consultations-gp16-ohip-rules-limits-repeat-limited-2025-03-03

Consultations (GP16) – OHIP Rules, Limits and Definitions for All Specialties

Summary / Description
This article explains how OHIP defines a consultation, repeat consultation and limited consultation, how often consultations can be billed, and how emergency room and special surgical consultations work. It is based on the General Preamble GP16 of the Schedule of Benefits – Physician Services.

All specialties use these rules
The Consultations section in the General Preamble (GP16) applies to all specialties and sits under the “Consultations and Visits” framework in the Schedule of Benefits.

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What is an OHIP consultation under GP16?

  • A consultation is a service provided by a physician (the consultant) to a patient at the written request of a physician, nurse practitioner, or dental surgeon (for hospital dental procedures).

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  • The referring provider uses their clinical knowledge to decide that expert advice is needed due to complexity, seriousness, or obscurity of the case, or because a second opinion is requested by the patient or representative.

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  • The consultation must include:

    • A general, specific or medical specific assessment, including review of relevant data.

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    • The work necessary to prepare a written report (findings, opinion, recommendations) back to the referring provider.

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Referral definition (GP4):

  • A referral is a written request from a physician, nurse practitioner, or dental surgeon in a hospital setting, asking another physician to provide expert services to their patient.

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If these consultation requirements are not met, the service is eligible only for a visit/assessment fee, not a consultation.

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What documentation is required for a consultation?

For a consultation to be payable, GP16 requires specific documentation:

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  • Written request kept in the record:

    • A signed written request by the referring physician, nurse practitioner, or dental surgeon must be kept in the consultant’s medical record, except where common institutional records are used (hospital, LTC, multi-specialty clinic).

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  • Request must identify:

    • Consultant’s name

    • Referring provider’s name and billing number

    • Patient’s name and health number

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  • Request must describe:

    • Relevant clinical information and the service(s) requested.

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  • Written report:

    • A consultation includes the services needed to prepare a written report back to the referring provider (or to both NP and primary care provider when referral is from an NP).

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If these documentation requirements are not met, OHIP down-rates the claim from consultation to a lesser assessment fee.

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How often can consultations be billed for the same problem?

GP16 sets strict frequency limits for consultations for the same problem, same consultant, same patient over two consecutive 12-month periods:

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1. Limits over 24 months for the same problem

  • OHIP provides a table of “Limits on Consultation Services Rendered for the Same Problem Within Two Consecutive 12 Month Periods”.

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  • In summary:

    • All locations; hospital inpatient or emergency department

      • Total: 2 consultations over 24 months.

      • 1st 12 months: 1 consultation.

      • Months 12–24: 1 consultation (if medically necessary).

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    • All locations except hospital inpatient / ED

      • Total: 1 consultation over 24 months.

      • 1st 12 months: 1 consultation.

      • Months 12–24: no additional consultation.

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2. Unrelated diagnoses

  • For the same consultant, same patient, but clearly unrelated diagnosis, consultations are limited to one per 12 months.

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3. Down-rating to assessments

  • The amount payable is adjusted from consultation to general or specific assessment if:

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    • Consultation is in excess of these limits.

    • Requirements for a repeat consultation are not met.

    • The consultation is requested by a medical trainee.

4. Which services count toward the limits?

  • The limits apply to all consultations, including time-based and age-specific services (e.g., special, extended, comprehensive consultations), but do not include repeat consultations.

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What is a repeat consultation?

GP16 defines a repeat consultation as:

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  • An additional consultation by the same consultant,

  • For the same presenting problem,

  • After the patient has received care from another physician between the initial and repeat consultation,

  • With a new written request from the referring physician, nurse practitioner, or dental surgeon.

A repeat consultation must satisfy all requirements of a consultation (including documentation and written report).

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Note: GP16’s main numeric limits on consultations exclude repeat consultations, i.e., repeat consultations do not count against the standard consultation frequency table.

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What is a limited consultation?

A limited consultation is:

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  • Less demanding and usually requires substantially less time than a full consultation.

  • Otherwise must meet all the same requirements as a consultation (referral, assessment, written report, documentation).

In Family Practice & Practice in General (00), a limited consultation is the service rendered by any physician who is not a specialist, where the full consultation requirements are met but, due to the nature of the referral, only the services of a specific assessment are actually provided.

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How do emergency room (ER) consultations work?

GP16 sets specific rules for ER physician consultations:

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Payment rules:

  1. The consultation fee is down-rated to an assessment if:

    • The patient is referred by another ER physician in the same hospital; or

    • The service is rendered outside the emergency department or other critical care area, or to a non-critically ill patient.

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  2. ER reports are sufficient documentation of the written consultation report if:

    • All constituent elements of a consultation are clearly documented on all copies of the report; and

    • A copy is sent to the referring physician or nurse practitioner.

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If the ER consultant fails to send a copy of the report to the referrer, OHIP will adjust the fee to an assessment.

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Billing codes:

  • H055 – ER consultation by a specialist in emergency medicine (FRCP).

  • H065 – ER consultation by all other physicians.

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What is a special surgical consultation?

A special surgical consultation is a higher-complexity, time-based consultation:

  • A surgeon provides all the elements of a regular consultation; and

  • Must devote at least 50 minutes exclusively to the consultation with the patient

    • Time spent on other separately billable procedures does not count toward the 50 minutes.

Billing codes:

  • A935 – Special surgical consultation (outpatient).

  • C935 – Special surgical consultation (inpatient).

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These codes are used when the GP16 definition and time requirement for special surgical consultation are fully met.

When is a pre-operative consultation for low-risk procedures payable?

For certain low-risk elective procedures done under local anaesthesia and/or IV sedation, GP16 is explicit:

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  • Pre-operative consultations by any physician are only eligible for payment if the medical record clearly shows the consultation was medically necessary.

  • This applies to pre-op consultations for:

    • Cataract surgery

    • Colonoscopy

    • Cystoscopy

    • Carpal tunnel surgery

    • Arthroscopic surgery

The commentary in GP16 notes that such medically necessary pre-operative consultations for these procedures should be “very uncommon”.

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How do consultations relate to specialty-specific codes?

  • GP16 sets generic rules; specific consultation fees are found in each specialty’s “Consultations and Visits” section (e.g., Anaesthesia, Internal Medicine, Paediatrics, Diagnostic Radiology). The table of contents shows these specialty subsections under “Consultations and Visits”.

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  • Example (Obstetrics & Gynaecology):

    • A205 – Consultation

    • A206 – Repeat consultation

    • A935/C935 – Special surgical consultation, using the GP16 definition.

Your billing workflow should apply GP16 rules first, then choose the correct A-, C-, or H-code from the specialty section.

Common consultation billing scenarios

These examples are generic (multi-specialty) and show how GP16 rules might be applied.

Scenario 1 – First outpatient consultation, then hospital consultation 18 months later

  • Situation:

    • Specialist sees a patient in office for a new complex problem (first consultation).

    • 18 months later, same problem flares, patient is admitted to hospital and same specialist is asked to consult in-hospital.

  • GP16 logic:

    • First service: office consultation (A-prefix).

    • Second service (hospital inpatient, 18 months later): another consultation (C-prefix) is allowed because:

      • It falls between 12 and 24 months, and

      • The second service is in hospital inpatient setting.

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  • Billing approach:

    • Office: appropriate A-consultation code.

    • Hospital: appropriate C-consultation code for same problem.

Scenario 2 – Repeat consultation after interim care by another physician

  • Situation:

    • Specialist provides initial consultation for a problem.

    • Over the next months, the patient’s care is managed by another physician.

    • Due to ongoing issues, the other physician sends a new written referral back to the same consultant for the same presenting problem.

  • GP16 logic:

    • This is a repeat consultation (same consultant, same problem, interim care by another physician, new written referral).

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    • Repeat consultations are not counted toward the main consultation frequency limits table.

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  • Billing approach:

    • Use the appropriate repeat consultation code (A- or C-prefix, depending on setting).

Scenario 3 – Limited consultation by non-specialist in Family Practice & Practice in General

  • Situation:

    • A non-specialist physician in Family Practice receives a written referral.

    • The consultation meets all GP16 requirements, but the clinical question is narrow and the physician only needs to perform a specific assessment-level examination.

  • GP16 logic:

    • This meets criteria for a limited consultation (less demanding, shorter, but still fulfilling all consultation requirements).

    • In “Family Practice & Practice in General”, limited consultation applies to physicians who are not specialists when only specific-assessment services are required.

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  • Billing approach:

    • Use the appropriate limited consultation code listed under Family Practice & Practice in General (00), ensuring all GP16 consultation requirements and documentation are met.

FAQ Micro-Articles (for separate Zoho Desk KB items)

Below are 7 micro-FAQ items you can publish individually.

FAQ 1

FAQ Title
How many OHIP consultations can I bill for the same problem in two years?

FAQ Keywords / Tags
OHIP, consultation limits, GP16, same problem, 12 months, 24 months, inpatient, emergency, office

FAQ Body
For the same patient, same consultant, same problem, OHIP usually allows one consultation in the first 12 months. Over the next 12 months, a second consultation is only payable if it is rendered in a hospital inpatient or emergency department setting.

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In all other locations (e.g., office, clinic), only one consultation is payable over the full two-year period.

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FAQ 2

FAQ Title
What are the documentation requirements for an OHIP consultation?

FAQ Keywords / Tags
consultation, documentation, referral, written request, report, GP16, OHIP

FAQ Body
An OHIP consultation must have a written referral from a physician, nurse practitioner, or dental surgeon in the record. The request must identify the consultant, the referrer (name and billing number), and the patient (name and health number), and it must specify the service requested and relevant clinical information.

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The consultant must also complete a written report with findings, opinions, and recommendations for the referrer. If these requirements are not met, OHIP reduces the fee to an assessment.

FAQ 3

FAQ Title
What is the difference between a consultation and a repeat consultation?

FAQ Keywords / Tags
consultation, repeat consultation, GP16, same problem, interim care, new referral

FAQ Body
A consultation is the first GP16-defined consult for a problem, based on a written referral and a full consultation-level assessment and report.
A repeat consultation is an additional consultation by the same consultant for the same presenting problem, after the patient has received care from another physician in between and there is a new written request.

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Repeat consultations must meet all consultation requirements but do not count toward the main consultation frequency limits table.

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FAQ 4

FAQ Title
What is a limited consultation under OHIP?

FAQ Keywords / Tags
limited consultation, consultation, GP16, family practice, non-specialist, specific assessment

FAQ Body
A limited consultation is a consultation that is less demanding and normally takes substantially less time than a full consultation, but still meets all GP16 consultation requirements (written referral, assessment, report).

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In Family Practice & Practice in General (00), a limited consultation applies when a non-specialist meets all consultation criteria, but only needs to provide the services that make up a specific assessment.

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FAQ 5

FAQ Title
How do I bill an emergency department consultation under OHIP?

FAQ Keywords / Tags
ER consultation, H055, H065, emergency department, GP16, assessment downgrade

FAQ Body
In the emergency department, a consultation is billed with H055 (for FRCP emergency medicine specialists) or H065 (for all other physicians), as long as all consultation requirements in GP16 are met.
If the patient is referred by another ER physician in the same hospital, or if the service is provided outside the emergency department or critical care area, OHIP down-rates the fee to an assessment.

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FAQ 6

FAQ Title
Can I bill a consultation without a written referral?

FAQ Keywords / Tags
consultation, written referral, GP16, referral requirement, assessment instead

FAQ Body
No. GP16 defines a consultation as a service provided at the written request of a physician, nurse practitioner, or dental surgeon (for insured hospital dental procedures).
Without this written request and proper documentation in the record, OHIP will pay only an assessment/visit fee, not a consultation fee.

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FAQ 7

FAQ Title
When is a pre-operative consultation for low-risk procedures payable?

FAQ Keywords / Tags
pre-operative consultation, low-risk surgery, cataract, colonoscopy, GP16, medical necessity

FAQ Body
For certain low-risk elective procedures under local anaesthesia and/or IV sedation (cataract surgery, colonoscopy, cystoscopy, carpal tunnel surgery, arthroscopic surgery), a pre-op consultation is only eligible if the chart clearly shows it was medically necessary.

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The GP16 commentary notes that such medically necessary pre-operative consultations should be very uncommon.

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If you’d like, next we can clone this structure into specialty-specific consultation KBs (e.g., “Consultations – Diagnostic Radiology (33)” or “Consultations – Anaesthesia (01)”) by layering their A-/C-codes and nuances on top of these GP16 baseline rules.