1What Is the W265 OHIP Code?
The W265 billing code pertains to consultations given to pediatric patients residing in long-term care facilities. It is intended for situations where the child or youth has a focused concern, such as altered seizure activity, feeding tolerance issues, or skin or respiratory problems requiring a pediatrician's assessment. This code should not be confused with other settings like C265 for hospital in-patient consults or A265 for office consultations. Misunderstandings frequently arise because of the specificity of the long-term care context, which mandates a particular professional evaluation that doesn't necessitate the breadth offered by a more extended assessment.
2Related Codes
| Code | Name | Frequency | Description |
|---|---|---|---|
| A260 | Special paediatric consultation | Limited to specific cases requiring in-depth examination. | A comprehensive pediatric consultation usually for complex cases requiring detailed assessment. |
| A265 | Consultation | Same patient, once every 12 months. | Office-based consultation similar in scope but for non-long-term care settings. |
| A266 | Repeat consultation | Appropriate for subsequent assessment of earlier consultations. | Reduction in fee reflecting follow-up necessity rather than initial assessment complexity. |
| A565 | Limited consultation | Used for narrowly focused patient queries. | Serves specific, brief consultation needs without the comprehensive nature of full consultations. |
3Eligibility Requirements
The W265 consultation service can be billed once per two consecutive 12-month periods for the same patient, physician, and diagnosis, with provisions allowing a second service when the follow-up occurs to a hospital inpatient or Emergency Department patient between 12 and 24 months after the first. Unrelated diagnoses may permit billing once every 12 months. This service is ineligible for payment when rendered concurrently with other services unless the newborn is classified as sick, where a medical specific assessment (C263) applies alongside attendance at maternal delivery. Additionally, standard in-hospital medical fees are claimable on top of surgical fees for certain pediatric surgical cases where medical direction is warranted.
4What Your Clinical Note Must Show
Ensure the patient's medical record includes the specific conditions and requirements outlined in the eligibility section for W265 billing.
- Patient residency in a long-term care facility
- Documentation of specific pediatric concerns requiring assessment
- Confirmation of billing frequency alignment
5Weak vs. Strong Note Examples
The strong note provides comprehensive documentation, addressing both the primary health concern and relevant interdisciplinary actions, ensuring justifiability for billing. The weak note fails to assertively document the consultation's scope and rationale.
Evaluation conducted for feeding issues in long-term care. No significant findings.
Initial consultation due to increased seizure frequency. Complete assessment included seizure history review, medication review, and coordination with neurologist. Recommendations for EEG and follow-up in one month.
Additional concern of feeding intolerance noted and addressed with speech therapist consultation.
- Documented change in seizure frequency
- Medication review outcomes
- Coordinated multidisciplinary input
