1What Is the W516 OHIP Code?
W516 is a billing code under the Ontario Health Insurance Plan (OHIP) for repeat consultations provided by physicians specializing in Physical Medicine & Rehabilitation. It specifically pertains to non-emergency long-term care inpatient services, covering settings such as chronic care hospitals and nursing homes.
The Clinical context for the use of W516 often involves re-referrals for long-stay residents exhibiting conditions like new pressure injuries or unmanageable spasticity. The repeat consultation must be based on a new written request by a referring physician, nurse practitioner, or dental surgeon. This ensures that critical follow-up care is provided to patients, potentially making a significant impact on patient outcomes.
This code can often be overlooked due to the complexity of maintaining appropriate documentation or the assumption that a prior consultation precludes another charge. It is crucial, however, to meet all outlined requirements to secure proper reimbursement.
2Related Codes
| Code | Name | Frequency | Description |
|---|---|---|---|
| A315 | Consultation in Physical Medicine & Rehabilitation | N/A | Initial consultation for complex assessments. |
| A316 | Repeat consultation | N/A | Repeat consultation for similar cases in physical rehabilitation. |
| A425 | Comprehensive physical medicine and rehabilitation consultation | N/A | In-depth initial evaluation for comprehensive care. |
| A515 | Limited consultation | N/A | Restricted evaluation focusing on specific health issues. |
3Eligibility Requirements
Eligibility for billing W516 requires the following:
- The patient must be in a non-emergency long-term care inpatient setting such as a chronic care hospital, nursing home, or similar facility not involving palliative care beds.
- The repeat consultation should follow a new written request from the referring physician, nurse practitioner, or dental surgeon addressing the same diagnostic issue but post-intervention by another physician.
- Virtual consultations are eligible, provided the service is rendered via video, as telephone consultations are not payable under OHIP as comprehensive virtual care.
All consultations must satisfy the criteria specified in GP16, and each new referral should be documented and retained in the patient's medical records.
4What Your Clinical Note Must Show
A copy of the new written request signed by the referring practitioner must be maintained.
- Signed by a referring physician, nurse practitioner, or dental surgeon.
- Kept in the consultant's medical records unless a shared system is in place.
Each consultation rendered must meet the requirements for thorough documentation.
- Document patient status at consultation time.
- Evidence of previous interventions and ongoing issues.
- Clear reason for the reconsultation related to the initial problem.
Ensure consultations billed virtually are executed via eligible methods.
- Conducted via video; telephone-only consultations are not billable.
- Retain records of the virtual consultation details.
5Weak vs. Strong Note Examples
The strong note clearly identifies the clinical issue and includes documentation of a new referral, fulfilling all requirements. The weak note fails to document a new referral, necessary for billing under W516.
Patient seen for same issue as prior consultation. No new referral documented.
Patient presented with worsening spasticity. Had seen facility physician; new referral noted on chart.
- New referral from referring physician on file.
- Detailed notes on spasticity evolution and intervention response.
- Follow-up plan clearly documented.
