligibility,
By accurately identifying situations that require C585, physicians can enhance the quality of care, ensure proper billing procedures, and maintain compliance with OHIP regulations.
2Related Codes
| Code | Name | Frequency | Description |
|---|---|---|---|
| A285 | Consultation | One service every 12 months | Used for consultation services in the Laboratory Medicine (28) listings. |
| A286 | Limited consultation | One service every 12 months | Applicable for consultations that do not require the full extent of A285. |
| A580 | Comprehensive internal medicine consultation | One service per year unless otherwise specified. | A detailed internal medicine consultation in Laboratory Medicine listings. |
| A585 | Diagnostic consultation | Similar to C585 but for outpatient settings. | Diagnostic consultation under similar conditions to C585 but outside hospital inpatient settings. |
3Eligibility Requirements
Eligibility Requirements for C585
The Schedule lists C585 as "subject to the same conditions as A585". C585 is the code for the same service where the material comes from a hospital in-patient; it is not a face-to-face consultation.
- Same definition as A585: tissue, slides, specimens and/or laboratory results prepared in one licensed laboratory are referred to a laboratory medicine physician not in the same licensed laboratory for a written opinion. The specific elements are those of the L800 series of codes.
- Different licensed laboratory: material prepared in the consultant's own laboratory does not qualify.
- Comparison-use exclusion: not eligible for payment when material from a different licensed laboratory is used for comparison purposes with material done in the consultant's own laboratory.
- Other services billed with it: with the exception of the services set out under "Special Procedures and Interpretation - Histology or Cytology", any other service rendered in association with the consultation is not eligible for payment.
- Setting: C585 sits under NON-EMERGENCY HOSPITAL IN-PATIENT SERVICES in the Laboratory Medicine listing (see General Preamble GP40 to GP48). Outside hospital in-patient settings, use A585.
- Virtual delivery: C585 appears in Appendix J, Section 1 under the VIDEO ONLY heading and may be billed as C585A when rendered by video. Telephone delivery is not an eligible Comprehensive Virtual Care Service.
What does not apply. The General Preamble consultation requirements and frequency limits (GP16 to GP18) are not part of this service. The Schedule does not require a written request from a referring physician, nurse practitioner or dental surgeon for C585, and it sets no per-patient or per-12-month limit.
4What Your Clinical Note Must Show
The Schedule states no separate documentation requirement for this service beyond the record of the service itself. What has to be demonstrable is the two facts payment turns on:
- That the material was prepared in a licensed laboratory other than the consultant's.
- The written opinion itself - the interpretation is the service.
- That the outside material was the subject of the opinion rather than a comparison against work done in the consultant's own laboratory.
5Weak vs. Strong Note Examples
What makes a record adequate for this code is not a referral letter but provenance and product: which licensed laboratory prepared the material, that it was not your own, and the written interpretation itself.
Reviewed in-patient lab results. Opinion provided.
Neither the provenance of the material nor the in-patient status is recorded, and both decide whether C585 is the right code.
Histological slides on an admitted patient, prepared at XYZ Laboratory (a licensed laboratory other than this one), referred here for a written interpretation while the ward team held treatment pending the diagnosis.
- Provenance: material prepared at XYZ Laboratory; no material from this laboratory was involved.
- Patient is a hospital in-patient, which is what makes C585 rather than A585 the correct code.
- The referred material is the subject of the opinion, not a comparison against work done here.
- Written interpretation issued and returned to the referring laboratory, retained in the record.
