A Strategic Guide to OHIP Billing for Internal Medicine Consultations and Assessments

Aug 1

For those in Internal Medicine, the distinction between billing for a consultation versus an assessment is particularly nuanced and a common source of confusion and billing errors. Mastering these differences is not just about compliance; it's about ensuring you are accurately compensated for the specialized care you provide. This guide is designed to offer clarity and strategic direction, helping you optimize your billing practices with confidence.

This article provides a definitive breakdown of the OHIP requirements for consultations and assessments. We will explore the specific criteria, documentation best practices, and fee codes you need to know. By understanding these core principles, you can enhance your claim accuracy, ensure compliance during potential audits, and focus more on what matters most—patient care.

What are the fundamental differences between an OHIP consultation and an assessment?

The primary distinction between a consultation and an assessment lies in the referral process and the required clinical depth of the evaluation. A consultation is initiated by a formal, written request from a referring physician or nurse practitioner for your specialist opinion on a complex case. It necessitates a comprehensive evaluation, including a full history and examination, and must be documented with your findings and recommendations sent back to the referring provider. In contrast, an assessment does not require a referral and may involve a more focused evaluation without a full history, often used for follow-ups or patient-initiated visits ontario.ca. This core difference directly impacts which fee codes are eligible and how you must document the service to ensure compliance with the OHIP Schedule of Benefits ontario.ca.

What are the key OHIP fee codes for outpatient consultations?

For outpatient services, Internal Medicine specialists have several consultation codes, each with specific criteria. Understanding these is a key component of Physicians First best practices for accurate billing.

A135 (Standard Consultation): This is the base code for a specialist evaluation following a referral. It requires a complete history, examination, and a written report of your recommendations to the referring provider.
A130 (Comprehensive Consultation): This code is reserved for exceptionally complex cases that require at least 75 minutes of direct, face-to-face time with the patient. It's crucial to document the start and end times in the patient's record to justify this higher-paying code.
A435 (Limited Consultation): Use this code for cases that require an abbreviated evaluation but still meet the criteria of a consultation (i.e., there is a referral). It is compensated at a lower rate than the standard consultation.
A765 (Pediatric Consultation): This code provides an enhanced fee for consultations involving patients who are 16 years of age or younger oma.org.

Are there frequency limits for billing OHIP consultations?

Yes, frequency limits are a critical aspect of OHIP compliance. For most standard and limited consultations (like A135 and A435), you can only bill one per patient, per diagnosis, within a 12-month period. If you need to see the same patient for a consultation within that year, it must be for a completely new and distinct diagnosis, which would be billed as a repeat consultation (A136). Failing to adhere to these frequency rules is a common trigger for MOH audits, so careful diagnosis-specific billing is essential ontario.ca.

How does billing for inpatient consultations differ?

Inpatient consultation billing mirrors the outpatient structure but uses "C" prefix codes (e.g., C135 for a standard inpatient consultation). However, there are critical distinctions and additional opportunities for billing that are unique to the hospital setting.

Service Location Codes: All inpatient claims must include the "HIP" (Hospital-In-Patient) service location code along with the specific hospital's facility number oma.org.
MRP Premium (E082): If you are designated the Most Responsible Physician (MRP) upon admitting a patient, you can bill this add-on code with your admission consultation oma.org.
Special Visit Premiums (C960-C964): These premiums compensate for the time and travel required for non-elective visits during evenings, weekends, or holidays. They are a crucial component for accurately billing after-hours inpatient work oma.org.

When should I use assessment codes instead of consultation codes?

Assessment codes are appropriate when a referral is not present or when conducting follow-up care for an established issue. The key is that the visit does not meet the strict criteria for a consultation. One of the most important Physicians First tips is to document clearly why a consultation code was not applicable.

A133 (General Assessment): This can be billed once per 12-month period for a patient.
A134 (Reassessment): This is typically used for follow-ups and can be billed twice per 12-month period for the same diagnosis.
A132 (Partial Assessment): This code has no frequency limit and is useful for brief, focused follow-ups. Strategically using A132 can help conserve your limited A133 and A134 assessments for more substantive visits.

Crucially, your documentation for any assessment must clearly state why a consultation code was not used, specifically noting the absence of a referring provider's request ontario.ca.

How do I bill for virtual and telephone care?

Since December 2022, OHIP has established permanent codes for virtual care. The temporary K-codes (K080-K083) have been replaced.

Video Visits: For video appointments, you can use the standard consultation and assessment codes (e.g., A135, A133) but must add the "VC" modifier. The documentation requirements are identical to an in-person visit ontario.ca.
Telephone Consultations (K730/K731): These codes are for physician-to-physician telephone discussions that last 10 minutes or more and result in clear recommendations. They cannot be used for simple care transfers or as a prelude to an in-person visit.

It's important to note that virtual codes cannot be claimed if an in-person visit for the same issue occurs within 48 hours ontario.ca.

What are the most common billing errors that trigger OHIP audits?

The MOH-OMA Education and Prevention Committee highlights several common triggers for audits. Being aware of these can help you maintain a compliant practice.

Frequency Violations: Billing multiple consultations for the same diagnosis within the 12-month limit without a new, distinct diagnosis.
Documentation Gaps: Missing referral letters in the patient file, or failing to record start/end times for comprehensive consultations (A130).
Code Mismatch: Using a consultation code (e.g., A135) for a visit that was initiated by the patient and therefore should have been billed as an assessment (e.g., A133) ontario.ca.

Maintaining meticulous and parallel clinical and billing documentation is your best defense in the event of a claim review or audit oma.org.